Is Local Business more important than Health?
February 9, 2018

How To Keep Your Family Safe Amidst COVID 19

By

Sheila Rege MD

Please share this information but try not to reproduce, duplicate, or transmit any part of this document in either electronic means or printed format for commercial or medical purposes.  Recording of this publication is strictly prohibited. 

This guide is dedicated my mother who has shown me what courage should be like during pandemics. 

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Table of Contents

Introduction. 1

PART I: How To Prevent COVID 19 From Entering Your Body (or Home) 2

Chapter One: Why Hand Washing, Alcohol Sanitizers and Masks work  (and the Controversy) 3

Chapter Two: Is This Just Like The Flu Virus or Worse. 7

PART II: What To Do If Someone In Your Family Gets COVID-19 (Test 18)

Chapter Three: Self Quarantine at Home. 19

Chapter Four: Hospitalization anectdote. 21

Chapter Five: Testing for COVID19 – Swab or Blood Antibody Test to Help Move Past This and Not Remain Hostage  23

Epilogue/Conclusion. 27

Bibliography. 27

Acknowledgments. 28

About the Author 28

Introduction

The COVID-19 disease and death statistics are grim but we as Americans will get through this.  I have been asked so many questions about this by patients, families and friends.  This guide will help you keep your family safe even while living as normal a life as possible amidst this crisis. 

As a cancer doctor, I have seen many patients with compromised immune systems beat the odds.  There are somecommonsense strategies to help reduce your risk of getting this virus.  And if you get this virus, then there are methods to boost your immune system so you can help your body fight this.

Many of us are confused and see friends being overzealous about sanitizing.  We see others being nonchalant.  And when we hear or see a loved one hospitalized with COVID 19 or even die from this atypical pneumonia we panic.  This is a guide on what to do in each of these circumstances.

This information will help you cope with the unexpected.  I have counseled many with these commonsense tips and want to help others through this guide.  Please feel free to share this information.           

PART I: How To Prevent COVID 19 From Entering Your Body (or Home)

            There are so many myths out there about things to do.  I have heard of people using Clorox (bleach) wipes along their nostrils and also people cleaning their cars every day to sterilize the inside.  The only proven thing is to wash your hands with soap and water since we usually get COVID-19 disease by introducing the coronavirus into our body via our hands touching our mouth, eyes or nose (avoid MEN). 

Chapter One: Why Hand Washing, Alcohol Sanitizers and Masks Work

Many of us heard about people dying in China of a “new virus” sometime in December 2019.  Most of us never imagined that so many Americans would also die from the same virus.  This seems unbelievable within the United States where we have the best medicines and technology. 

When this first happened, I recall my mother saying that if she got sick she would see her doctor.  And if she got a temperature then he would give her some antibiotics.  After all, it’s just a virus.

But wait, what’s a virus?  Is it just another germ?  We as humans get infections by either bacteria (for which antibiotics work) or viruses (for which antibiotics don’t work).  Strep Throat or a Urinary Tract Infection is usually caused by bacteria.  We have all heard of food contamination by E. Coli which can cause diarrhea. 

Did you know that there are “good” bacteria which can help us digest our food?  A bacterium has a single cell and can live outside in nature as well.  For example, researchers study a type of bacteria that live on the ocean floor and gobble up methane (and we know that an excess of gases in Earth’s atmosphere may lead to global warming).  Scientists have found bacteria that eat rocks and sewage. 

A virus is even smaller than a bacterium.  A virus is a zombie outside of their host (human or animal or bat etc.).  They cannot survive outside in the open for very long.  The virus enters our body and then invades our cells.  The coronavirus, like any other virus, then hacks our cellular machinery to manufacture more virus particles.  Chickenpox or HIV (AIDS) are examples of viral diseases.  The common cold or flu are also caused by viruses. 

So, in summary, bacteria can be our friends or foes, good or bad.  Most of us think that all viruses are harmful to us as humans.  But some scientists believe that there may be helpful viruses as well.  In 2013, Jeremy Barr, a microbiologist at San Diego State University in California published a study about possible beneficial virus in mucus.  We all know mucus, the slimy substance coating the inside of our mouth, nose, or eyes that sometimes spills out and we use tissues to wipe it off.  Mucus is gel like; and our lungs are protected by mucus.  Jeremy Barr believes that we have a phage (a type of beneficial virus) within our mucus. 

Unfortunately, the coronavirus is a harmful virus that enters our bodies through our mouth, eyes or nose (acronym MEN hence my advice to avoid MEN) and is most harmful within our lungs.  I have always wondered why scientists have never figure out a cure for the common cold or the flu.  For example, this year’s flu vaccine might not be as effective as the prior year. 

Recall that the virus enters our cells and forces our cells to make more virus babies?  Viruses multiply really fast.   The Measles virus is a stable virus in that it does not change its genetic material in the new baby measles virus.  That’s why your measles vaccine in childhood keeps you safe even today.  However, influenza virus (that causes the flu) is a fast mutator which means that every new virus particle may have a slight difference in their genetic material.  That’s why last year’s flu vaccine may not work for the new flu bug this year.  HIV that causes AIDS for example, can produce 10 million new virus babies within 24 hours; and mutates fast as well. 

Do we know if the coronavirus is a fast mutator?  It’s not entirely clear.  Scientists believe that the coronavirus causing COVID-19 (SARS-CoV-2) lived in bats within southern China.  Coronavirus is a “zoonotic virus” meaning they can jump from animals to people.  Jonathan Epstein, an epidemiologist at the EcoHealth Alliance in New York, was part of a research team that went hunting for the source of the COVID 19 coronavirus in China’s Guangdong Province.  Epstein’s team discovered the horseshoe bats that carry coronavirus.  Surprisingly, although the coronavirus also co-infects multiple bats and turns their bodies into virus production machines, the bats do not get sick.  While some humans do not get sick, in others the coronavirus SARS-CoV-2 has become the elusive killer. 

What Does the Coronavirus Look Like?

Coronavirus gets its name because it has spikes that surround its inside core like a crown or corona.  These spikes interact with receptors on our cells (like keys opening a lock) and enable the virus to enter our cells.  The coronavirus spike is believed to be a member of the class-1 membrane fusion protein (similar to those from the influenza virus, human immunodeficiency virus HIV, and Ebola virus).  The spike leads the coronavirus to enter our human cells by binding to a receptor on our cell surface.  Then the coronavirus is able to replicate within our cells; almost like making our cells into a virus production factory.  In summary, the virus is a packet of genetic material surrounded by a spiky protein shell.  It’s a zombie on any surface, and only wakes up once it reaches our body. 

