Coronavirus (COVID-19) – Fighting Fear with Facts

[Updated as of March 16, 2020]

As the world continues to mediate the spread of the new coronavirus (COVID-19) not only do we have to protect the most frail in our community, but we also have to protect ourselves from the mis-information associated with the new virus.  News and social media bring us a range of COVID-19 opinions.  These opinions range from coronavirus hysteria to coronavirus denial – neither is appropriate or accurate.  In his address to the Munich Security Conference on Feb 15, 2020, World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus stated:

“… we’re not just fighting an epidemic; we’re fighting an infodemic …
This is a time for facts, not fear.
This is a time for rationality, not rumors.” (Reference)

Nothing is more true, so in this post I’ll try to present a science based review of the COVID-19 virus and answer some pertinent questions. 

To be sure this virus is new and scientists throughout the world are working aggressively to learn more and more about COVID-19 and possible treatment and prevention strategies.  But by the same token we have a lot of good information today and it’s important that these facts are widely known so that you can calmly and rationally prepare, while not unnecessarily upending your life.  I’ve tried to compile here the best evidence-based research I could find to help you navigate through the next little while with solid information.  I have tried to reference my comments so you can see that this information comes from credible sources and even go to the primary source to dig deeper into what I have found.  I will try to update this information as updates become available.  Also, this blog is long and a bit dense as I take some space to define terms that are usually limited to virologists and epidemiologists.  

What is COVID-19?

COVID-19 is the name of a respiratory illness that is caused by a new strain of coronavirus (SARS-coV-2).  COVID-19 was first reported in Wuhan, China on December 31, 2019.  Genetic evaluation of virus samples indicate that the virus that causes COVID-19 may have been introduced to humans around mid-November of 2019.  Chinese public health officials first noticed COVID-19 as an outbreak, but now the outbreak has morphed into an epidemic, and in its March 11th Virtual Press Conference the World Health Organization (WHO) declared COVID-19 a pandemic (https://www.who.int/docs/default-source/coronaviruse/transcripts/who-audio-emergencies-coronavirus-press-conference-full-and-final-11mar2020.pdf?sfvrsn=cb432bb3_2). 

Before we move on let’s level set and review some definitions:

• Outbreak.  A outbreak is when a disease occurs in a community in numbers that are greater than expected.
• Epidemic. An epidemic is an outbreak that spreads rapidly to many people.
• Pandemic. A pandemic is an epidemic of global proportions that has become widespread across several countries or continents.

What is a Coronaviruse?

In actuality there are many types of viruses that we refer to as Coronaviruses.  We lump all of these viruses together in one “family” of viruses because despite their differences they all have these very characteristic spikes on their surfaces that look like crowns (“corona” in Latin means crown).

Coronaviruses can cause very mild (illness like the common cold, or more severe illness like we’ve seen with SARS (Severe Acute Respiratory Syndrome) or MERS (Middle East Respiratory Syndrome).  Now we ad  COVID-19 to the list of diseases that result from a type of coronavirus.

How many people have COVID-19?

The number of COVID-19 cases and deaths are increasing every day.  Figuring out how many people have been exposed to the virus that causes COVID-19 is difficult because we are just ramping up production laboratory tests.  There are a few trackers that you can look at to follow the number of cases and deaths world wide.  There are two that we suggest.  The Johns Hopkin’s School of Public Health is tracking COVID-19 cases.  You can access their tracker by clicking here – global Coronavirus COVID-19 tracker .  The WHO also is tracking cases and deaths and you can access the WHO Situation Dashboard using this link. 

As of March 16, 2020, the WHO reports that there are 168,019 confirmed cases with 6,610 COVID-19 related deaths (a 3.9% case mortality rate).  The largest number of confirmed cases are in China (81,077 cases) and the rate of new daily cases in China is slowing down.  Italy (24,747 cases), Iran (14,991 cases) and South Korea (8326 cases) have the next highest number of COVID-19 cases and in these countries the rate of new cases has not yet started to decline.  In the US, there have been 1678 confirmed cases with 41 related deaths (a case morbidity rate of 2.4%).

