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Is the United States moving towards group immunization? The hospital is facing a choice between life and death?  

2020-04-25
 The number of confirmed cases of new coronary pneumonia in the United States totaled 890,000, and the cumulative deaths were 51,000. Both data ranked first in the world. From the first case diagnosed on January 21 to 890,000 cases diagnosed today, in three months, the epidemic in the United States has gone from silent to rapid outbreaks and now it has gradually stabilized, including politics, economy, society, culture, health care, etc. The problems are intertwined and attract global attention.
 
Regarding the US epidemic, why are the number of diagnoses and deaths in the United States so high? What is the situation in American hospitals? Is there any delay in the Trump administration's response to the epidemic? These three issues have received much attention. The Beijing News reporter connected with Dr. Wang, a Chinese doctor who has worked in a hospital in Boston, Massachusetts, for 12 years. He listened to his observation of the US epidemic and answered these three questions.
 



Since March 30, the number of newly diagnosed cases in the United States is higher than 20,000, and the most new cases on April 9 are 34,100. Since March 31, the number of new deaths in a single day is higher than 1,000, and the most new deaths on April 21 are 2683. Two figures have caused concern.

 
Large amount of detection; cross-infection in elderly care institutions and hospitals at the beginning of the epidemic
 
The number of confirmed cases in the United States ranks first in the world, Dr. Wang believes that it can be interpreted from four levels.
 
First, a direct reason for the sharp increase in the number of diagnoses in the United States is the accelerated testing speed and increased testing volume. As of the 24th, the United States has detected 4.69 million people, making it the country with the largest number of tests in the world. At the same time, the speed of testing in the United States has accelerated, and the results can be produced in about 15 minutes under normal circumstances. Taking Massachusetts (hereinafter referred to as "Massachusetts") as an example, many cities in the state now have multiple detection points, many of which are drive-through (can be detected without getting off the car) detection points, which is very convenient. The number of people testing has greatly increased, and the number of diagnoses has naturally increased.
 
Second, the large number of infections in the United States is also related to the American medical emergency system. During normal times, when calling 911 for emergency help, a first response team (First Responder, including medical emergency personnel, police, firefighters, etc.) is required to jointly dispatch. This was the case when the outbreak began in a nursing home in Washington State. The first response team frequently traveled between nursing homes and hospitals, resulting in a group of first responders with group infections. This group of first responders also had cross infection with other groups, especially the most vulnerable elderly groups. To a certain extent, the number of potential infections of the entire social group is huge.
 
Third, the US CDC's guidance on the general population not to wear masks has, to a certain extent, led to the infection and transmission of the pre-assembled people. From the initial stage of the outbreak to the peak, the official guidance of the United States is that it is useless for healthy people to wear masks, so almost no locals will wear masks during this time. It wasn't until early April that the CDC changed its guidance and advocated wearing masks in public places such as supermarkets, or at least covering the nose and mouth with a scarf.
 
Fourth, the income level and living environment of the various communities in the United States are very different, and the proportion of infections is also very large. For example, in several districts in Boston, some areas with low- and middle-income groups have a high population density and many service industry personnel. Most of them need to take public transportation to and from work. Therefore, these areas, such as Chelsea and Revere, have a very high infection rate. In addition, Westerners have a weak sense of self-protection, and their hygiene habits are not as good as those of Chinese and Asians. To a certain extent, they also contribute to the occurrence of large-scale group infections.

 
At present, almost all elderly care facilities in Massachusetts have infection cases, and the new coronavirus is very deadly for the elderly, which leads to very high mortality rates in institutions such as American nursing homes. Statistics from Massachusetts two days ago showed that there were more than 2,000 deaths in the state, with an average age of 81 years, which means that most of the deaths were elderly.
 
A veteran's home (soldier's home), this nursing home was very severely infected a week ago, a large number of veterans died of infection, leading to a sharp rise in deaths. In this type of nursing home, the elderly are basically over 80 years old, and over 90 years old account for a certain proportion. They are old and weak in resistance. A considerable number of them have also signed agreements to give up treatment when the condition is critical. Therefore, when there is a serious crisis, sometimes it is impossible to treat. This has caused the number of deaths in the United States due to the new coronavirus to rise sharply. Dr. Wang pointed out that the United States is more similar to European countries such as Spain because of the large number of deaths in institutions such as nursing homes, resulting in a very high number of deaths.
 
After the outbreak, the situation in American hospitals has caused widespread concern: American medical personnel are in short supply of protective equipment, and some nurses say that they are like "streaking"; many states are in urgent need of lifesaving equipment such as ventilators, and doctors face where to use ventilators The life-and-death choice of a patient; the infection rate of medical staff is high, and many medical staff openly seek help ...
 