For more detail:  Studies from the prior coronaviruses (CoVs) show that these are enveloped viruses with a positive sense, single stranded RNA genome.  CoVs have the largest genomes for RNA viruses.  They can infect humans and cause disease that range from upper respiratory tract infections resembling the common cold, to lower respiratory tract infections such as bronchitis or pneumonia or now Covid-19 which can result in severe acute respiratory syndrome (SARS).  Past coronavirus genomes encode four major structural proteins:  The spike (S) protein, nucleocapsid (N) protein, membrane (M) protein, and the envelope (E) protein to form a complete infectious virus but some structural proteins may be dispensable.

Why Soap Works

The virus has an outer spiky protein shell crown with a layer of lipids (fat) immediately underneath, which is visible from the outside.  Imagine the spikes to be like the needle of a cacti, and the fat layer to be the green part of the cactus.  When we wash our hands, any oil or grease on our hands is broken down by soap.  Imagine a coronavirus on my hand.  I put some soap on my hand, and the soap comes in contact the fatty layer of the virus as I rub my hands together.  The soap begins to break down the fatty layer just like it breaks down grease on a pan.  The virus is helpless, as soon the inside genetic material will come gushing out into the running water to be washed away for eternity. 

Water and scrubbing are important because you need to create more soap bubbles and you need to get the soap into every area of your hands and fingers (fingernails too) which takes at least 20 seconds of rubbing.  Warm water with soap gets a much better lather and more bubbles.  Sing the Happy Birthday song twice to make sure you wash for 20 seconds.  

Why 60% Alcohol Based Sanitizers Work:

Alcohol breaks up the virus shell membrane (the spikes) but you need to get it into direct contact with the virus.  Then the alcohol unfolds and inactivates the virus proteins (denaturation).  Alcohol based sanitizers kill viruses that have an outer wrapping (envelope) like coronavirus but no other viruses that are non-enveloped.  Most alcohol-based sanitizers have at least 60% ethyl alcohol. 

Pure alcohol (or isopropyl alcohol that is 70% alcohol) dries out your skin and causes it to be irritated.  Also, alcohol is volatile which means that over time the alcohol slowly evaporates so the sanitizer loses its ability to kill the virus. 

How Large is Coronavirus and the mask controversy:

Coronavirus is a large enveloped virus and lands on surfaces we touch all the time such as doorknobs or handles.  The average person touches their face 20+ time an hour.  Half of these touches are to MEN (mouth, eyes, nose) which have mucosal surfaces that coronavirus infects.  On one cruise ship the coronavirus was thought to have survived on their stair railings for 9 days. 

The particles that carry the coronavirus may easily move right through dust masks.  N95 masks filter out 95% of the small virus-containing particles but require a seal around your face and cannot leak air on the sides. 

A surgical mask will help at preventing droplets (someone coughs on you) which is the main transmission of coronavirus.  The mask may prevent you from touching your nose or mouth.  Surgical masks and N95s contain an inner mesh of tiny plastic fibers that function as a filter.  When we cough, sneeze, talk or simply take a deep breath we emit a stream of air and droplets (saliva, mucus, salts and if we are infected the virus).  The smallest of these droplets (called aerosols) can hover or drift through the air for hours potentially infecting others who enter that airspace.  Large droplets travel a few feet (hence the 6-foot distance social distancing) before falling to the ground or onto another surface such as someone’s skin or clothing. 

Influenza and coronavirus are usually between 0.08 and 0.12 microns.  Some believe the surgical mask can filter at least 60% of 0.3-micron particles.  Cloth masks are about one-third as effective as surgical masks (https://academic.oup.com/annweh/article/54/7/789/202744).  Scientists in Hong Kong have suggested a mask from tissue paper, paper towels, tape, and a twist tie, coupled with a transparent file folder binder-clipped to glasses to serve as a face guard.  The Hong Kong researchers believe this paper mask may work about 80-95 as well as a surgical mask. 

Here is how to don your mask:  https://www.youtube.com/watch?v=OABvzu9e-hw.  It’s important to wash your hands with soap and water before you put on your mask and ideally before taking your mask off as well but please ensure you do not touch MEN (mouth, eyes, nose) at any time.  My advice is to consider wearing a mask anytime you go into a closed area where others have been (e.g. store, post office) and also when you think you may come into contact with people and cannot be 6 feet away.  Also, always wear a mask if you are sick (have a cough, sneeze or allergies, sore throat or fever) or if someone in your home has symptoms.  There are others who believe that everyone should wear a mask, store bought or homemade, anytime we are out in the public. 

Bringing in Products from the Outside (e.g. mail, groceries, packages, take-out etc):

Remember that viruses cannot live outside our bodies.  So, when they are out on a surface (e.g. cardboard box, plastic bags or metal railing), they are like zombies and barely alive.  Scientists have studied how long virus particles could live indoors in March 2020 (The New England Journal of Medicine).  It appears that within the air (atmosphere), the virus may live as long as 3 hours.  When dropped onto plastic, viable coronavirus particles were detected 3 days later.  Metal was unusual in that the virus was not alive 4 hours later on copper but was alive 48 hours later on stainless steel.  Most scientists believe that factors such as UV light and heat may speed this process up with fewer viruses alive than what was found indoors.    

On February 27, 2020, the Food and Drug Administration (FDA) Commissioner Stephen Hahn said that “We are not aware of any reports at this time of human illness that suggest COVID-19 can be transmitted by food or food packaging.”  The FDA does recommend cooking foods to their proper temperatures and washing produce thoroughly. 

Jeffrey VanWingen, a Family Medicine doctor has created a 13-minute video on how to bring food into their homes as safely as possible.  I have included a link here: https://www.youtube.com/watch?v=sjDuwc9KBps.  I would encourage you to watch it.  The takeaway is to use common sense on “dirty” products such as the paper bag or plastic bag you carried in from the grocery store (and dispose of this).  If you can, have the products “wait it out” (24 hours for cardboard and 72 hours for plastic), and try to not use the food as soon as you buy it.  Realize that coronavirus may actually last longer in the refrigerator or freezer so try to wash those foods carefully or cook them well. 

There is an Avian Pathology article (June 2004, 33(3), 303-306) by Elhafi et al, suggesting that microwave for 20 seconds is effective at killing some infectious virus.  France’s health and safety agency (ANSES) convened an expert group whose recommendation is that “Heat treatment at 63 degrees C (145 degrees F) for four minutes can reduce virus contamination by a factor of 1,000.  The most likely way for transmission through food would occur if a person infected with the virus prepares or handles food either with dirty hands (or sneezes or coughs and exhales and droplets containing the virus falls on the food).  I recommend not ordering anything via take-out that you cannot reheat.  I avoid salads just in case the person preparing it was coronavirus positive (and may have even been asymptomatic). 