In the US the number of new cases will continue to rise and very likely there will be a spike in the number of new cases as production laboratory testing becomes available and we test more and more potential cases of COVID-19. 

How is COVID-19 spread?

It is now clear that COVID-19 is being transmitted by human-to-human contact. Transmission is mainly through respiratory droplets and close contact – similar to how influenza (the flu) is spread. The CDC defines close contact as being within 6 feet or within a room or care area for a prolonged period without personal protective equipment OR having direct contact with secretions of a person with COVID-19 infection. There is some evidence that fecal-oral or blood transmission may be possible, even when COVID-19 is not detected in oral swabs (Reference). Investigation is underway to determine how long COVID-19 can survive on various surfaces and possibly be transmitted through “fomites” (a fancy word for objects or materials that can carry infection, such as tabletops, keyboards, clothes and utensils).  

A study published in the Annals of Internal Medicine (Reference) studied 181 patients who had visited Wuhan China.  Based on the data from this sample of patients they came up with models that estimate average incubation time (IT) of COVID-19 at 5.5 days.  For 97.5% of infected persons, symptoms appear by 11.5 days. Fewer than 2.5% are symptomatic within 2.2 days. Estimated median IT to fever was 5.7 days.  

Incubation time is the amount of time between exposure to the virus and when symptoms and signs are first apparent.

What are the symptoms of COVID-19?

The majority people who have a case of COVID-19 will have a mild infection.  They will either exhibit no noticeable symptoms or have mild cold-like symptoms.  Reported symptoms include:

• Fever (which may not be present in the very young or very old, or immunocompromised)
• Uncomplicated upper respiratory symptoms (Cough, sore throat, nasal congestion, malaise, headache, muscle aches)

People who are immunocompromised or have existing breathing disorders may exhibit or progress to more sever symptoms which require supportive services (antibiotics, breathing support and hospitalization) 

• Difficulty breathing
• Mild pneumonia
• Severe pneumonia (the severe pneumonia caused by COVID-19 is now named severe acute respiratory infection (SARI))
• Acute Respiratory Distress Syndrome (ARDS)
• Sepsis and Septic shock

It is interesting to note is that children seem less vulnerable to infection and appear to have milder symptoms than adults. To date their are NO reported deaths in children 0-9 years of age. One very small study of 9 infants under 1 year of age infected with COVID-19 found that none of the infants had severe illness or complications. In fact, 1 had no symptoms, 2 had mild upper respiratory tract symptoms, and 4 had fever (Reference).

Based on the information we have so far pregnant women do not appear to be at greater risk for complications. In a small study of 9 women in Wuhan in their 3rd trimester of pregnancy with confirmed and symptomatic COVID-19 infection, none developed severe pneumonia or died. All gave birth via c-section to healthy-appearing babies with normal Apgar scores. No virus was found in amniotic fluid, cord blood or breastmilk. (Reference).

It is important to note that the studies in children and pregnant women are small and not conclusive they are just the best data that we have at this time. 

What is the COVID-19  mortality (death) rate?

The honest answer is that we can’t really know what the death rate is because we don’t know how many people have been infected.  Based on the number of infections we have been able to confirm the death rate in China (as of 3/16/20) is (3.9%), in Italy (7.3%) and in the US (2.4%).  This wide range in death rates can be effected by the availability of hospital beds and staff, medical supplies, ICU beds, and test kits.

What we can be almost sure of is that these death rates are almost certainly artificially high, because we lack readily available testing to confirm cases of COVID-19.  We know that without widely available laboratory tests that we are almost certainly not identifying a large volume of COVID-19 cases that resolve themselves without incident.

How do we test for COVID-19?

COVID-19 is detected by inserting a long q-tip into the nose, swabing the throat, or obtaining a sputum sample.  If a person is infected each of these samples types will contain the genetic material of the virus which produces COVID-19.  The CDC has developed a test kit known as – 2019-Novel Coronavirus (2019-nCoV) Real-Time Reverse Transcriptase (RT)-PCR Diagnostic Panel. 

