Tuesday, March 24, 2020

COVID-19 Management Brainstorm Ideas, Part I: COVID Hotels

The idea I am about to propose is just a hypothesis, NOT a recommendation.  I am not qualified to make recommendations, except for psychiatric issues, but I feel I am qualified to ask questions and put forward new ideas to be tested.

I invite anyone reading this, especially experts in infectious diseases, epidemiology, or public health, to critique these ideas--shoot my ideas down if that's what's needed!   But I'd like to hear what you think.

Here is my first idea, I call it "COVID Hotels."

COVID HOTELS

A COVID hotel would be a building sealed off from the outside world.   Nobody would be allowed in or out without exhaustive screening and quarantine.  It could use a literal hotel building, such as the Marriott or the Holiday Inn.

Every member of the staff of the hotel would need to have previous COVID-19 infection, and would need to have proof of having recovered from COVID-19.  Staff would have to subject themselves before beginning employment, voluntarily and with informed consent, to be exposed to a viral inoculation of COVID-19, then followed for several weeks, to demonstrate that they have full immunity.   The staff would consist of basic workers, including food and cleaning staff, but there would also be doctors, nurses,  researchers, and entertainers.

The hotel would have a research lab.

The hotel would have an intensive care unit, with enough spaces to accommodate the approximate 5% of guests who might need this (this percentage would have to be adjusted based on the best and most recent evidence).

New guests at the hotel would be COVID-19 negative.  They would have to be in perfect health and under 30 years old.  They would of course have to volunteer, with detailed informed consent, to enter the hotel.

Upon entry, guests would be required to stay until they had acquired COVID-19 and fully recovered from it.

The risk to each guest would therefore be approximately a 0.1 % risk of death.  This is the biggest ethical question about my idea.

There could be a variety of opportunities for research.  For example, some guests could be randomized to use face masks, others not, and they could be followed over the next month to see if mask usage would affect infection rates.

Genetic research could be done, to determine if there are genomic variants that confer risk or resistance to developing infection or more severe disease easily.

Other guests could be randomized to try a prophylactic drug (such as chloroquine) vs. placebo, upon entry, to answer definitively if these drugs are actually beneficial to either reduce infection rates or reduce the severity of subsequent disease.

Other guests would be directly inoculated with the virus upon admission.  The inoculation method could also be varied in a randomized controlled manner, for example to test the hypothesis that gradual low-dose viral exposure might reduce the severity of subsequent disease compared to being exposed to a sudden high viral load.

Viral testing would be done daily, with viral load counts etc. if possible.

Every guest would eventually have full exposure and infection with COVID-19, and because of the healthy young demographic, almost everyone would recover uneventfully.  Those who did struggle would be cared for, if necessary, in the hotel ICU.

Every surviving guest would recover, and hopefully become immune to COVID.  Proof of immunity would once again have to be established, by a re-inoculation with a large dose of the virus, then following for weeks to guarantee that there would be no new infection.

Once these guests had recovered, with absolute certain virologic proof of immunity and no virus shedding, they could be released into the community.

Guests who were released could then go on to become staff in a new COVID hotel.

BENEFITS 

The benefits include developing a clearly identified group of people who are immune, who would then be relieved of their own anxiety, be guaranteed of their subsequent health, and who could safely be employed to care for others or begin normal work to boost the economy.

Health care workers and other high-risk staff could also be encouraged to volunteer for this, and in so doing we would develop a much healthier, safer, happier cohort of health care professionals.  Immense anxiety in them could be instantly prevented or relieved, since they would have no worries anymore about getting infected again, or passing infection to their loved ones.

If the idea was employed on a massive scale, it could lead to massive numbers of immune people in the community, and help reduce the rate of spread.

If convalescent plasma proves to be an effective treatment for COVID-19, then the recovered volunteers from this cohort would be a rich, safe source of plasma to treat acutely ill COVID-19 patients.

I suspect that one of the biggest sources of COVID-19 contagion in the world is asymptomatic people who are COVID-19 positive and under age 30.  This technique would start to directly target and eliminate this source of infectivity.

Another benefit is the rich opportunity for extremely clear randomized-controlled studies of infection behaviour, prevention and treatment techniques.

RISKS 

The main risk would be of severe illness and death in a small number of guests.  If the risk is truly 0.1%, this represents a whole year's worth of baseline mortality risk (or so) for someone under 30. 

Another risk is to consider whether it is a cost-effective approach, since it would involve dedicated resources.  My hypothesis is that it would be very cost-effective compared to the status quo.

Another risk could be that it did not work, i.e. that people did not become immune.  That would be a catastrophically depressing thing, if true, but pretty important to know in any case.

COMPARISON TO VOLUNTEERING IN A WORLD WAR

The mortality or morbidity risks of this plan could be compared to the risks of someone joining the military, voluntarily, to serve their country in a major war.  In World War II, about a million Canadians served in the military, of whom over 42 000 died (4 %), and of whom over 55 000 were injured (5 %).  This is a casualty rate 50 times higher than the expected casualty rate of the plan I am describing above.

This is a world war against COVID-19.  Let's build an army to fight it.

In compensation to volunteers for this plan, they could be treated as war heroes, and given full veterans' benefits for themselves and their families afterwards.


Please let me know what you think of this idea.



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