For mail deliveries, my suggestion is to assume that this is like cardboard (paper) and that the virus could last on this for 24 hours.  So, keep the mail or packages out for 24 to 72 hours in “quarantine” and then open them.  Wash your hands before and after opening the packages. 

Personal Hygiene and Home Hygiene:

On a personal level, if you treat everything that comes from the outside as potentially “COVID contaminated” then you will reduce the risk of the virus entering your home.  So, if you come in from the outside then theoretically your clothes and shoes are contaminated.  So are your spectacles, phone, car keys, hair accessories or purse.  If there is any way you can put all these “potentially contaminated” items in one area (perhaps a bucket?).   Take off your shoes and wear indoor shoes.  If you are fortunate enough to be able to do laundry or shower more frequently then please do so.  You can have one “contaminated” bucket of items and know that when you touch anything in there within a certain time frame (24-72 hours) then there may be potential for the virus to still be present on those items.  So be extra careful when you touch that. 

Think of your hands as having annoying glitter on the skin, and you don’t want to get this all over your body or home.  So, wash your hands vigorously as soon as you get home.  The door handles that you touched when you come home could have the virus and you could consider wiping those down with an antiseptic solution or just a regular cleaning product.  Think glitter on hands until you wash them and try not to get the glitter (aka virus) on other surfaces once you get home.  

For mail deliveries, my suggestion is to assume that this is like cardboard (paper) and that the virus could last on this for 24 hours.  If you can keep the mail or packages in a “contaminated” area for 24 to 72 hours in “quarantine” that makes things safer.  Wash your hands before and after opening the packages.

For take-out, consider throwing away the box the food came in immediately (COVID contaminated).  The food will be sterilized if you heat it in the microwave or oven or stovetop.  Personally, I avoid salads that someone had to prepare because they may be a COVID carrier without knowing it.  I heat all my food before ingesting it. 

Remember that the virus enters our body through our mouth, eyes or nose (MEN).  Most of us do use a pillow and our sheets may come in contact with our mouth, eyes or nose.  If you can shower as soon as you come home for the day (and definitely before you go to bed) then that may decrease the likelihood of the virus getting on your sheets.    

Chapter Summary/Key Takeaways

Wash your hands and social distancing (6 feet away from people who don’t live in your home) is the best way to stop this virus.  Once this virus cannot jump to another person then it will die out.  However, until this virus dies out, we need to take extra precautions whenever we leave our home.  We need to ensure that we do not bring the virus from others we meet outside to our home.  So, treat everything that comes from the outside as potential “COVID 19 contaminated” and either quarantine these items (e.g. purse, car keys, hat, sunglasses) for 24-72 hours and sterilize things you need to bring inside and use (e.g. mobile phone, take-out food or groceries). 

Most states and countries are on a lock down.  It is likely that we may have trouble finding certain supplies.  Although most of us can make do without toilet paper (hard to believe but it is possible) please be prepared for shortages.  Please make sure everyone has a 30-90 day supply of medications.  

See this interesting video from Beijing from an American reporter on what is being done in China.  

https://www.wsj.com/video/coming-out-of-coronavirus-lockdown/123E1464-4727-48B1-B74D-A1613650C2A5.html

In the next chapter you will learn how to recognize symptoms of coronavirus as well as why this is more dangerous than the regular common cold or flu. 

Chapter Two: Is It Just Like the Flu Virus or Worse?

As medicine and technology becomes more sophisticated, we have fewer infectious disease outbreaks or epidemics.  We as Americans have heard about prior influenza pandemics.  

An epidemic is when an infectious disease spreads within a community or area within a certain time period.  A pandemic is when the epidemic has spread to a larger area such as an entire country, continent or even the whole world. 

Influenza Viruses:
Influenza virus belongs to the Orthomyxoviridae family and is classified into 3 different types – Influenza A, influenza B and influenza C.  Influenza A and B cause symptoms while influenza C is subclinical.  These are enveloped viruses with segmented, negative sense RNA genome.  Influenza A and B genomes have 8 segments while influenza C has 7 segments.  Most prior pandemics are a result of a global outbreak of a new influenza A virus, usually as a result of an “antigenic shift”. 

The most common type of change for Influenza viruses is through a process called “antigenic drift”; but our immune systems can be trained to recognize an antigenic drift change via yearly vaccines.  Antigenic Drift is the random accumulation of small changes.  The influenza virus does not have a “proofreading or correcting” mechanism to check for “typos” during virus replication.

The CDC estimates that small changes (called “antigenic drift”) cause virus strains that may be closely related to each other so that the antibodies your immune system creates will likely recognize and respond to this antigenically similar virus strain (this is called “cross protection”).  However, sometimes this “antigenic drift” or changes in the genes of the influenza virus causing change in the surface protein may be a significant change so that a person’s existing antibodies won’t recognize or neutralize the newer influenza virus.  This is why the vaccine composition must be reviewed and updated each year (as needed) to keep up with the evolving virus strains. 

Of greater public health concerns is the process of “Antigenic Shift” which is also called reassortment.  Recall that the influenza virus is broken up into several segments, each of which codes for a gene.  When two flu viruses are in the same cell, they can swap some segments, potentially creating a new combination instantly.  The WHO labels this an “antigen shift” where at least two different viruses combine, resulting in the formation of a mosaic virus.  Since swine can be infected by swine, avian and human influenza viruses they are thought to be a potential “mixing vessel” from which a virus with a pandemic “antigen shift” potential may occur.  This is felt to have occurred previously when the H2 appeared in 1957 (H2N2) and the H3 which appeared in 1968 (H3N3).   