As of today, in the US, these test kits have NOT been available through doctor’s offices, pharmacies, community clinics, or hospitals.  If a person exhibited symptoms of COVID-19 your physician would have to send you to the public health department for testing.  Last week Vice President Pence indicated in his Friday task force briefing that a number of private labs were ready to allow for testing more widely. 

The CDC recommends that clinicians should “use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing).” Priorities for testing may include:

1. Hospitalized patients who have signs and symptoms compatible with COVID-19 in order to inform decisions related to infection control.
2. Other symptomatic individuals such as, older adults and individuals with chronic medical conditions and/or an immunocompromised state that may put them at higher risk for poor outcomes (e.g., diabetes, heart disease, receiving immunosuppressive medications, chronic lung disease, chronic kidney disease).
3. Any persons including healthcare personnel, who within 14 days of symptom onset had close contact with a suspect or laboratory-confirmed COVID-19 patient, or who have a history of travel from affected geographic areas (see below) within 14 days of their symptom onset.

The testing criteria from the CDC are fluid and change as we learn more about COVID-19 risk factors and spread.  You can keep up with the CDC testing guidelines. The CDC also recommends that clinicians work with their local departments of health.  In Erie county for example testing guidelines can be found here. 

The CDC also recommends that clinicians continue to test for other respiratory pathogens, as they would as part of their usual practice for anyone who comes in with fever, runny nose, and cough – like the flu.

You should NOT rush to your doctor’s office or hospital to get tested at the first sign of fever or cough unless your health is declining and you need urgent medical attention.

Your doctor or emergency department does not currently have the capability to test for COVID-19, and going unnecessarily to the doctor’s office or emergency department may inadvertently expose you or your child to COVID-19 or other infections and likewise expose other people to whatever illness you may have.

If you have signs or symptoms of COVID-19 or believe you have been exposed to the virus, you should call your health care provider to discuss your symptoms and get their advice and direction for receiving testing and / or care

How is COVID-19 treated?

There are no specific medications to treat COVID-19,  For the most part the treatment for COVID-19 is to provide supportive care while he virus runs its course.  In mild cases, supportive care includes rest and fluids.  In people who develop other conditions as a result of COVID-19 – like pneumonia – standard treatment protocols are used and work well.  In people who are immunocompromised or have existing respiratory conditions support could include oxygen, and more intensive hospital based care.

Scientists are actively researching existing and new antiviral medications that may have activity against COVID-19, and vaccines that may help to prevent COVID-19.  While initial the initial phases of clinical trials for a vaccine are underway it is estimated that we are a year away from a publicly available vaccine.  

Can we stop the spread of COVID-19?

Our experience with COVID-19 is that this is a disease that like influenza and the common cold it will spread widely through the global community.  While it is unlikely that we will stop the spread of COVID-19 there are strategies for slowing the spread. 

Why is slowing the Spread of COVID-19 so important?

The US, at federal, state and county levels, has strongly recommended a number of strategies aimed at flattening the curve of COVID-19 spread.

• Social distancing. Social distancing is the process of reducing human to human contact. Since the transmission of COVID-19 happens largely via human to human interaction practicing social distancing will slow human to human transmission of COVID-19.  Strategies for social distancing include:
  • Cancellation of sports events, cruises, festivals and other gatherings you to avoid larger crowds or crowded spaces are:
  • Working from home instead of at the office
  • Closing schools, dorms and switching to online classes
  • Visiting loved ones by electronic devices instead of in person
  • Cancelling or postponing conferences and large meetings
• Self-Quarantine. Self-quarantine refers to isolating yourself from others on a voluntary basis.  This strategy is especially effective for people who have been exposed to the new coronavirus and who are at risk for coming down with COVID-19 or who are exhibiting mild COVID-19 symptoms.. Health experts recommend that self-quarantine lasts 14 days.  It is currently estimated that two (2) weeks provides enough of a self-quarantine.  People might be asked to self-quarantine if they have recently returned from traveling to a part of the country or the world where COVID-19 is spreading rapidly, or if they have knowingly been exposed to an infected person.  Self-quarantine involves:
  • Using standard hygiene and washing hands frequently
  • Not sharing things like towels and utensils
  • Staying at home
  • Not having visitors
  • Staying at least 6 feet away from other people in your household
• Isolation.  Isolation is a health care term that means keeping people who are infected with a contagious illness away from those who are not infected. Isolation can take place at home or at a hospital or care facility. Special personal protective equipment will be used to care for these patients in health care settings.

