Caixin Global Webinar: Coronavirus Frontline Experiences from China and Singapore

Covid-19 continues to spread globally and countries are gearing up to fight the virus. China and Singapore, although different in many ways, have tackled the challenge since January and are ahead of most countries in their fight. This Caixin Global webinar brings leading doctors from Wuhan and Singapore together to share valuable lessons from the frontlines.

Caixin has been closely following the coronavirus issue from the beginning, and as its impact continues to grow, we presented a webinar on March 26 to provide our audience with the information and insight they need, as well as an opportunity for discussion with relevant experts.

After each making a presentation, Dr. Peng Zhiyong and Dr Vernon Lee answered questions from the audience. (Session video)

Dr Peng Zhiyong (slides) answered most of the questions on clinical treatment and ICU practices:

How to avoid false negative? Some say that the nose is more preferable for swab sampling than the throat, what is your recommendation?
• Samples from the lower part of the respiratory tract are better, but harder to obtain.
• Sample from the nose has quite low sensitivity compared with samples from the lower part of the respiratory tract.

What markers were most sensitive and specific to predict early which patient will improve or deteriorate?
• We monitor the IL-6 level of patients. If the IL-6 level is high it often indicates higher severity or worse outcome.
• Another simple marker is, if the patient has persistent lymphopenia, with very low absolute count, this also indicates bad outcome.

Does Covid-19 inflict permanent damage to patients’ health?
We don’t know. Some patients have been discharged with lingering symptoms like difficulty breathing, but we need more time to follow-up and see how much they’ve improved.

Is there any evidence that putting patients in prone position has an impact?
• Prostrating patients is quite important to improve the oxygenation.
• We prostrate patients relatively a longer time compared with other ARDS patients. Because if only be done in short time, we could not find any improvements. So we prostrate patients as early as possible, even if they are still conscious.

Is high-flow oxygen a better device for respiratory failure?
• We are concerned about safety and highly recommend high flow used only in the ICU with negative pressure.
• We monitored the virus level between the ICU with negative pressure and the regular. In the regular ICU, we detected virus on the equipment, on telephone and in the air.
• It is not safe for medical professionals to work within regular ICU.

What is the experience with non-invasive ventilation?
• We should carefully monitor how the patient response to non-invasive ventilation.
• If the patient conditions don't improve for some time (e.g. 2 hours in our ICU), then we probably need to switch to invasive ventilation. Because the non-invasive ventilation will probably worsen the lung injury.

Have you used traditional Chinese medicine to treat patients? Is it possible to avoid herbal and drug interactions?
In ICUs, we never use traditional Chinese medicine or herbs with our patients.

There is a high infection rate among medical professionals, how to protect them?
• Hospital acquired infection is often at the beginning, due to limited personal protective equipment (PPE) supply.
• Control the consumption of PPEs, and healthcare workers are allowed to leave ICU for meal or restroom for only once a day, before PPE supply goes back to normal.
• As a result, infection rate in Zhongnan Hospital is quite low: 2 nurses were infected and only 1 from ICU, both in early stage.

How did health care workers recycle or disinfected PPE even if they are intended for one-time use?
Most of the PPE are disposable. We only recycle the goggles, which can be disinfected with alcohol.

Knowing what you know now, is there anything you wish you could have done differently? What was the toughest choice you’ve had to make in the last two months?
• I would focus much more on ventilation strategy and make sure patients’ lungs don’t take any further damage from mechanical ventilation.
• The hardest choice has been when to give up, as patients died waiting for ICU beds. This has been the toughest period in my whole life.
• Should mobilize resources in the early stage of the outbreak, mobilize ICUs and mobilize medical beds.