The table below is from the CDC data about prior pandemics in the US:

YearPandemic NameVirus NameDeaths in USAAge Group with highest mortalityUnique featuresOther Facts
1918Spanish FluH1N1675,000<5, 20-40, >65High mortality in health people3-5 days fever and then recovery
1957-1958Asian FluH2N2116,000 Most deaths in people with underlying heart or lung disease; 3rd trimester pregnant womenMortality relative to baseline were greatest in school-aged children and young adults
1968Hong Kong FluH3N2100,000>65This is our most common “seasonal flu” virus causing severe illness in older peopleOne theory is that people born before 1968 were not imprinted with H3N2 virus (their flu immune response was set by variants of either H1N1 viruses circulating between 1918 to 1957 or H2N2 viruses circulating between 1957 to 1958)
2009Swine FluH1N1pdm0912,46920-40 year olds had highest death rates; followed by 40-60 year olds and then >60Nearly one-third of people over 60 years old had antibodies against this virus.  Globally, 80% of eath rates were in people younger than 65 years of ageThis affected children and young to middle aged adults.  This virus continues to circulate as a seasonal flu virus
       

The CDC estimates that from October 1, 2019 through April 4, 2020 there have been 40,000-60,000 flu illnesses resulting in 18,000-26,000 flu medical visits and 410,000-740,000 flu hospitalizations with 24,000-62,000 flu deaths (https://www.cdc.gov/flu/about/burden/preliminary-in-season-estimates.htm).  Assuming the US population is 328.2 million (2019 numbers) then 225 patients per 100,000 population needs hospitalizations. 

Most people who get the flu get it suddenly over a day but in some people it may take several days to develop symptoms.  Symptoms may include cough, fever, sore throat, muscle aches, headaches, nasal discharge, weakness, watery eyes.  People may even then develop dyspnea (trouble breathing).  Fevers and chills can occur as well.  The sore throat is the main reason that people see a doctor because it may be severe and last 3-5 days.  Physicians believe that the incubation period (time from when a person gets exposed to the virus to the time they develop symptoms) may be an average of 2 days but range from 1-4 days.  People who have preexisting immunity (e.g. have had the same virus strain attack before) or who have received vaccine may have milder symptoms. 

Other bacterial or viral pandemics that have been contained:

We have seen infectious diseases change the course of history.  For example, the European settlers brought smallpox here in the 1600’s which killed majority of the Native American population.  Then we had yellowfever in 1793 followed by Cholera between 1832 to 1866.  Strep throat or scarlet fever killed children until we developed antibiotics.  Remember Typhoid Mary who was a healthy carrier for typhoid fever in 1906? 

Polio is another viral disease that killed 3,145 people in 1952.  Thanks to the vaccine the United States has been polio-free since 1979.  Fortunately the polio virus does not mutate so 3 doses of inactivated polio vaccine is 99%-100% effective.  The CDC recommends a booster vaccine if you travel to areas such as Pakistan, Nigeria or Afghanistan which still has wild poliovirus.  Measles killed between 2,000 to 10,000 people every year between 1981-1991.  We still hear about measles outbreaks in communities where children are not vaccinated. 

The CDC reports that whooping cough or Pertussis causes coughing attacks that can last for months and we will have an outbreak every 3 to 5 years as the “new normal”.  A vaccine is recommended for pregnant women during the third trimester to protect the newborn.  HIV or AIDs led to a rare lung infection beginning in 1981.  We now have antiretroviral medicines but the results of HIV vaccines have been disappointing.  There was a report at the 2020 Conference on Retroviruses and Opportunistic Infections (CROI) that scientists have produced a vaccine that may induce human cells to generate broadly neutralizing antibodies to HIV.            

Coronavirus:

This information is from UpToDate and CDC sources:  The new coronavirus (2019-nCoV) was declared a pandemic by the WHO on March 11, 2020.  Coronavirus are classified as a family within the Nidovirales order, viruses that replicate using a nested set of mRNAs (“nido-“ means “nest”).  The coronavirus subfamily is further classified into four types: alpha, beta, gamma and delta.  Only the alpha and beta types have been found in humans.  The gamma coronavirus genus contains mostly avian coronavirus (e.g. infectious bronchitis in chickens) and delta coronavirus genus (seen in songbirds). 

Both the HCoV-229E and HCoV-OC43 were discovered in the 1960’s and were shown in volunteer experiments to cause common colds in adults.  Human coronaviruses probably account for 5 to 10% of all adult colds (Yale J Biol Med. 1974;47(4):234; J Infect Dis. 1974;130(5):502).  Coronaviruses can be detected in middle ear effusions and may cause acute otitis media in children (Clin Infect Dis. 2008;46(6):815). 

Molecular diagnostic tests such as the polymerase chain reaction (PCR) showed that HCoV-NL63 and HCoV-HKU1 had worldwide distribution and caused common colds (J Infect Dis. 2005;191(4):492; Nat Med. 2004;10(4):368).  A nine year survey of all children under 16 years of age admitted to a Norway hospital showed that HCoV-associated respiratory tract infection hospitalization rates for the population under five years was 1.5 per 1000 children per year (J Infect Dis. 2019;219(8):1198).  A high HCoV genomic load was associated with a substantial burden of respiratory tract infections needing hospitalizations. 

There are 7 types of coronavirus felt to infect humans:

Year discovered   Receptor UsedSymptomsPresent in USA? 
1960’sAlphaHCoV-229E Aminopeptidase N (APN)Upper respirator tract symptoms such as nasal congestion and rhinorrheaYes 
1970AlphaHCoV-NL63 Angiotensin-converting enzyme-2 (ACE-2) Yes 
1970BetaHCoV-HKU1 Sialic acid residue Yes 
1960’sBetaHCOV-OC43 Sialic acid residueUpper respirator tract symptoms such as nasal congestion and rhinorrheaYes 
2012BetaMERS-CoVMiddle Eastern Respiratory Syndrome MERSDipeptidyl peptidase 4 (DPP4)Severe respiratory illness with symptoms of fever, cough and shortness of breath. About 3 or 4 out of every 10 patients reported with MERS have died.  2 cases tested positive 
2002BetaSARS-CoV-1Severe Acute Respiratory Syndrome SARSAngiotensin-converting enzyme-2 (ACE-2)High fever and dry cough followed by shortness of breath and diarrhea; 2nd week may result in rapid pneumonia leading to death73 cases tested positive in US 
2019BetaSARS-CoV-2COVID19Angiotensin-converting enzyme-2 (ACE-2)Loss of smell, fevers, hypoxia leading to rapid respiratory distress syndrome1.5 million with 60-90K deaths by mid May 

SARS-CoV-2 that causes COVID19 is an enveloped virus with a positive-sense, single-stranded RNA genome of around 30 kb.  When it infects its host cells, SARS-CoV-2 replicates its genomic RNA and produces smaller RNAs known as subgenomic RNAs.  These subgenomic RNAs are used to make various proteins such as the spike protein S, envelope protein E, membrane protein M and nucleocapsid protein N.  Although not completely proven, it is felt that coronavirus has an unprecedented RNA correction machinery (aka genome proofreading function) that has allowed RNA genome size expansion.  This means the coronavirus might have some way to recognize and correct errors

            Calculating the COVID19 statistics may be more challenging because 20-40% of people may be asymptomatic carriers of COVID19.  The CDC maintains a website to track hospitalizations and estimates that 66.5 patients per 100,000 population will need hospitalization.  The CDC does admit that these rates may underestimate the true COVID-19 hospitalizations because the test was in short supply or the facility may lack test kits.  If I am doing the math correctly then this translates to 218 patients per 100,000 population needing hospitalizations. 