Early infection rate of medical staff is high, and protective equipment is insufficient
 
Dr. Wang said that from the early stage of the epidemic until 10 days ago, Massachusetts announced the number of infections by medical staff every day. At that time, the number of medical infections had exceeded 1,000. However, since then, the official no longer publishes data on infections of medical personnel. He believes that it is mainly because the hospital's protective measures have kept up with the recent period, and the infection rate of medical care has dropped significantly, which is no longer a problem that needs to be focused on.

 
However, the number of infections by medical staff at the beginning of the outbreak was indeed not low. Dr. Wang believes that this has nothing to do with the CDC's guiding principles at the time and the hospital's management system. From the perspective of the CDC, the guidance at the time was that it was not necessary to take comprehensive protection for the medical care of general departments; from the perspective of the hospital, in addition to following the guidance of the CDC, an important consideration was to Leave the most inadequate protective materials until the most urgent time-because under normal circumstances, the hospital will not store a large amount of medical materials, the normal situation is only enough for two weeks of use. Medical institutions initially did not allow medical personnel to use their own protective equipment, which led to a sharp increase in the rate of medical infections.
 
 
 
It is gratifying that all frontline medical staff have been given priority testing. In addition, many hotels in Boston are also specifically vacated to isolate those diagnosed medical staff; in the latter stage, some university dormitories are also vacated for infected medical staff. Among the infected medical staff in Massachusetts, one nurse is known to have died, so the rate of medical casualties is not as high as expected.
 
Doctors in general departments go to work at home, and senior hospital officials take the initiative to reduce wages
 
 
 
After the epidemic gradually fermented, many hospitals have adopted a measure, that is, except for doctors in emergency departments, respiratory departments, and infection departments, doctors in other general departments can work at home-it can be said that doctors are better than other industries in the whole society. People work from home first. This is also related to the US medical system. There is a relatively complete online diagnosis and treatment system. This system is linked to the pharmacy. After the doctors diagnose and treat the medicine online, they can pass the prescription to the pharmacy. Dr. Wang believes that this measure protects a considerable number of doctors from infection.
 
 
 
However, under the epidemic, hospital income was greatly affected, and almost every hospital's income fell by at least 30%. Therefore, starting in March, the directors of some hospitals offered to reduce wages by 50% and senior management staff by 20%. However, the salaries of medical staff did not drop, but instead increased some subsidies, because the federal government and state government have special for first-line medical care. Funding.
 
The situation is improving now, only 70% of normal emergency cases in Massachusetts
 
 
 
Dr. Wang pointed out that in the United States, the situation varies greatly from state to city. Like New York City, the hospitals were overcrowded in the past few weeks, and the medical staff must have been very shocked. Fortunately, this has not happened in Boston. In fact, except for the initial lack of protective equipment that caused a certain amount of confusion, the protective equipment for medical personnel is basically sufficient, and everyone's mentality is relatively peaceful. The “flatten the curve” strategy proposed by the CDC and various states is relatively effective, because it can avoid the impact of the sudden increase in the number of patients on the medical system.
 
 
 
Especially in Massachusetts, the overall situation is okay. Dr. Wang said that Massachusetts hospitals are numerous and medical resources are sufficient. Therefore, although Massachusetts is the third most infected state in the United States, the hospital has not experienced overcrowding and large numbers of deaths. The ICU at Boston Hospital is also controllable, and there are no doctors in the hospital who face the so-called "life-and-death choice"-that is, how to allocate and use the ventilator.
 
 
 
In addition, two weeks ago, Boston had transformed the exhibition center into a 1,000-bed square cabin hospital, 500 of which were planned for the homeless. But so far only a few mild patients have been admitted, and the cabin hospitals are still on standby.
 
 
 
Dr. Wang added that the latest data released by the Governor of Massachusetts on the 23rd shows that half of the general beds and ICU beds in Massachusetts Hospitals are currently vacant, and the number of emergency cases is only 70% compared with the normal situation. Therefore, the state government and medical institutions encourage people with emergency needs such as stroke and heart disease to see a doctor in time to avoid delays.
 
Question 3:
 
How to treat Trump's epidemic prevention and control measures?
 
 
 
During the fermentation of the US epidemic, the Trump administration's response was highly controversial. Some criticized the Trump administration ’s sluggish response and did not pay enough attention in the initial stage. Some accused Trump of politicizing the epidemic and using it to fight for re-election for himself. Others believed that Trump announced the reopening prematurely in order to develop the economy.
 