Hardening yourself to COVID-19 exposure?

What we are seeing is that this particular virus spreads quickly throughout populations.  By the same token the vast majority of people who get COVID-19 will have mild symptoms, especially children. While we know generally who might be at increased risk for sever symptoms (i.e. people who are immunocompromised, have existing respiratory disease, cardiac disease, kidney disease), researchers are still investigating what makes certain populations more vulnerable to severe illness. Based on our experience with other viral illnesses there are ways to reduce our susceptibility to serious illness.

In general clinicians think about infections disease from the perspective that exposure to an infectious organism (like a virus) plus the body’s susceptibility to the infection lead to disease symptoms.

Infection + Susceptibility = Symptoms

Therefore if we can reduce our body’s susceptibility to an illness, our likelihood of developing only  mild symptoms if we are infected is much higher.  There are a number of measures that are proven to decrease susceptibility to the type of virus that causes COVID-19.  These measures include: 

• Frequent hand washing,  Wash your hands especially before eating or touching your face. Washing hands with warm soap and water for at least 30 seconds is the best option. This study found that washing hands even with plain running water without soap was more effective than alcohol-based hand disinfectants at killing the Influenza A virus.
• Avoid touching your eyes, nose, and mouth. COVID-19 is primarily transmitted when the virus enters the mucous membranes of the eyes, nose or mouth.  As the virus that causes COVID-19 has been shown to remain live on inanimate objects (doorknobs, tables, keyboards, etc) it is important to avoid touching your face.   Studies have shown that we touch our faces on average 23-50 times per hours. 
• Stay home when you’re sick, unless you need urgent medical attention. You may be increasing your possible exposures to COVID-19 if you don’t have it, or exposing others unnecessarily if you do.
• Cover your cough or sneeze with your elbow or tissues.  Proper cough and sneeze etiquette has evolves so that you should cough or sneeze into a tissue and when a tissue is not available into the crook of your elbow.  Coughing an sneezing into your hands increases the probablity that you transfer a virus to an object or another human.  Regardless, after you cough or sneeze you should wash your hands.
• Keep your distance. Try to stay at least 6 feet away from anyone who is obviously sick with fever and/or respiratory symptoms.
• Stay well-hydrated. Stick to water, coconut water, herbal teas. Soda or sugary drinks are in general not great for your health. How much water do you need daily?  A good rule of thumb is to divide your body weight (in pounds) in half and drink that number in ounces.  So for me I weigh 156 lbs., so I would need to drink 78 ounces (about 5 16 oz. bottles) of water daily.  Not only is this good for your immune system, but it’s also a great weigh loss strategy.
• Get fresh air and moderate daily exercise. Moderate exercise can boost the production of macrophages, the kind of white blood cells that “eat” bacteria and viruses.  Intense exercise can actually temporarily decrease your immune function, so no need to overdo it.
• Get adequate sleep. An increase in sleep actually increases the number of your white blood cells. On the other hand, loss of sleep even for a few hours at night, increases inflammation in our body which makes us more susceptible to catching virus based diseases and having more severe symptoms. 

Will a mask help to prevent COVID-19?

Face masks are not currently being recommended for the public in general. Masks are recommended if you have a cough that you could transmit, at high risk of having severe COVID-19 symptoms or are taking care of someone who is sick with COVID-19.

While mask wearing is not recommended for the general public, there is certainly no downside.  So if “out of an abundance of caution” you decide that you want to wear a face mask, you need to make sure it’s is rated P95, R95 or N95 (it filters at least 95% of very small particles). 

Currently, the question of masking may be moot as they are currently not available in most retail establishments.  Even community physicians, pharmacists and nurses cannot find n95 masks for use as they are treating patients.