            Coronavirus affects different age groups than the flu.   Data from the CDC ending April 4, 2020 confirms that hospitalization for COVID 19 was age related:

Hospitalizations per age groupPer 100,000 population COVID 19 2019-April 4, 2020*Relative Risk Hospitalizations Influenza Virus 2011-2012**
0-4-year-old0.63.03
5-17-year-old0.21.21
18-49-year-old6.31.62
50-64-year-old20.70.81
65+ year-old (total)38.70.39
    66-7431.2 
    75-8445.6 
    85+59.1 

*https://gis.cdc.gov/grasp/COVIDNet/COVID19_3.html

** https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4469206/

Children are definitely at lower risk (especially 5 to 17-year-old children) but it was worrisome to see 18-40-year-old adults having “coronavirus parties” until that age group began to require hospitalizations. 

I was reading a government funded study from the 2009 influenza hospital discharge data which estimated that 20% of influenza patients may require hospitalization and that 15% may require ICU care.  50% of those ICU patients may require ventilators and that the ventilator is needed for 1 week in 2/3 and for 2 weeks in 1/3.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5443432/   Then along came the coronavirus needing double that amount of hospital beds and ventilators within the US (and other countries).  Imagine saving ventilators for a rainy day but a stealth new virus (carried sometimes by asymptomatic people) has doubled the amount needed.  That’s why the medical community recommended social distancing to reduce the spread of coronavirus. 

How is Coronavirus Different than the Flu

The problem is that the coronavirus is a new virus and is spreading among us Americans at the same time as the flu.  It is also thought to be more infectious than the flu and some people won’t even know they have coronavirus and spread it.  Usually the person getting the flu has symptoms and feels sick.  Therefore, the flu patient stays away from others or in bed.  The coronavirus asymptomatic patients may unwittingly spread this virus to others. 

Why Coronavirus Can Spread Faster than the Flu Virus

This is for a variety of reasons: 

  • One coronavirus infected person on average can infect 3-5 people; versus with the flu it is believed flu patients infect 1.3 people
  • Some patients infected with coronavirus may feel fine; and some researchers estimate that 25% of these patients can infect 3-5 people on average
  • Coronavirus infected people can infect people several days before they develop symptoms.  Usually the flu patients only infect others close to when they start feeling poorly (at which time most of them stay home because they don’t feel so good). 
  • Coronavirus can be completely devastating rapidly in one person and do absolutely nothing in another person.  But both the symptomatic patient and the asymptomatic patient can each infect 3-5 other people. 

Symptoms:  Flu Virus versus Coronavirus: 

FLU:  People typically have fevers, cough, muscle or headaches, runny nose or sore throat and fatigue (CDC).  People who have the flu can experience symptoms within 1-4 days.  Most people with flu symptoms recover within 2 weeks.  Some people have complications such as pneumonia.  In 2019-2020 flu season, about 1% of patients have developed symptoms severe enough to be hospitalized (61 hospitalizations per 100,000 people).  Also, since after 1975/6 influenza-related mortality has decreased in the US and the US has the lowest death rates as compared to UK, Japan, Australia or France (https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-10-162).  For example, in Australia and New Zealand, in the 2010 influenza season, ventilated patients were on a ventilator for 8.5 days (range: 3.2–25.6), and 7 days (range: 3.0–16) for the 2009 season [Critical Care 2011; 15: R143; https://www.ncbi.nlm.nih.gov/pubmed/21658233]. 

CORONAVIRUS:  People typically present with anosmia (loss of smell), fevers, dry cough and fatigue.  People may be sick with the virus for 1 to 14 days before developing symptoms.  Most people (80%) recover without needing additional treatments.  However, on average 12% people with coronavirus (March 18 MMWR) need hospitalization. Most people with coronavirus do not have a runny nose or watery eyes. 

 Time to SymptomsTime to SymptomsHospitalizationDeath Rate (average)Death Rate (80+ yrs)% US Population get sick with this
FLU1-4 daysAbruptAge related (see above)0.1%0.1%8%
       
CORONAVIRUS1-14 days (median 5 d)Gradual12% (WHO: 15% severe and 5% critical – needing ventilator)1 – 1.5%15%?

Death Rates Coronavirus:

            The death rates are slowly being reported to the CDC.  Unfortunately, older patients are at higher risk of dying and also others with medical problems (e.g. obesity, smokers). 

The Chinese Center for Disease Control and Prevention reported these death rates:

Death Rate by AgeRisk of Death
10-19 years0.2%
20-29 years0.2%
30-39 years0.2%
40-49 years0.4%
50-59 years1.3%
60-69 years3.6%
70-79 years8%
80+ years14.8%

New York is reporting similar death rates and perhaps more deaths in the younger populations:

Rate by AgeObserved People that needed hospitalizations per 100,000 peopleObserved Deaths per 100,000 peopleComment
0-17 noneCalifornia has had deaths in this age group
18-44122.567.86 
45-64465.3162.4 
66-74819.46190.95 
75 and older1153.8464.92 

Data from https://www1.nyc.gov/site/doh/covid/covid-19-data.page#download

How Human Immune Systems Work and Why Older People are More at Risk:

I am simplifying things and my physician and scientist colleagues may be able to give a more detailed explanation.  Our immune system has a first line of defense that comes to our aid within minutes to hours.  Our immune system also has a second line of defense that gets mobilized within days. 

The first line of defense is almost like foot soldiers or the front-line immune cells.  They include our white blood cells (leukocytes) as well as others.  These are produced in our bone marrow among other sites.  They are blunt defense instruments and recognize “outside threats” as not our body cells, so different.  The word is put out to destroy.  They create a massive inflammatory response with lots of swelling or fluids etc. within the area of the “outsider”. 

The second line of defense is more specialized.  These involve T-cells which are made in our thymus.  Unfortunately, our thymus produces fewer T-cells after age 40 or 50.  The second line of defense does have other cells as well.  But for now imagine that there are fewer of these T-cells in the older person.  In addition, the T-cell has to be “programmed” to defend against a certain virus.  Older people have fewer “unprogrammed T-cells” which means fewer second-line cells to defend our body.  In older people or people with compromised immune systems these defense cells are overwhelmed or just plain tired.  In a young robust person, the front-line cells show the second-line cells the enemy; almost like saying, “Guys, we need help.  This is what this new enemy looks like, so please program a targeted virus killer ASAP.”  In an older adult, this communication is not as well coordinated.  Therefore, the immune response may be too late and too little.  