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Dr. Vernon Lee (slides) answered most of the questions related to prevention methods, testing procedures and public health policies to fight the virus:

What prompts the Singaporean government to act so early? Is it the result of many unknown overreactions, or a scientific and efficient monitor system that picks up information early on, and translate that into action?
• It’s necessary to be prepared and to act to stay one or two steps ahead of the virus. A lot of indicators are lagged. By the time we detect something, like a transmission, it was actually an event that happened maybe a week ago. Therefore, things needs to be done to prevent infections from happening over the next few days or a next week.
• In Singapore many activities are done in an anticipating way. If we see increasing number of some indicators, we try to do something to prevent more spread in the next few days.
• The measures are also calibrated so what we do neither too little nor extremely too much. Because coronavirus will not go away quickly. It's not a sprint. It's a long marathon. Our measures taken need to be sustainable over the long run.

• We are also trying to do things that the population can accept, and can deal with in the long term, including being socially responsible and making small changes to their daily routine.
• It is very important to emphasize - to detect cases as early as possible, to try to contain them because if not, the outbreak can very quickly.

What is the attack rate in Singapore? Is there any difference between attack rates among different demographics?
• Case in Singapore is few, so attack rate data is limited.
• Among the early cases in Singapore, the effective reproductive number is actually way below 1; about 70% of individuals that we have seen do not spread the disease to others.
• There are a few individuals that cause quite bit of spread, mostly due to the fact that they are circulating in the public. Under those instances, the attack rate is high, ranging from 10% to even 30, 40%.
• The same suggestion: stay home and do not congregate.
• By studying affected households, we found that older people are getting more sensible both to infection and to also more severe infection.

Could you compare the pros and cons for mass testing vs. targeted testing?
• It depends on the testing capacity of each country, and also the intention of disease control official. If you want to pick up as many cases as possible, and testing capability is not an issue, you can do mass screening.
• Technology makes a difference. A lot of countries are now using PCR based technologies, which is not very amenable for mass testing. If there are new technologies such as point of care test kits, or even serological tests that are being researched at the moment, this will certainly increase the capacity for mass testing.
• In Singapore, we focus on areas where we can get the highest yield: all pneumonia cases, symptomatic close contacts of cases, symptomatic people entering the country, etc. This way, we can ring-fence the whole outbreak even if we miss a few cases.

Will warm weather have impacts on slowing down the transmission?
• It's too early to tell at this point. This is a new virus and we don't know much about it. We need to wait until the middle of the year to see if there is indeed any correlation between warm weather and transmission.
• A lot of the transmission are going on in winter in temperate countries, but at the same time, tropical and sub-tropical countries like Singapore in Southeast Asia are also reporting cases, and the virus is very transmissible.
• In Singapore, we had several very large clusters of a cases, usually due to a symptomatic individual being out in the community, going to work, or going to a different social Activities that have spread the disease.
• We would rather be prepared to deal with any possibility of spread than place bet solely on the virus not spreading quickly in warm climate.

What are the key lessons colleagues in other countries should be aware of?
• Do not underestimate this virus or how fast it can spread. Countries should be prepared to: identify as many cases as possible; isolate cases as much as you can, whether in hospitals or at home depending on capacity; perform contract tracing to find more cases and ringfence the outbreak.
• Communication to the public is very important to empower individuals and make them feel they are in control of the situation.
• Employ surveillance to see the progression of the pandemic and roll out proportional measures.
• Collaborate globally. The more data we can share, the better we will be able to respond.

Will European PPE guidelines suffice? Notably, they don’t recommend hoods, and hazmat usage is low.
• It depends on what level of protection you need for any given situation.
• For general clinical work, mask, gown and goggles are enough.
• For intubation and other procedures, it’s better to have protection against airborne transmission like hoods and face shields.

How will Africa fare if the virus infects the continent? What do you think the death rate would be?
• It is difficult to predict death rates for any country.
• The most important aspect: we can control COVID-19 if individuals are socially responsible and practice good hygiene. This is easy and don’t need strong healthcare infrastructure.
• “Flatten the curve” is a key goal for any country, to reduce the number of cases and spread the cases across time. This can be achieved with simple measures.