By Vincent P. Hsu ’95
As an epidemiologist, I should have been prepared for COVID-19. But no amount of training could have prepared me for what was about to happen.
In March 2020, the coming of COVID-19 infected patients were inevitable, and our hospital was expecting their arrival. Our first admission was a returning female tourist who had gone on a Nile River cruise. The second one was linked to a known COVID-19 outbreak at a local church. Initially, these patients came in only in a small trickle, mostly related to travel or as part of a known outbreak. As the days progressed, we also began to see local cases that were part of Orlando’s tourist industry — a hotel receptionist, an Uber driver. Soon enough, admissions came in without any known contact to a previous positive or link to travel. Occasionally entire families would be admitted together. Community spread was here.
From a career perspective, I have the training and skills to handle epidemics. Although born and raised in the United States, my family moved to Taiwan when I was 11. The experiences of living in Asia coupled with my premed interests at Pacific Union College led me to an interest in public health and epidemiology during medical school at Loma Linda University, followed by an internal medicine residency in Portland, infectious disease fellowship at USC, and master’s degree in public health at UCLA. By that time, I knew I wanted to join the Centers for Disease Control and Prevention as an Epidemic Intelligence Service (EIS) officer, a fancy name for disease detectives that identify new or re-emerging infectious diseases to protect public health. Accomplishments this CDC program contributed to include the elimination of smallpox, polio eradication, and managing Ebola outbreaks. As an EIS officer from 2001 to 2003, I was fortunate to have participated in the response to the Washington D.C. anthrax attacks, West Nile Virus outbreaks, and the first SARS outbreak in Asia. After moving to Orlando to work at Florida Hospital in 2004 (now known as AdventHealth), I became situated as the hospital epidemiologist and as a faculty member in the internal medicine residency program. Most of what I do in normal day-to-day activities focuses on management and prevention of “normal” health care-associated infections, such as Clostridiodes difficile, which causes a severe gastrointestinal illness, or Legionellosis, a pneumonia that is transmitted through contaminated plumbing systems. During my years at AdventHealth, I have led hospital efforts on protecting patients and employees on larger community outbreaks, such as the H1N1 influenza pandemic and Zika outbreaks. But those paled in comparison with the issues that COVID-19 brought to us.
One fundamental principle all epidemiologists have learned is that to be effective in stopping disease spread, one has to recognize what the disease looks like and how it is transmitted. In that sense, COVID-19 was a nightmare. We now know that many unusual symptoms, such as loss of taste or gastrointestinal symptoms, occur without typical symptoms, such as fever or shortness of breath. Patients admitted with stroke, in diabetic ketoacidosis, or those that coded within the hospital were later found to have COVID-19, which contributed to their condition. Worse yet, many infected patients had no symptoms. Other issues still being debated include the relative contribution of airborne (small virus-containing particles that circulate in the air) versus droplet (larger fluid particles that fall to the ground) spread that contributes to infection, which is a primary reason that universal mask wearing is encouraged. How can you stop a disease when it is not easily recognized?
Epidemiologists are often asked to predict what to expect as an outbreak spreads so that we appropriately prepare. As was the case with this, we are often wrong. After seeing the carnage that the pandemic wrecked on Italy, Spain, and initially New York City, attention focused locally. Model after model shown indicated that Florida could easily be next with admissions that would overflow our hospitals. Our pandemic response team focused on obtaining ventilators, additional staff, and additional PPE and discussed overflow sites with now-empty tourist hotels. Hundreds of ventilators were ordered and arrived in our warehouse for anticipated use. Physicians were anticipated to be in huge demand, and courses were being set up to train family physicians and cardiologists on how to run ventilators. Huge shortages in N95 respirators were predicted, and our supply chain sourced many leads that turned out to be dead ends. As it turned out, at least initially, those predictions never materialized, thanks to policies that required staying at home and social distancing. We reopened at an earlier stage than expected for elective surgeries and routine care. Although it is always better to over- rather than underprepare, I wish our forecasts could have been more accurate. Thus, figuring out what happens next is a murky science.
“Never let a good crisis go to waste,” stated Winston Churchill, and the COVID-19 pandemic exemplifies that. I have learned fundamental lessons during this crisis that were not necessarily taught during training. First, expect the unexpected and embrace the unknowns. As mentioned above, there was so much unknown about the behavior of this virus and in the world’s response to this virus that made accurate planning obsolete. You must plan but be prepared to adjust quickly and in ways you can’t imagine. Second, be prepared to change or readjust course — quickly. It’s difficult for a large health care system to change course on a dime. As we learned more about the disease, even having to do an about face was necessary. At the onset of the pandemic, I touted the CDC’s initial guidance that masks were not necessary for routine care. I walked the halls, asking providers to remove their masks for non-COVID care and to conserve supplies. By April, the agency stated that masks should be worn by all health care providers, followed by mask-wearing for all patients. Although I had to swallow my pride to face these same providers by now asking them to wear a mask, it was something I needed to do as the guidance changed. Lastly, to effectively respond to a pandemic, an epidemiologist is needed, but I am just one of a team of dedicated health care professionals at AdventHealth. I am blessed to be part of an organization that has the leadership that uses my skills and expertise to effectively respond to this crisis. I was asked early on to lead as the scientific expert, the source of “truth” for our C-suite decision makers, who made the safety of our employees and the outcomes of our patients the priority no matter what the financial costs. We have a top-notch group of clinicians that created protocols on the fly and effectively innovated to create virtual communication between COVID-19 patients and their loved ones who were unable to visit. I cannot overstate the importance of great teamwork and leadership in a time of crisis.
Unfortunately, we remain in the middle of the pandemic, and the lessons of COVID-19 are still being learned. As I am writing this article, we are now in the middle of another wave in Florida with a record number of newly diagnosed cases. Although we now have experience treating thousands of COVID-19 patients, this wave has its own set of new challenges — an overflowing census many times our peak for the first wave, shortages in getting necessary testing for patients, defiant visitors who refuse to wear a mask, and staffing shortages due to exposure and infection with COVID-19. If you asked me to predict at the outset how unprepared the United States would be in handling this crisis and that mask wearing would trigger a political culture war, I would have laughed. Who could have predicted this? Don’t get me wrong — I remain thankful for the training I received, and it has made me a better epidemiologist. But formal training can only take you so far. As long as we continue to expect the unexpected, adapt quickly to changing conditions, learn on the fly, and maintain team dedication, we will get through this — and we’ll emerge out of this pandemic stronger as a result.
Dr. Hsu is an infectious disease physician who serves as Executive Director for Infection Prevention and Assistant Program Director for the internal medicine residency at AdventHealth in Orlando, Florida.