            Fortunately, by the time we become older (60+ years) our bodies have seen most of these virus threats.  So, it’s an “aha” moment and the older person is protected because they have T cells with “memory” of prior virus attacks and can mount a response faster than with a new virus.  However, this coronavirus is a brand-new virus to humans and our bodies just don’t have any prior “memory” immune cells to fight it off.  For the more scientific readers, there is a nice summary of the impact of aging on viral infections at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998572/

Chapter Summary/Key Takeaways

We now know that both the flu (influenza virus) and COVID-19 (coronavirus) can be transmitted between one person and another.  Both are respiratory illnesses that can affect the lungs.  Neither can be treated with antibiotics which only work on bacterial infections.  We treat both with supportive care (meaning we encourage symptom reduction such as fever reduction and adequate fluids) and severe cases may require hospitalization and ventilator support. 

The difference is that our bodies have lived with the flu virus for decades and most of us have developed a small amount of immunity to this virus.  Coronavirus is new to us as humans.  COVID-19 positive patients may remain asymptomatic and never know they had the virus.  Other COVID-19 positive patients may get better at home and then suddenly develop respiratory distress and need urgent hospitalization.  Within the medical profession we do not know what medications work and what doesn’t for the mild cases and we cannot predict who will get worse.  We do know that the spread of flu and COVID-19 can be reduced by vigorous hand washing with soap and water, coughing away from others (into your elbow if possible or wear a mask) and social or physical distancing to stay 6 feet or more away from others.  Below is a CDC report of deaths from COVID-19, influenza and also pneumonia. 

Reported Deaths to National Center for Health Statistics week ending 2/1/2020 to 4/4/2020

Age GroupCOVID-19InfluenzaPneumoniaPneumonia and COVID 19
All ages4,9844,54136,4232341
Under 1 year09190
1-4 years126271
5-14134260
15-24635872
25-344610625721
35-4412916053844
45-542913751416119
55-646248164247269
65-7410859767397456
75-841372102510139691
85 years and older142973812270738

From https://www.cdc.gov/nchs/nvss/vsrr/COVID19/index.htm

Part 2 will go over helpful tips for what to do if someone in your home develops symptoms or has a positive COVID-19 test. 

PART II: What TO Do If Someone In Your Family Gets COVID-19 (Test)

Every morning, do ask your housemates how they feel.  If anyone feels poorly, or feels like they are coming down with a cold, then please have them call their doctor to see if they qualify for COVID-19 testing especially if they have a fever.  Remember that if anyone in your household is feeling poorly then it is best to remember that this virus transmits through droplets (a sneeze or cough or even breathing) so stay 6-8 feet away from the person feeling poorly.  A mask on this person (and even on you) will help catch these possibly contaminated droplets. 

It is assumed that 1 in 4 people may have COVID-19 and have no symptoms.  Therefore, assume that everyone including your partner may have COVID-19.  It’s okay to hug and kiss them if they are feeling well.  But do increase the number of times you do hand washing if you live with others especially children who may remain asymptomatic while passing this to adults. 

We should all quarantine ourselves if we know that we have come in contact with people who tested positive for COVID-19 within the last 14 days of our encounter.  Quarantine means that you try to stay home except to grocery shop if absolutely needed.  If you need to go out, then please wear a mask.  These are other situations when you should consider quarantine (staying away from other people who do not have these risk factors):  (1) Travel via cruise or airplane; (2) you were in close quarters or had drinks/coffee or walked with someone who is now COVID-19 positive; (3)  wear a mask if others live in your home and wash your hands frequently. 

If you test positive for COVID-19 then you should consider complete isolation.  Isolation is more severe than self-quarantine.  Outside of getting medical care, you should stay at home.  Avoid use of public transportation.  People should remain in isolation until at least 7 days after the end of their symptoms, or 3-4 days after their fevers go away, whichever is longer.  

Chapter Three: Self Quarantine at Home

Let’s assume you wake up and your husband says he is not feeling well (sore throat or dry cough especially with loss of smell).  He may say he is fine but just under the weather.  I would recommend checking his temperature because sources report that perhaps 50% of patients with COVID-19 have a low-grade fever.  If he has a fever, then I would recommend isolating him from others and calling the doctor to see if he qualifies for COVID-19 testing.  If he has no fever, then recommend that he stay away from others, including the children, but especially the elderly. 

Regardless of whether he gets the test or not, assume that he may be “contaminated” for 7 days after he feels fine again.  If you have a spare bedroom, then suggest that you sleep there (remember that the bed he slept in should be considered “contaminated”).  Try to use a separate bathroom if possible.  Wash your hands often and clean all “high touch” surfaces (e.g. kitchen counters, door knobs) every day.  If he has symptoms such as a cough or fever, then try to even have him close the door to his room and put his food out in front of his door so he can pick it up when you are not there.  Use disposable plates or wait at least 24 hours (or use gloves) to clean dishes or clothes used by him.   

Make sure your husband gets plenty of fluids and rest.  Avoid sharing any household items, including such things as the remote control to the TV, with him.  Try to stay at least 6 feet away from him at all times.  You and others within the home should shower before bed if possible, to avoid bringing the virus into your bed or sheets.  Do not eat anything that you cannot heat up right before you eat it.   

Monitor Symptoms

The CDC feels that 1 in 4 people can be asymptomatic but may still pass the virus on to others.  The aircraft carrier Theodore Roosevelt reported 350 crew members tested positive for COVID19 and were asymptomatic out of a total of 600 infected.  The Tyson meat facility in WA state reported more than half who tested positive had no symptoms at the time of testing. 

Most COVID19 patients have mild symptoms:

   
Mild81%No symptoms or mild pneumonia
Severe14%shortness of breath, hypoxia or 50% or more lung involvement on imaging
Critical5%respiratory failure, shock or multiorgan dysfunction
   

The median time for a patient to develop the shortness of breath or other severe symptoms is 5 to 8 days.  The median time to critical symptoms or organ failure ranged from 10-12 days.  The median length of hospitalizations among survivors was 10 to 13 days. 

So, if your loved one has any symptoms, please call your doctor.  If self-isolation at home is recommended then monitor symptoms by asking, “are you the same as yesterday, better or worse?” for cough, fever and sore throat or tiredness. 

