COVID Warrior: Malibu’s Dr. Suzanne Donovan
Dr. Suzanne Donovan is a UCLA Professor of Medicine and Infectious Diseases expert who travels the world advising on outbreak control. At the end of last year, Donovan was a speaker at the 2019 Emerging Infections Conference in Kathmandu. At the time of her visit, Nepal was experiencing both scrub typhus and dengue outbreaks. The COVID19 epidemic occurred shortly thereafter in neighboring China. Donovan took care of the first Los Angeles patients diagnosed with COVID and was a member of the Clinical COVID group that co-authored the CDC paper describing the initial COVID patients in the US.
Just before the COVID19 shutdown in March, I ran into Dr. Suzanne Donovan at the last local event the 90265 Magazine staff attended in person. “We need to talk” Donovan said to me in a worrisome tone. Fast forward 6 months later, and after the devastating toll the pandemic has taken globally, I was able to virtually sit down with the COVID warrior who was very candid about her disappointment in the U.S.’s intital response to the pandemic, and her thoughts for the future with COVID19.
90265 Magazine: What is your Medical Opinion of COVID? Why do some people get sick and others have no symptoms?
SD: Globally, we have never seen this virus, SarsCoV-2, that causes COVID19 before — therefore we call it a novel, or new, coronavirus. Because this is a novel viral infection, most of us do not have preexisting experience or immunity to this virus. Even though most people will not get seriously ill when infected with this virus, there is still a large burden of disease in persons that do require hospitalization, due to chronic health conditions or advanced age. Eight out of ten deaths are in those 65 years or older—so communities or countries that have an older population will be disproportionately impacted. We also do not know the long-term complications from this virus. We do know that many of those infected have persistent symptoms months later after their initial infection.
The clinical presentation of COVID is quite interesting—it appears to have a secondary inflammatory phase after initial infection that was initially recognized in those that are sick enough to be hospitalized. The spectrum of complications during this inflammatory phase may include respiratory failure, a hyper-coagulable state (increased tendency to form blood clots) where potentially life-threatening clots form in the lung and other organs, renal (kidney) failure, myocarditis or inflammation of the heart and involvement of the brain with delirium or strokes. We know that persons with chronic medical problems, such as diabetes, obesity, cancer, pulmonary and cardiac problems are at higher risk for these complications. In addition, older age is an independent risk factor for doing poorly — including being admitted to the ICU on a ventilator and dying.
“We are just 6 months into the pandemic – the learning curve has been steep”
There is much discussion about the uniqueness of COVID19 causing a spectrum of disease from many cases being asymptomatic to life-threatening complications—and we are still learning about the underlying processes leading to the clinical manifestations. But is this unique to see a variable presentation? I travel all over the world and never get traveller’s diarrhea, but others consistently get gastroenteritis.
Valley fever, caused by a soil fungus (coccidiomycosis) causes mild symptoms in over 90% of those infected, while others develop life-threatening infections. People may be reinfected with the flu or other common respiratory viruses in one season or develop chicken pox more than once. The spectrum of disease between individuals is one of the interesting facets of the complex exposure-host-immune response to an infection. We are just 6 months into this pandemic — the learning curve has been steep and the infodemic or explosion of research and publications unprecedented. The next 6 months will tell us even more about the infectious dose, immune response, reinfection risk and how effective a vaccine will be. We will also have a better idea of the frequency and type of long-term complications after initial infection.
90265 Magazine: What went wrong in your opinion?
SD: This is the largest respiratory pandemic in over 100 years since the 1918 flu pandemic—and we were not prepared. The US has been impacted the greatest by COVID cases — with the largest number of reported cases and deaths.
I was on a podcast at the end of last year and discussed the next pandemic in the context of global changes and the under-resourcing of international agencies such as the World Health Organization and our own public health system. Globally, there is no robust integrated surveillance system with rapid diagnostic technologies in high risk areas that could quickly detect and communicate early emergence of novel viruses. These infections happen all the time — we just don’t know about it as it may occur in a remote area or it is a dead-end infection without epidemic potential.
As we continue mass encroachment on previously untouched habitats globally — we will see more of these zoonotic infections. Global warming is changing where we see these outbreaks. Air travel allows rapid exportation of these novel infections to any country. If you examine the Zika virus — for many years it was confined to Uganda, but later reached the Americas causing a devastating epidemic in Brazil.
We are seeing the same shifts with dengue outbreaks. The US was woefully unprepared for this pandemic. Our country does not have a national public health response like other nations. I believe we failed in a unified public health message with targeted strategies that made sense to our communities — which undermined trust in our public health figures. The under-resourcing of the CDC and local public health departments is a chronic problem that extends beyond just one administration. Both the CDC and local health departments do not have sufficient personnel to respond to a pandemic of this size. The CDC and WHO initially underestimated the infectiousness of this virus, which was clearly demonstrated in super-spreader events at conferences and in universities.
“The U.S. was woefully unprepared for this pandemic.”
The foundation of any epidemic response is early containment with aggressive surveillance for new cases, including testing, isolation and contact tracing. We failed early on all fronts. The CDC fumbled in the development of rapid diagnostic testing — I can not overemphasize the impact lack of testing capacity had in this country. The delay in testing capacity impacted our response locally and nationally. If you cannot rapidly identify cases, you cannot isolate and identify contacts. Efficient contact tracing was virtually non-existent in most states in the spring and by the time tracers were recruited and trained — the number of new cases was overwhelming. Lack of confidence in accurate and timely CDC data, due to the use of antiquated systems in many Public Health departments, has led to other organizations, like John Hopkins, publishing regular updates.
Finally, our hospital and long term care facility systems were woefully unprepared for this pandemic. Many healthcare workers did not have access to adequate personal protective equipment (PPE). Although the CDC has incomplete data on HCW and other occupation-based COVID cases—HCWs likely have the highest number of infections and deaths of any profession. We did learn some valuable lessons. Source control through universal masking, handwashing and physical distancing has had a significant impact on transmission of this virus.
90265 Magazine: What does the future look like with COVID19?
SD: It is likely this novel coronavirus will continue to circulate in the future like other coronaviruses. I am going to be optimistic and state vaccines will likely provide some protection against infection and severe disease, but we are awaiting this data from the vaccine trials. As COVID19 is not going away in the immediate future, Public Health departments will need to balance “flattening the curve” strategies with competing priorities, such as school and business re-openings.
Instagram: @drsuzannedonovan
Read the magazine version here: Issuu.com/90265magazine
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