Never Let a Good Crisis Go to Waste

A scourge of respiratory infections kills millions of people across the world every year. The coronavirus disease 2019 (COVID-19) pandemic has caused tremendous suffering and mortality, both directly and indirectly as a result of the resulting economic slowdown. However, the “usual” highly incident respiratory viruses, including rhinovirus, enterovirus, coronavirus, respiratory syncytial virus, influenza and parainfluenza viruses, and adenovirus, are also responsible for a huge toll of morbidity, mortality, and lost economic productivity.

Human rhinovirus may be the most common cause of community-acquired pneumonia (CAP) requiring hospital admission¹ and respiratory viruses overall are responsible for more than half of all CAP in which an etiologic agent can be determined,¹ and one third of severe pneumonias.² Given the 13% 30-day mortality among the 1.6 million CAP hospitalizations per year in the United States,³ viral pneumonia causes nearly 70,000 deaths per year. Viral infections also cause approximately 40% of COPD exacerbations⁴ and are thus responsible for approximately 400,000 of the one million annual COPD hospitalizations,⁵ of which more than 8%⁶ (32,000) are fatal. Influenza, even without pneumonia, often results in exacerbations of underlying comorbidities, explaining the Centers for Disease Control and Prevention estimate of approximately 40,000 average annual influenza deaths. Less appreciated is the fact that “uncomplicated” viral respiratory infections can activate thrombotic pathways, leading to stroke, myocardial infarction, exacerbation of heart failure, and other cardiovascular events, adding to the morbidity and mortality associated with viral respiratory infections. Based on these data, a conservative estimate is that respiratory viruses cause at least 150,000 deaths per year in the United States. The incidence of CAP⁷ and the prevalence of COPD⁸ in the rest of the world are similar to that seen in the United States, suggesting that the global mortality associated with highly incident respiratory viruses is over 3 million per year. The additional impact on antibiotic resistance due to inappropriate antibiotic treatment as well as appropriate treatment of secondary bacterial infections is likely substantial.

Of course, the most common clinical syndrome associated with these viruses is the “common cold,” generally perceived as a mild illness with little morbidity. Furthermore, the impact is seen throughout the year and is the “usual state.” Likely for these reasons, the burden of morbidity and mortality associated with the highly incident respiratory viruses does not receive adequate attention from medical professionals, public health officials, and the public. Although much work is ongoing to develop compounds to treat or prevent many of these infections, there has been little success, and, other than influenza vaccine, whose effectiveness can greatly vary, vaccines are not available.

Knowledge and experience gained during the current COVID-19 pandemic provide an opportunity to decrease the morbidity and mortality associated with highly incident respiratory viruses: their airborne human-to-human transmission shows the same pattern as COVID-19, highlighting the importance of physical distancing and mask wearing to decrease the forward spread. This is evidenced by the very low incidence of influenza, influenza-like illness, and respiratory syncytial virus reported from numerous locations around the world this year, almost surely explained by physical distancing and mask wearing. Numerous studies demonstrate correlation of COVID-19 rates with physical distancing measures, and other studies have demonstrated the effectiveness of mask use in preventing respiratory virus transmission.

A year ago, it would have been unthinkable to call for patients with just a “cold” to use hand sanitizer, to isolate, or to wear a mask while in public. However, COVID-19 has made mask wearing acceptable in most countries and has been widely adopted. Similarly, there has been widespread acceptance of the necessity of isolating people with proven severe acute respiratory syndrome coronavirus 2 infection or quarantining those with documented exposure. It is not a stretch to believe that the public could be convinced of the importance of commonsense efforts to reduce respiratory viral transmission with appropriate education and advocacy. In fact, in some Asian countries (eg, Japan and China), mask wearing when suffering from a respiratory infection has been considered a common courtesy for decades.

It has been said that one should “never let a good crisis go to waste.” The COVID-19 pandemic provides the opportunity to change the perception of respiratory viral infections as benign, self-limited illnesses that do not require efforts to prevent their transmission. With an appropriate public health campaign, knowledge, attitudes, and ultimately, human behaviors can be changed.

Of course, it would be folly to suggest that businesses should be shut down and schools should be kept closed to control highly incident viral respiratory infections. Nor is it likely to be accepted that anyone with a cold should be prevented from going to school or work, or that anyone exposed to such a person should be quarantined. However, our experience with COVID-19 strongly suggests that less drastic interventions targeting people with active respiratory infection, including physical distancing (not isolation), mask wearing (eg, indoors and on public transportation), and perhaps more frequent use of hand sanitizers and hand washing would decrease viral transmission.

Accordingly, we have the following proposals for consideration by the clinical and public health communities:

• 1.Public health, respiratory, and infectious disease experts should collaborate on research examining the effectiveness of interventions such as mask-wearing, physical distancing, and hand washing/hand sanitizers in preventing transmission of respiratory viruses in real-life settings. Subsequent research will need to examine the potential acceptance of the various interventions found to have benefit. Both effectiveness and acceptability will likely vary among different countries and socioeconomic and cultural settings. What works or is accepted in urban high-resource areas might not work or be acceptable or affordable in rural or low-resource areas. Research will need to address the expected variability and should find suitable solutions.
• 2.Funding agencies should recognize the tremendous societal benefit of such research, despite it not being “mechanistic” or “cutting edge.” Specific funding lines should be created to foster these areas of investigation.
• 3.Once the optimum interventions are established, media campaigns will be needed to educate the public on their benefits and, similar to anti-smoking campaigns, modify attitudes and behaviors. These could include advocacy, employing survivors of severe respiratory infections. The initial campaigns themselves will need to be examined critically to assess impact and allow modification as needed.

The response to COVID-19 has demonstrated that simple interventions can slow community spread of viral respiratory disease and that large populations can be motivated to rapidly change behavior when convinced of the need. It should be possible to achieve the same goals with respect to highly incident respiratory viruses, and in doing so, reduce on a global level their associated morbidity, mortality, and lost economic productivity.