If you suspect COVID19 then please call your physician and ensure that your loved one has enough fluids and food as well as monitor their temperature (and perhaps even their pulse oximeter) and encourage over the counter anti-inflammatory medications for fevers. 

Your Loved One is Hospitalized with COVID 19

This is such a difficult time because there is still a stigma among neighbors about this disease and whether you are increasing their risk of getting sick.  Also, you may not be able to visit your loved one in the hospital.  Please use facetime or zoom or other video conferencing tools to keep in touch. 

Also please self quarantine yourself if you had spent time with your loved one who is now COVID19 positive.  Please let others who may have come in contact with COVID19 know about the test results as well.

I have several physician colleagues who have sent their entire family away because they could not risk getting them sick.  My hospitalist and Emergency Room physicians and nurse colleagues go in everyday to the hospital to take care of COVID-19 patients despite the fact that there are not enough masks or protective gowns or gloves.  The risk of your doctor or nurse getting sick from COVID-19 is so much higher than the risk for you.  But I have heard heartbreaking [A1] stories of these physicians and other health care workers being there at the patient’s bedside while they were dying because their families could not be present.   

Chapter Summary/Key Takeaways

Please do self-quarantine or isolate at home if you have any of these risk factors:  (1) You are immunocompromised (e.g. cancer survivor or having cancer treatments including chemotherapy; transplant patient; poorly controlled HIV or AIDS; prolonged use of steroids); (2) smoker or have COPD or asthma; (3) Severe obesity BMI of 40 or higher; (4) Diabetes; (5) Chronic kidney disease including dialysis; (6) Liver disease OR (7) 65 years of age or older. 

If you have to go out and are in these “high risk” categories, then please go early in the morning (some stores have special hours for seniors) and wear a mask.  If you have a loved one who is self-isolating at home, then please keep your distance from him/her; don’t share plates or food and try not to eat or sleep in the same room if possible.  

In the next chapter we will discuss some hospital stories and also tips from those health care workers on the front lines of this pandemic.  We will try to answer the question of when we will be able to return to normal etc.

Chapter Four: Hospitalizations Anecdotes

Fortunately, I am not on the frontlines within the hospital systems or emergency rooms.  Our local hospitals are trying to keep a “dirty clinic” for suspected COVID-19 patients and a “clean clinic” for those coming in with other life-threatening symptoms such as a heart attack or seizure. 

I know many think the news has sensationalized the COVID-19 pandemic.  I have personally spoken to many colleagues in the front lines.  They feel helpless and scared because they know they are getting exposed since they don’t have adequate protective gear.  This is a new virus, so we don’t have established guidelines on what works and what doesn’t.  It’s like drinking from a firehose on what may work.  Colleagues are sharing possible “miracle” cocktails but now we may be faced with drug shortages because India (where a lot of generic drugs are made) is on lockdown as are other countries. 

Many have heard that some antimalarial drugs may have potential as well as Remdesivir an antiviral drug.  But nobody knows for sure until more testing is completed.  

While I cannot share personal stories because of privacy issues there is a good report that I will include https://www.dailymail.co.uk/news/article-8138581/Coronavirus-frontline-NHS-doctor-reveals-patients-dying-agony-just-start.html

Quotes from the article online:

“Have you ever seen someone gasping for their last breaths?  Not many have, but for those who have experienced it, you will never forget the horror.  I wish I could forget all the faces of the dying I saw last week.  The look of panic across every face, the chugging sound people make as they desperately try, and fail, to get oxygen in their lungs.  It doesn’t leave you.”

“…a patient had had a respiratory arrest and I rushed across the hospital to attend a man in his 70’s with Covid-19 whose heart had stopped beating.  What I was met with when I arrived was sheer panic.  The staff, through no fault of their own, were hesitant in exactly how we should respond…They were all brilliant colleagues, respected professionals who have, like me, been doing their jobs for a long time.  There shouldn’t have been any fear for them.  But there was.  I could see it.  And I felt overcome with it, too.”

“Me?  I am asymptomatic, but I have been exposed to it – frequently.  I am, therefore, most likely carrying it, as are most of the medics up and down the country.”

“The virus has forced doctors to do something we should never have to do:  play God…Italy has already stopped intubating patients over 60…Once a patient is in critical condition with this virus, there is never more than a couple of hours before it kills.”

“It feels like we are trying to play some sort of computer game and with each day we enter a new, harder level.  We simply cannot keep up.  How much worse will it get?” 

Most of us have had trouble getting supplies.  But what’s worse is that there is a shortage in most American hospitals (and also European and British hospitals) of personal protective equipment (PPE).  These are the masks that both prevent healthcare workers getting sick and spreading the virus to others.  Dr. Frank Gabrin is a New York Emergency Room physician who recently died of COVID-19, 2 weeks after he texted a friend about his concerns over lack of medical supplies.  He had no choice but to use the same mask for several shifts against Food and Drug Administration (FDA) guidelines. 

There are stories of hope as well.  There is a Facebook group to support those whose families may have been affected by COVID-19, “Let there be Light”.  Some medical students are helping with childcare for health care workers.  Please say “thank you” to our doctors on the frontlines.  They are putting their lives at risk.  And unlike soldiers who are given helmets or firefighters who are given protective gear our doctors today are having trouble finding masks or gloves.    

Elective Surgeries

Please follow your doctor’s advice, but if you can safely delay non urgent surgery then consider doing so.  Supplies in certain areas may be in high demand so conserving this may be helpful.  Also, what if something goes wrong and you need to be hospitalized?  Since many hospitals are housing COVID-19 positive patients this may unnecessarily expose you to a higher risk of getting the coronavirus. 

Diet and Exercise

It is so important to drink enough fluids and to exercise to keep your body at its peak performance level.  Please do solitary exercises that are safe such as running outdoors, bicycling, or walking.  Please stay away from people outside your home. 

Chapter Summary/Key Takeaways

This virus can be deadly and is very contagious.  It’s new so we don’t know yet what works or what doesn’t.  The first patient in New Jersey who survived was discharged on oxygen and he was young in his 40’s.  So, although the chance of death or serious lung problems later is lower in the younger age group, it is not zero.  Like I tell my cancer patients who have some cancers that are 99% curable, this still means that 1 in 100 will die, and it could be you.  Therefore, take proper precautions to reduce your risk of getting this “killer” coronavirus.  And if you or your loved one has to be hospitalized then please make sure you have the ability to video call others. 

In the next chapter we will discuss what’s next to get us back to a normal way of living, resuming work, and how to prepare for the next pandemic so that won’t be as devastating. 

