This week will be a little bit different. This is an open letter to hospital and clinic administrators, as well as any healthcare organization. Feel free to share widely, particularly to any administrators you may know.

Executive Summary

The US is starting the next pandemic wave. Most of the population has not received boosters in the past four months and are not taking mitigation measures. Data from other countries suggests that this will be a challenging wave, particularly as school starts which is a known source of community spread.

Globally, these new variants have led to the cancellation of elective surgeries due to the infected patient volumes as well as ER diversions and patients held in the ER for days with no beds available on nursing units.

Wastewater COVID concentrations in the US are at the highest they have been during this time of year since the start of the pandemic. Both COVID ED and outpatient visits are climbing across the US.

Most of the population thinks of COVID as a respiratory disease, when in fact it is a vascular disease with an acute respiratory phase, but that has chronic sequelae in almost every organ system and repeat infections significantly increase the risk of chronic disease. It is driving increases in infectious disease due to immune system dysregulation. This can be seen in increase rates of pertussis, RSV, tuberculosis, and even is thought to be a contributing factor to the rise in dengue, among other diseases.

There are secondary impacts as well, such as increased MVAs, major increases in long-term disability, major increases in sickness among HCWs, and the failure of businesses.

The threat of a H5N1 pandemic continues to climb and could become far worse than what was seen with COVID.

Administrators should take measures to reduce infections among employees, visitors, and the community and serve as leadership examples to other health providers and organizations across their communities.

I recommend several strategies to reduce sickness and decrease costs.

• Stockpile N95s.
• Purchase more PAPRs.
• Review and monitor supply shortages.
• Mandate respiratory protection during pandemics and the normal cold/flu season.
• Test all patients on admission for COVID, and H5N1 if it begins to rapidly spread.

Situation

The KP.2 and KP.3 variants, collectively known as the FLiRT variants, have become dominant in the US, representing about 50% of samples.

These variants contributed to the need to cancel elective surgery in parts of Australia last month. Last week, a few paragraphs of an article in a Spanish newspaper also gave an indicator of what is to come.

Hawaii has been the canary in the coal mine for the US, due to the high levels of travel from SE Asia and Oceana where the FLiRT variants have become more established. Their hospitalizations show what is to come for much of the US.

Wastewater data shows this increase is happening throughout the US. In addition, note that these concentrations are at the highest for this time of year since the start of the pandemic.

This wastewater data suggests that there are somewhere between 600,000 – 800,000 cases/day in the US. That translates into a little over 1:100 people being actively infected. Michigan is at the very beginning of this rise based on wastewater samples.

This trend is also clear when looking at other data for the entire US, including positivity and the percentage of ED visits that are confirmed COVID.

All of this is happening in the context of a public that has not had any type of booster recently and very few taking any personal mitigation measures using various non-pharmaceutical interventions. Part of the reason that we have had reduced COVID in 2024 is that we have to this point been dealing primarily with the same variant since last fall, which has given some herd immunity, but that only lasts for a few months. That will change with the new variants. (Note that the FLiRT variants are not separated out in this plot and are part of the light blue area.)

Background

The severity of COVID has been grossly underrepresented by the media. The public thinks that it is a respiratory disease, when in fact it is a vascular disease with acute respiratory symptoms. The affinity of the virus to bind to ACE-2 receptors leads to damage throughout the body and across organ systems, which is clearly illustrated in a mouse model comparing H5N1 influenza to COVID.

Rong et al. used transparent mice to image the affinity of SARS-CoV-2 spike protein, and two control proteins (the WT spike protein which doesn’t have an affinity for ACE-2 receptors, and influenza virus hemagglutinin [HA]) to ACE-2 receptors using fluorescently labels. The results paint a clear picture of how the SARS-CoV-2 spike protein affects most of the organs in this model.

Dr. Danielle Beckman is a leading neuroscientist studying the impact of COVID on the brain and has produced some stunning images, such as this one.

All of this endothelial damage and resulting microthrombi cause focal tissue necrosis and scarring. While young, healthy tissue can currently offset the deficit, as that tissue ages, it won’t have that capacity. In my professional opinion, we will be facing severe pandemics of diabetes, heart failure, pulmonary fibrosis, and many other chronic conditions, as well as infectious diseases due to the immune system dysregulation by the virus.

A study by Bowe et al. showing the cumulative risk and burden of sequelae in people with one, two and three or more SARS-CoV-2 infections compared to noninfected controls. As a society, we are expediting those chronic disease pandemics because of a lack of mitigations.

Even someone without any medical training can easily see the damage to the coronary vasculature.

The epidemiology of infectious diseases is drastically changing due to COVID as well. Unfortunately, data from the CDC is often 2-3 years old in these areas, so UK data provided the most current data for these increasing rates. This visualization of pertussis (whooping cough) rates was quite clever if you are a Star Wars fan.

These are Legionnaire’s disease cases. I added approximated trend lines for both pre pandemic and since the start of the pandemic.

Tuberculosis is a concern as well. The blue line is the number of new cases per 100,000 population. Overall, it has been decreasing over time, except in the red period. The yellow line is the percentage change from the prior year and the dotted yellow line is the five-year average of that percentage change, which helps smooth out the random variation from year to year. In the 1980s, the percentage change increased for the first time since the 1960s. TB was a marker for AIDS, which takes about 10-15 years to develop after untreated exposure to HIV. It’s concerning that we are approaching what could be another positive period in that trend, possibly due to the immune damage from COVID.

This is simply not sustainable. This is evident by the number of sick calls by HCWs in the UK since the start of the pandemic, which has increased by about 30%.

It’s not just sickness that will be drawing down the healthcare workforce. In this survey from 2023, nearly half of unionized healthcare workers are indicating that they might retire or quit. The main points of this survey are quite alarming.

