We welcome our readers to the October issue of the VOICE, we hope again packed with interesting and relevant information for patients, colleagues, and any other party interested in reproductive sciences and clinical infertility. October is ...
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CHR's front desk will follow this process to screen for COVID-19. Figure adapted from Northwell Network Emergency Management.
[This article deals with a rapidly developing situation. It was written by Norbert Gleicher, MD, on March 12, 2020 and published on March 13, 2020. Our COVID-19 safety precautions have evolved with emergence of new guidelines and evidence. For our current safety procedures, please see this post. For further updates and links to other COVID-related articles, please scroll down to the bottom.]
CHR's Dr. Norbert Gleicher explains the steps we are taking to protect our fertility patients, staff and community.
The novel CORONA virus appears to have been causing a disease, widely referred to as COVID-19, in humans since December 2019 (first cases were reported in the Chinese city of Wuhan). Its spread around the world has been fast and furious, as the daily onslaught of news reports well documents. Greatly increased connectivity in the world creates, however, often wrongly perceived time lines because, while speed of spread of the virus may, indeed, be enhanced by exponential growth in worldwide travel, increased interconnectivity via social media may also enhance the speed of available information and, unfortunately, as is now already well recognized, the spread of “fake news.” Here we, therefore, are attempting to be as transparent as possible in describing how we, as of this moment, perceive the CORONA crisis and what actions the CHR has taken to protect our patients and staff, while continuing the center’s medical services basically unchanged. Should there be changes and/or updates, we, of course, will communicate them as quickly as possible.
Not only within the New York City but worldwide, the COVID-19 is still an unknown entity. It appears to be highly contagious but how contagious it is, is still unknown. It appears to have significant mortality, especially in older and/or immune-compromised individuals, but whether the mortality rate is under 1% (which would make it similar to influenza mortality rate (the “flu”) or over 3%, as suggested by some outcome reports, is also unknown, even though those, of course, are all crucially important data. Some data suggest that in older individuals and immune-compromised patients, the mortality may exceed 10%.
The reason for all of this ignorance is not necessarily incompetence of the relevant government authorities, though it smacked of incompetence when the U.S. government initially sent out faulty diagnostic testing batches. But one, at least so far, cannot blame the governments for its handling of the COVID-19 crisis because the speed of spread of this virus over almost all continents (except for Antarctica) has been really unprecedented in recent time.
The response from governments has been epidemiologic, in that most governments have been attempting to minimize spread through person-to-person contacts. Such an approach, however, can only slow down further spread of the virus into communities; it cannot stop it or cure the already existing disease. To do that, what is needed are 3 essential new contributions:
A freely available and affordable diagnostic test has been a pipe dream so far but, as these words are written, New York’s governor promised a quick and substantial scaling up of availability and one of the two biggest commercial laboratories announced availability of a commercial test in NYC within days, though we do not yet have further details on insurance coverage, costs, turn-around time, etc.
Availability of reliable diagnostic testing, alone, will improve the COVID-19 situation significantly, as we now will have reliable numerators and denominators in determining the severity of this viral disease in different locales. So-far published mortality rates have been highly inaccurate because they used as numerator only the sickest patients since, in the absence of reliable diagnostic tests, milder cases were often considered the “flu.” This represents an interesting analogy to a subject frequently discussed in these pages: correct IVF outcome reporting by intent-to-treat (i.e., IVF cycle start) or by embryo transfer which, of course, excludes all the patients who never made it to embryo transfer from the numerator. Here, the calculation is similar: By reporting only the most severe cases of COVID-19 reaching hospital care, mortality rates were highly inflated (just as pregnancy and live birth rates are highly inflated in IVF if only patients are considered who made it to embryo transfer). With increased capabilities to test numerators and denominators more accurately, the mortality rate of COVID-19 can be expected to significantly decline.
Public health experts who have attempted to extract mortality rates from regions where testing was broader than in the U.S. have concluded that the virus, likely, does not cause death in more than 1% of afflicted individuals. This, however, does not mean that mortality is not higher in older and immune-compromised women and men, though men appear almost twice as susceptible to the virus than women. Interestingly, children appear least susceptible, though have been reported at times to be asymptomatic but contagious carriers for the virus.
One additional parameter is important in assessing the virulence of a new virus and that is the so-called R0-factor, which defines how contagious a virus is (i.e., to how many people every infected person can be expected to pass the disease on). The R0 for COVID-19, currently, has been reported around 2.2, but this measure can also be expected to decline once accurate population testing expands the denominator. But just to put the COVID-19 R0 into context: The R0 for measles is 12.0-18.0 and for influenza (the “flu”) it is, depending on strain, 1.2-1.6. In other words, it increasingly looks like the current COVID-19 epidemic may not be very different from a bad flu season. One then has really to ask, why are we treating it like Ebola has spread all over the world, which until very recently had a mortality rate in the 50-60% range for every infected person?
In formulating a maximally protective policy for patients as well as staff, CHR basically followed policies formulated by CDC, state and city governments and hospitals. We are especially grateful to the Northwell Network Emergency Management which distributed excellent graphic materials, we are drawing on in Figures 1 & 2 to demonstrate how CHR’s front desk and clinical coordinators, respectively, will manage risk assessments.
What is most important to point out is that, barring extraordinary circumstances, CHR will remain fully functional and available as a fertility center for patient from all over the world. CHR fully recognizes time limitations, especially older patients and women with low functional ovarian reserve are under, and is fully committed to continuing all of CHR’s routine treatments at standard pace.
At the same time, we also have to call upon our patients’ help and collaboration: This includes everybody’s willingness to wear surgical masks (which CHR provides) when called upon, and to respect access restrictions to certain areas at the center. While most hospital restrict all access to children and teenagers up to age 18, CHR is restricting access only up to age 16. We, however, expect everybody with a temperature of 100°F or above to refrain from entering the center, irrespective of the presumed cause of the elevated temperature. Instead, we request that patients with fever call CHR’s front desk at (1) 212-994-4400 and report the elevated temp to a staff person. This message will then automatically be passed on to the patient’s physician who will contact the patient by telephone.
CHR's clinical coordinators will follow this process for COVID-19 precautions. Figure adapted from Northwell Network Emergency Management.
The same restrictions also apply to CHR staff. We, therefore, do expect possible staffing shortages since every employee with an elevated temperature and/or other symptoms possibly suggestive of COVID-19 will be prohibited from coming to work. With accurate COVID-19 testing becoming available, it should, however, become quickly possible to determine whether anybody is infected or not. In short, together we will make it through these “crazy” times. Look for further answers regarding COVID-19 in the section of this newsletter that answers patient questions. Stay healthy!
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
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