 
 
The latest US media polls show that 65% of Americans believe that Trump did not take the virus seriously in the early stages of the epidemic and did not take timely action. Half of the respondents expressed dissatisfaction with Trump's anti-epidemic performance.
 
Advocating freedom, many people do not live in isolation
 
 
 
According to Dr. Wang, the federal government's response cannot be considered slow. When the outbreak of the Chinese epidemic began, the United States quickly stopped the flights between China and the United States, and several cases imported directly from China were quickly brought under control. However, the main reason for the subsequent loss of control in the United States was the large number of imported cases from Europe, especially in New York and Boston. Take Boston as an example. The first mass infection was due to the large number of people who came to Europe from Boston to attend a medical company meeting, which caused the epidemic to spread rapidly. Therefore, the federal government also quickly suspended flights between the United States and Europe.
 
 
 
Dr. Wang pointed out that the overall response of the Trump administration is reasonable. However, the political structure and values ​​of the United States determine that although the federal government and state governments have successively declared a state of emergency, there is no way to force people to be isolated at home. Declaring a state of emergency only gives government agencies more power to mobilize social resources to help fight the epidemic. For example, the National Guard can be used to participate in treatment.
 
 
 
In addition, although most states have issued "home segregation orders", this is only a recommendation, not legislation. Just as people have recently been encouraged to wear masks, it can only be advice, which means that if someone does not wear it, there is no way. In other words, most Americans advocate freedom and have a strong sense of freedom, so there are still a considerable number of people who do not abide by the rules of home segregation and various restrictions. Taking Boston as an example, although there is a requirement for home isolation, there are still many people in some unclosed parks; the number of vehicles driving on the road has not been reduced than normal, which has led to a high number of infections.
 
The US is actually moving towards "group immunization"
 
 
 
On the issue of reopening, Dr. Wang pointed out that the situation between the states is very different, and some states, such as Florida and Utah, are actually half open. President Trump announced the detailed guidelines for reopening last week, but handed over the decision to the states, and the state government will gradually release them on a small scale under the various conditions stipulated in the guidelines according to the actual conditions of the localities.
 
 
 
However, Dr. Wang believes that an important prerequisite for reopening is to have sufficient detection capabilities. Because of the reopening and normal return to work, antibody testing is required to be able to work with confidence and gradually return to normal life. However, overall, the current antibody detection capabilities are still relatively weak, and only small-scale tests can be performed on groups such as front-line personnel. Therefore, each state needs to be very careful in opening up.
 
 
 
In fact, New York State conducted its first round of antibody testing this week. Of the 3,000 people sampled, 13.9% have been infected and have antibodies, compared with 21% in New York City. New York State Governor Como believes that if it is translated into actual morbidity, it means that 2.7 million people in New York State are infected and the mortality rate is about 0.5%.
 
 
 
Dr. Wang pointed out that although the US government initially opposed the "group immunization" strategy, the reality today is moving toward "group immunization." Because the current number of infections is too large, many infected people may have no symptoms or only mild symptoms. This sample test in New York State also proves this to some extent.
 
It is estimated that the United States needs 35 million tests every day to get people back to work. "
 
 
 
● Mild patients carry hard at home, there is still a long way to go for vaccine prevention
 
 
 
Dr. Wang said that the current situation in the United States is that asymptomatic and mildly infected people are mostly isolated at home or hotels, basically without medicine, and relying on their own immunity to resist the virus, just like the cold virus. Wait until the symptoms have disappeared, and then conduct another test. If it is negative, you can end the isolation.
 
 
 
On the treatment plan, Dr. Wang pointed out that strictly speaking, there is currently no particularly effective treatment plan, and some of the more popular drugs such as ridacive, chloroquine, etc., have not been effectively validated by large-scale clinical trials. Existing treatment options are mainly symptomatic treatment with antiviral drugs, antibiotics, antipyretics, etc. At present, the treatment with great hope is to use the donated serum from the cured patients to treat the patients who are getting worse.
 
 
 
For the new coronavirus vaccine, although some vaccines have begun to enter human trials, Dr. Wang believes that it is not very realistic to expect the vaccine to control the epidemic. He explained that on the one hand, it is still a question whether the vaccine can be successfully developed, just like SARS in 2003, when a large-scale vaccine was also developed at the time, but no successful vaccine appeared; there are also AIDS vaccines and Ebola virus vaccine , Strictly speaking, it has not been successful so far. In addition, vaccine development requires a certain period of time, whether it can stimulate the body to produce antibodies, and whether it will bring side effects to healthy people. It will take at least one year to carry out follow-up research. Therefore, it is estimated that the new crown vaccine has a long way to go.


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