Infectious diseases have played a significant role in the history of the world. COVID-19 is no exception. The virus has affected many aspects of life, including the economy, society, healthcare and specifically the practice of medicine. This note will reflect the personal thoughts of an ophthalmologist. Of note, one of the first Chinese victims of the virus was an ophthalmologist, no doubt reflecting the close face-to-face encounters. One of the pertinent unanswered questions is, “Will we be able to return to life as we knew it?”. The answer is – probably not, as outlined below.
As the world reacted to initial reports of an unusual, and often fatal, pneumonia and how to respond, the World Health Organization ultimately declared this new virus to represent a global pandemic. There were understandable initial concerns of becoming infected: patients infecting healthcare workers, healthcare workers infecting patients, and healthcare workers infecting themselves. Early mitigation efforts included social distancing, hand-washing and wearing face masks. Mask-wearing was met with some resistance in the United States whereas it seems to be more culturally accepted in Asia. Other efforts to reduce risk of infection and preserve personal protective equipment (face masks especially) included cessation of all non-urgent surgery and suspension of outpatient clinics for all but urgent cases. Cancelling non-urgent surgery was intended to make more staff and hospital beds available for COVID-19 cases. Cancelled non-urgent surgery and suspended outpatient clinics produced profound revenue deficits for hospitals and clinics, and led to untimely delays in care for numerous patients. Most healthcare organizations now realize that the cancel orders were issued too early into the pandemic, as hospital beds did not fill, patients had delayed care and revenue fell. The last measure intended to reduce transmission, reduce deaths and relieve pressure on hospitals was a lockdown. The social costs, including depression and anger toward officials, were high, though, and are discussed further below.
Testing for COVID-19 proved difficult at first. Demand for the test simply overwhelmed the supply of being able to perform the test. Laboratories struggled to keep up and some results took up to four or five days to be reported. Testing was done for anyone who was sick, especially with respiratory symptoms, loss of taste or smell, and most elderly assisted-living or nursing home occupants. Testing was (and still is) required for anyone undergoing an invasive procedure in the hospital.
The cornerstone of therapy for virtually all viral infections is a vaccine. Within a year vaccines were developed and are of four general types. There are two messenger RNA (m-RNA) vaccines (Moderna and Pfizer) which use genetically engineered m-RNA that induces antibodies against cell surface proteins. Two jabs are suggested and most recently booster jabs were recommended six months after the last jab. Since the m-RNA does not enter the cell nucleus, there is no possibility of its causing an infection or being incorporated into the patient’s DNA. The other major category of vaccines is a vector vaccine in which a portion of the genetic material from COVID-19 is incorporated into a different type of virus (called a viral vector) which then produces antibodies against cell surface proteins. As with the m-RNA vaccines it is not possible to develop a COVID-19 infection following vaccination and the genetic material is not incorporated into the patient’s DNA. Examples of this type of vaccine are the Astra-Zeneca, Johnson and Johnson, and Sputnik vaccines. These are one-shot vaccines but booster shots have also been recommended. The third type is termed a whole virus vaccine, in which a weakened or inactivated COVID-19 virus is injected. This vaccine cannot infect cells or replicate. The last type of vaccine is a protein subunit type (Novavax), in which a purified segment of the surface proteins from the COVID-19 virus is given to induce an immunologic response. It is not possible for this vaccine to replicate or cause COVID-19. The bottom line, and my personal opinion, is that vaccines are necessary and useful.