• Half of healthcare workers say they are likely to leave the healthcare profession in the next few years.
• Nearly 80% of healthcare workers report feeling burned out by their jobs.
• Short-staffing and workplace safety are among the top reasons healthcare workers are considering leaving the healthcare profession.
• Nearly half of healthcare workers report feeling unsafe at their jobs.
• Healthcare workers overwhelmingly support safe staffing standards.
• Nearly half of healthcare workers report patient harm at their hospitals that they believe was due to short staffing.

A study prior to the pandemic predicted quite a significant shortfall in the nursing workforce by 2030. “There will be a shortage of 154,018 RNs by 2020 and 510,394 RNs by 2030.” Both sickness and burnout will make this situation much worse. We have a clear warning in data again from the UK.

These problems are creating issue for all industries. This data on the economic impacts of unmitigated spread from Australia paint this picture clearly and are another warning of the financial, social, and economic headwinds that we are facing as a society.

These problems also increase substance abuse rates climb when unemployment or loss of loved ones from COVID itself or the sequelae from the disease increase mental health strain.

COVID also impairs spatial awareness, which could be part of the reason for the increase in MVAs in the US, which also would impact patient volume and drive burnout among HCWs. This is data from the National Safety Council showing this increase since the start of the pandemic, further increasing demand on the healthcare system, particularly in ER and trauma care.

It’s only a matter of time until we see increases in air travel incidents that cause injury and death as well as “brain fog” and other cognitive impairment influences decision making, whether it is during aircraft maintenance or in real time with pilots and air traffic controllers. As an example, “Military Pilots Reported 1,700% More Medical Incidents During the Pandemic. The Pentagon Says They Just Had COVID.” These problems are being seen in commercial aviation as well. “Pilots who had been infected with COVID-19 had a 1.8 times higher risk of SCD compared to those who had not been infected (RR: 1.8, 95% CI: 1.3-2.5).”

The cognitive impact from COVID becomes especially apparent when looking at younger populations. This also increases the risk of medical errors and thus hospital liability.

It’s clear that the supply side of healthcare is going to be heavily impacted. Some data from Spain also gives a clear warning about the demand side. Compare the percentage of the population with chronic illnesses before the pandemic and currently. It’s alarming thinking about what is coming, given how most of the chronic conditions caused by COVID are likely 5-10 years off.

Even more concerning, the rates of hospitalization in Spain since the start of the pandemic are about 9 standard deviations from the prior mean.

These are just some of the reasons I expect healthcare to collapse globally. Healthcare organizations owe both their staff and the population they serve to protect the health of both and to provide to the needs of the area for as long as possible.

Given how surgery is the financial lifeblood of hospitals, it is an important strategic move to reduce the spread of the pandemic among staff and as a result, in the community as much as possible. As such, I recommend returning to mask mandates immediately and preparing for what is to come. I suspect that just as Standard Precautions evolved in response to HIV/AIDS in the 80s, we will see respiratory protection become a part of Standard Precautions because of COVID. It would be best to start normalizing that immediately.

In a study from Australia published this week, McAndrew et al. found “Compared to no admission screening testing and staff surgical masks, all scenarios were cost saving with health gains. Staff N95s + RAT admission screening of patients was the cheapest, saving A$78.4M [95%UI 44.4M-135.3M] and preventing 1,543 [1,070-2,146] deaths state-wide per annum. Both interventions were individually beneficial: staff N95s in isolation saved A$54.7M and 854 deaths state-wide per annum, while RAT admission screening of patients in isolation saved A$57.6M and 1,176 deaths state-wide per annum.” A graphic portrayal of the financial costs by implementing these preventive strategies is very eye opening.

The H5N1 Threat

Everything to this point has been strictly related to COVID. However, we are hanging on the precipice of a H5N1 pandemic. Even if it were somewhat mild, the volumes of affected people would be overwhelming. On Wednesday, 71 poultry workers who were responsible to cull infected chickens were suspected to have H5N1. Five have now been confirmed. As this moves into more and more mammal populations, and especially among humans, the risks of the virus mutating into something that has efficient human-to-human spread and high morbidity and mortality climb.

At the worst outcome end of the spectrum, the calculations are horrifying.

• Global Population: 8.1 billion
• Attack rate of the Spanish Flu in 1918: 30%
• Mortality rate of H5N1 to date: 50%

This means that if H5N1 gains the ease of transmission between humans as we saw with Spanish Flu and maintains its mortality rate in humans, the number of deaths we can expect (assuming we can give everyone full medical care and not counting secondary deaths from failing infrastructure), the calculation is 8,100,000,000 x 0.30 x 0.50 = 1.215 billion deaths globally. COVID gave us our warning shot and we have failed miserably. The CDC should have been at forefront in prevention but has been poor in communicating risk.

Recommendations

Healthcare organizations should immediately implement a number of strategies that are both ethical to help prevent disease spread among staff, patients, and the community and are fiscally advisable to reduce hospital costs in the long run.

• Stockpile N95s.
• Purchase more PAPRs.
• Review shortages during prior surges with pharmacy and materials management and increase stock appropriately. There is currently a shortage of BD BACTEC Blood Culture Systems. Most generic medications used in the US begin as APIs in China, are shipped to India for manufacturing and packaging, and then travel to the US in the cargo holds of passenger flights. There are many points of failure along these supply chains, including government decisions NOT to export to protect their own populations.
• Mandate respiratory protection during pandemics and the normal cold/flu season. This is where I expect to see Standard Precautions going in the future.

There really are just two choices. Implement measures to protect staff, patients, and the public and perhaps delay the most severe impacts on healthcare organizations or continue as we are acting as if everything is normal and expedite their failure. Temporal discounting is our Achille’s heel.