Before the Flood

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A ripple led to a wave, and the wave led to a tsunami that ultimately landed, somewhat quietly, on the shores of Washington State. Our healthcare teams didn’t know then that cases introduced from outside the United States would lead to silent transmission and spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into our communities—out of sight and out of our control. We should have been mobilizing as a nation but were lulled by quarantines and travel restrictions, as policy makers called the virus a hoax, and to articles falsely claiming that the virus was an escaped bioterrorism agent. Americans were more worried about politics than about biology. Like any virus, SARS-CoV-2 is engineered by nature, not in a laboratory, to spread easily and undetected—a particle so small and yet able to bring a nation to its knees. Colleagues in Seattle at the University of Washington, University of Washington Medicine, Fred Hutchinson Cancer Research Center (Fred Hutch), Seattle Cancer Care Alliance, Seattle Children’s, and the Brotman-Baty Institute were not unprepared. Based on results from a large community surveillance study (the Seattle Flu Study) previously organized to track influenza and other respiratory viruses, SARS-CoV-2 testing was rapidly implemented to detect early cases: this ultimately identified genetic evidence of community transmission in Washington State. Statisticians and modelers had warned of worldwide spread and voiced ominous predictions. In preparation, our virology laboratory had been working diligently since January to develop an assay to detect the virus. We considered the effect of the global situation on our healthcare systems, we prepared for catastrophe, and administrators heeded our warnings. Despite all we knew and prepared for, unforeseen weaknesses in our nation’s preparedness hamstrung our responsiveness. Regulatory frameworks delayed community access to testing. Weak links in the supply chain limited our ability to procure additional sanitation supplies and personal protective equipment (PPE). Global supplies were sapped by early outbreaks and disruption of production outside the United States. Most importantly, restrictive testing criteria and limited capacity crippled our ability to detect and follow local cases and epidemiologic patterns. These challenges gave the virus a chance to establish a beachhead. In fact, when astute clinicians [1] and our surveillance systems detected the first community-acquired cases, genomic analysis and predictions from Fred Hutch scientists told us we were already behind the epidemic curve. SARS-CoV-2 began spreading during respiratory virus season, when mild cases were not recognized. Many with the illness likely worked in our communities because working when sick is tacitly expected in our culture. It is unclear how much asymptomatic shedding played a role in spread, but without awareness of local transmission, we couldn’t encourage important steps such as staying home when sick, telework, and social distancing. Furthermore, many employees lack paid sick leave or work multiple jobs. From custodians to baristas, many couldn’t work from their couches and still get paid [2]. This says nothing of those needing child or elder care for their families. Still, our science experts and savvy community providers gave us a chance. We learned from our colleagues in China, Iran, Italy, South Korea, and elsewhere that older adults and those with chronic illnesses are most vulnerable. Among these groups, many who get infected will become ill, and many will die. We also learned about the inherent limitations of any healthcare system—even sophisticated, well-resourced ones—to manage an influx of acutely ill patients. Our systems are not equipped to withstand a flood. Nonetheless, our hospital staffs learned much in the early days of the COVID-19 pandemic. We worked through challenges in screening, triage, and PPE availability. We moved quickly from airborne precautions to droplet and contact precautions, recommended by the World Health Organization [3] and Canada [4] among others, to reserve N-95 respirators and personal air-purifying respirator hoods for critically ill patients and those requiring high-risk aerosol generating procedures. Incident command centers at our institutions helped us to streamline communication and address emergent problems quickly. There were also logistical challenges. Guideline shifts led to confusion in the early days, resupply timelines and strategies for testing were unclear, and messaging to employees wasn’t always synchronized between institutions. Version control for documents was nearly impossible as guidelines, both external and internal, morphed hourly. Critical supplies were depleted; some even disappeared from the shelves. Other hospitals have seen similar issues. Moving to remote work was logistically challenging in the clinical arena. Public health infrastructures stretched thin by underfunding had to address multiple new clusters of transmission, including a nursing home at the epicenter of the local outbreak. Within days, all of us realized that the work ahead would be daunting. Yet, we persisted and found creative solutions. Colleagues developed drive-through employee and patient testing stations, emergency room assessment tools, structures and systems for community clinic screening, and guidelines for testing low- and high-risk patients in our hospitals. We efficiently discussed emerging issues and problems as a group, working to limit visitors and teams entering patient rooms, and sharing stocks of critical supplies. We became nimble, moving quickly from ideas to application and practice. Volunteer workforces and nonclinical staff stepped up to support areas with critical needs. Educating hospital staff, communities, and the media has been part of the effort to limit transmission chains, including keeping individuals with mild symptoms at home and out of emergency rooms and clinics. Many of us are following best practices by meeting virtually to share and disseminate knowledge across our institutions. Collaborative research ideas and protocols are abundant. Importantly, the city and its leaders listened to experts, and we moved to change how we live our lives. We also need to speak of Seattle in this time of coronavirus, a take on Love in the Time of Cholera, Gabriel Garcia Marquez’s seminal book of magical realism, because we have so much to appreciate. Our healthcare community and our commitment to public health are strong at their core. We have been awed by the sheer tenacity and grit of our frontline nursing and medical staff who have been at our patients’ bedsides, staffed our clinics and vital sign stations and saddened by our elders in long-term care facilities who have borne the brunt of this outbreak. Research teams volunteered to screen patients, and colleagues went into households and nursing homes, areas of ongoing transmission, to help address problems directly. We rolled up our sleeves, washed our hands, and confronted this virus head-on. Seattle embraced this spirit and followed suit, staying home, donating PPE, and sending food and support to frontline healthcare workers. Not just our community, but all communities must be more vigilant. In a spirit of altruism mixed with science, our centers have come together. We always loved Seattle and our medical community, but the crucible of COVID-19 has strengthened our comradery and belief in our colleagues and extended our love of the work we do and the people we serve. Despite our efforts, we will see additional patients succumb to this disease. We expect that some of us will develop COVID-19, and others will be admitted to the very hospitals we support. Tragically, many will mourn a neighbor, a friend, a family member, or one of our own, as we have already [5]. These facts strengthen our resolve. Reports from China and Italy are sobering, leaving us to ponder worst-case scenarios f

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