key: cord-0735403-sikgk58i authors: Breevoort, Arnar; Carosso, Giovanni A.; Mostajo-Radji, Mohammed A. title: High-altitude populations need special considerations for COVID-19 date: 2020-07-01 journal: Nat Commun DOI: 10.1038/s41467-020-17131-6 sha: 603a2a2681ceb33e70dca8c77adbc83327f7e5be doc_id: 735403 cord_uid: sikgk58i The atmospheric pressure that decreases with altitude affects lung physiology. However, these changes in physiology are not usually considered in ventilator design and testing. We argue that high altitude human populations require special attention to access the international supply of ventilators. aside traditional international diplomatic conventions. Thus far, 54 countries have placed restrictions on the export of ICU ventilators 7 . Moreover, on several occasions countries have confiscated other countries' ventilators during transit through their borders, which the press has referred to as "modern-day piracy" 8 . Commercial ICU ventilators are largely designed and tested near sea level. Yet, with altitude there is a progressive reduction in barometric pressure and subsequently in oxygen pressure leading to major physiological adaptations in the lungs 9 , which are not usually considered in ventilator quality tests. Limited studies have compared the accuracy in tidal volume delivery of commercial ventilators at varying altitude and were all in the context of aeromedical evacuation 10, 11 . In these tests, the majority of commercial ventilators failed at high altitude, delivering tidal volumes with up to 40% error from the set volume 10 . Importantly, technical errors and canceled ventilation were frequently reported 10 . Long-term care of critically ill patients, including COVID-19positive patients, at high altitude is therefore unfeasible with the majority of these ventilators and there is a general lack of ventilators specialized for the 140 million people living at higher elevations. History shows that a failure to contain a pandemic locally can lead to increased viral spread, and an increase in the global overall morbidity and mortality of a virus. The 1918 H1N1 pandemic and the 2019 SARS-COV2 pandemic are similar in which both the H1N1 and SARS-CoV-2 virus are antigenically novel, transferred zoonotically to humans, have adapted to the human body and are a cause of severe respiratory illness 12 . After the initial failure to contain the spread of H1N1 in 1918, a second more pathogenic wave swept across the world, accounting for the majority of casualties related to H1N1 12 . This second wave particularly affected ill-prepared populations which then became new sources of viral spread. Adequate containment and treatment of a virus is paramount to prevent its spread and hamper potential increase in pathogenicity. It is therefore in the interest of the international community as a whole that each nation is able to strongly respond to COVID-19. Geographically, several high-altitude countries are located and well connected to other nations with high population density. Bolivia, for example, being at the center of South America, neighbors five countries, including Brazil, the most populated country in the region. Having one of the poorest healthcare systems in the Americas, it is common for Bolivians to search for medical treatment in neighboring countries 13 . Consequently, failure to contain and treat the virus in Bolivia would hamper the efforts of other South American countries. Similarly, failure to contain the virus in Ethiopia, the second most populated country in Africa, would negatively affect the treatment efforts of the region. When international collaboration ensures that less-affluent nations are able to respond strongly locally, COVID-19 can be contained internationally. The West-African Ebola outbreak in 2014 met a strong international response spearheaded by the United States and the World Health Organization (WHO) resulting in the end of the internationally concerning public health emergency regarding Ebola in early 2016 14 . The further spread of COVID-19 can be halted under international collaboration and the understanding that success is dependent on the containment of COVID-19 in all countries, including economically challenged countries 15 . However, this success relies on two factors. Firstly, equipment to adequately treat and test for COVID-19 should be developed and made available that matches the geographical, economic, and educational challenges that are relevant to these countries. This is not limited to the development of ICU ventilators that are functional at higher elevation but can also be aimed at improving testing methods for COVID-19 at lower cost and easy scalability to a relatively small population of trained laboratorians. Secondly, although it is inherent that each country aims to acquire the necessary amount of equipment required for the treatment and prevention of COVID-19, lessaffluent countries should receive international support in their efforts to obtain the equipment and tests that are necessary and relevant to their response to COVID-19. Implementation of these two factors will both improve the epidemiological response of economically and geographically challenged countries to COVID-19 in a humanitarian way and reduce the chance that these countries might become centers of new SARS-COV-2 outbreaks to neighboring countries. 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Ebola Situation Report -30 Scientists as non-state actors of public diplomacy Correspondence and requests for materials should be addressed to M.A.M.-R.Reprints and permission information is available at http://www.nature.com/reprintsPublisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons license, unless indicated otherwise in a credit line to the material. 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