Conjunctivitis and COVID-19
While coughing, fever and difficulty breathing are common symptoms of the illness, a case study involving an Edmonton woman published in the Canadian Journal of Ophthalmology has determined that conjunctivitis and keratoconjunctivitis can also be primary symptoms. The finding makes eye exams more complicated and risky for ophthalmologists and staff. Photo: iStock
When patients presented for outpatient evaluation, they were asked a series of questions about potential exposure to COVID-19 and symptoms of infection. Digital temperatures were also taken but this was later dropped as it did not seem to be contributory. Everything including check-in lines and waiting rooms were “socially distanced”. For eye examinations, a special shield was placed on the slit lamp, a device that has a face-to-face distance of approximately 15 centimetres. Examination of the fundus is even closer. Examination rooms are thoroughly disinfected between patients, which by necessity reduced patient numbers in each clinic. Since COVID-19 is thought to be spread via respiratory droplets, otolaryngologists, dentists and oral surgeons are also at higher risk of infection. For anyone admitted to the hospital (for any reason) or undergoing any invasive procedure, COVID-19 testing is routine, even at the time of this writing. The use of telemedicine has proven to be a viable option for many specialties and patient satisfaction with this method is very high. The Singapore healthcare system is a leader in the use of telemedicine. Currently both patients and staff wear masks, and vaccines have been mandated for staff.
In conclusion, much has been written about the medical aspects of COVID-19 and the mitigation efforts, but the social aspects, in my opinion, have been under-reported. Both ends of the age spectrum have been affected although in different ways. Some preverbal and early verbal children now have difficulty with the pronunciation of certain sounds, presumably because the children could not see the facial dynamics of word formation from masked adults. Children have also clearly fallen behind in class, as demonstrated on standardised testing, which may be attributed to “distance learning”.
Conceivably the mitigation efforts could shape how children could interact with others because parents may seek out other parents with shared beliefs on COVID-19. For example, parents in favour of masking may not or discourage letting their children play with unmasked children. In another example, if only one child is masked in a larger group of unmasked children, the masked child then becomes “isolated” and, in a sense, an outcast.
Severe staff shortages during the pandemic
With the increasing number of COVID-19 cases in Mumbai, city hospitals are faced with a shortage of staff, as doctors, nurses and other healthcare workers across public and private facilities become infected with the coronavirus. Hospitals are reporting a staff shortage of anywhere between 5% and 30%. While many countries have reported staffing difficulties, India’s problem has been exacerbated by a dispute between trainee doctors and the government, which has delayed roughly 45,000 recent medical graduates from joining the workforce. Photo: ZUMA Press Inc / Alamy Stock Photo
Also, many children wear their masks incorrectly, thereby defeating the original purpose of the mask anyway.
At the other end of age spectrum, the lockdown and the accompanying social isolation had disproportionate effects on the elderly. The lack of social interactions seemed to hasten cognitive impairment issues.
The workforce, especially the female workforce, was also affected by COVID-19 and mitigation efforts. During the height of the pandemic, schools and daycare centres were closed. Women were disproportionately affected in that they would have to stay home with their children. Many of these affected workers have elected not to return to their former jobs, contributing to the marked worker shortage and attendant supply chain disruptions affecting consumers and producers.
At the present time, vaccine mandates are being enforced by healthcare systems, with job termination as the ultimate outcome for non-compliance. Once again, this policy has disproportionately affected female nurses. Over the past few years, healthcare systems have been struggling to maintain staffing levels. The vaccine mandates and their subsequent unintended side effects only exacerbate an already tenuous situation. It is doubtful that we can or will eliminate COVID-19. It will be interesting to see how history judges our efforts to deal with COVID-19 and the collateral damage associated with it.
DR JAMES GARRITY
Dr James Garrity is an ophthalmologist at Mayo Clinic in Minnesota, USA.
He is board certified in ophthalmology from the American Board of Ophthalmology and vastly experienced in treating conditions like cataracts, Graves’ ophthalmopathy and orbital fracture.
Dr Garrity is an honorary member of the American Society of Ophthalmic Plastic and Reconstructive Surgery, a member of the Clinical Practice Committee in the Department of Ophthalmology and of the Committee on Examination Props in the American Board of Ophthalmology.
Dr Garrity received his medical degree from University of Minnesota Medical School. He completed his residency in ophthalmology from Mayo Graduate School of Medicine, Mayo Clinic College of Medicine, and fellowship in neuro-ophthalmology and orbital surgery from Allegheny General Hospital, University of Pittsburgh.