Chapter Five: Swab or Blood Antibody Test to Help Move Past This and Not Remain Hostage  23

As medicine and technology becomes more sophisticated, we have fewer infectious disease outbreaks or epidemics.  Please refer to this website which is updated twice weekly https://www.centerforhealthsecurity.org/resources/COVID-19/serology/Serology-based-tests-for-COVID-19.html or the FDA website. 

Reports suggest that the first human with the SARS-COV-2 was in Wuhan China on Nov. 17.  On April 8, China ended its lockdown of Wuhan after 76 days.  Nobody was able to leave the city during lockdown.  For more than 2 months, public transportation was not running, and businesses were shut down.  Residents were not even allowed to leave their homes for grocery shopping.  These were draconian measures.  Residents with a government issued green QR code on their mobile phones (green light for them being healthy and safe to travel) are allowed to return to work if their employer issues them a letter.  One person per household with a green QR code can leave his home for 2 hours per day.  Residents were not even allowed to bury their dead since the dead were taken straight from the hospital to the funeral homes for cremation.  I cannot imagine any Western country or democracy being allowed to impose such draconian measures on their residents.   

Singapore also had stringent stay-at-home orders which were police-enforced.  Violators can be jailed for 6 months or fined $10,000.  All overseas travelers will have to serve their 14-day quarantine notice at dedicated facilities instead of in their homes regardless of the country they are coming from.    

As Americans, we cherish our freedoms and our right to disagree with a mandate.  Hence we have anti-lockdown demonstrations, supreme court challenges as well as coronavirus ‘parties’.

The good news is that the number of deaths per 100 confirmed cases (observed case-fatality ratio) is one of the lowest in the US as compared to other European countries per Johns Hopkins data (https://coronavirus.jhu.edu/data/mortality):

 COVID19 Mortality per 100 confirmed casesPercent Population over 65*# 65+ (in millions)# Total Population (in millions)
Belgium16.4%18.72.1511.46
France15.6%20.313.1664.83
United Kingdom14.2%18.312.2466.83
Italy14.2%22.813.7660.34
Spain11.9%19.18.9947.07
Canada7.5%17.26.4437.41
US6.0%1652.76329.19
Germany4.5%21.417.7883.10

From 2019 Worldbank data (https://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS and https://www.prb.org/countries-with-the-oldest-populations/)

            There are 2 main types of testing used for infectious diseases:  molecular and serological.  Molecular tests detect the virus while it is circulating in the body.  Molecular tests are the reverse transcriptase polymerase chain reaction (RT-PCR) via nasal or oral swabs.  Serological tests (or antibody tests) detect evidence of the body’s immune response to the virus infection.  Serologic tests via blood draws can be positive after the immune system has successfully eliminated the virus. 

            Two classes of antibodies, immunoglobulin M (IgM) and immunoglobulin G (IgG), are common targets for serological tests because of their roles in targeting and destroying new infections. The immune system typically produces IgM soon after infection as a frontline defense, and IgG is generated later. Additionally, IgG persists in the body longer than IgM and contributes to longer-term immune memory, which enables the immune system to rapidly identify and respond to future infections by the same pathogen. IgA is another type of antibody, typically found in mucous membranes, that can be produced in high quantities during infections.  Data suggests than IgM peaks approximately 12 days after COVID19 infection and could last as long as 35 days while IgG has been observed to peak approximately 17 days after COVID19 infection and may persist (IgG was found to last as long as 2 years after recovery for SARS in 2002). 

            The accuracy of the test can be influenced by the known prevalence in the population.  For example, the sensitivity of a serological test is the ability to correctly identify a positive result for a sample that has the antibody.  The specificity is the ability to correctly identify a negative result for a sample that does not have the antibodies.  Positive predictive value (PPV) and negative predictive value (NPV) factors in both test accuracy (sensitivity and specificity) as well as the prevalence of COVID19 in the given population.  For example, let’s assume the same test was done in Alaska (low COVID19 prevalence) and also in New York (presumably high COVID19 prevalence).  PPV would be lower in Alaska because the number of false positives would be a higher percentage of the total number of positive tests in Alaska.  Conversely NPV would be higher in Alaska. 

The Johns Hopkins group provided this analysis:  Assume 15% of a population of 1 million people were infected with SARS-CoV-2 at some point.  Using a serological test with 95% sensitivity and 95% specificity for the entire population:

Total TestedTotal PositiveFalse Positive so at risk for infectionFalse NegativeComment
1,000,000185,00042,500 (22.97%)7,500Need serology test with 100% accuracy.  Roche ECLIA test made available May 2, 2020 claims specificity of 99.81% and sensitivity 100% 14 days onward

Restarting the Economy versus Increasing the Death Rate – it’s a fine line

The issue is that not everyone who had the disease had the opportunity to be tested before the virus was cleared from their bodies, and between 20-50% of people may have been asymptomatic.  Some individuals are seeking antibody/serology testing because a positive result (with a history of symptoms) may theoretically release them from the constraints of public health physical distancing measures. 

There are significant areas of uncertainty because the FDA has not performed a full validation process for   

The dilemma is that the more we intervene to deal with the medical emergency and reduce deaths then the more we put the economy at risk.  The stimulus plans are expensive, but they are not cures.  Many stores, restaurants, gyms, hotels, bars, coffee shops have closed their doors (some for good).  Big sporting events have been called off.  It’s almost like a science-fiction movie.  Normal life has stopped.  Covid-19 is a true Black Swan – a seminal event that came as a total surprise and has had a dramatic impact but which, with the benefit of hindsight, should have been obvious.  Covid19

China’s strategy to resume their factories has included (1) a travel ban so anyone arriving into China undergoes strict screening including temperature checks en route and upon arrival and goes into quarantine (where a quarantine notice is placed across their door which is removed and replaced for grocery deliveries) for 14 days.  For those who have a government issued green QR code on their mobile phones, they also have to provide details when their clock in each morning of their body temperature and whereabouts.  There are mandatory temperature checks at office buildings and parking lots.  It is reported that augmented reality glasses with built-in thermal imaging capacities are being used in some Chinese provinces by security staff.  The glasses can check the temperatures of hundreds of people in minutes; but will also make a “digital record” of a person with a fever and use facial recognition.  Thus, authorities there rely on vast surveillance and big data networks to monitor and track their citizens via technology shared with law enforcement agencies. 

The big question for us as Americans is whether we will allow large scale temperature monitoring as well as accept restrictions on our movements outside of work hours in order for us to be allowed to go back to work.  Will we allow our movements to be tracked by law enforcement agencies via our mobile devices?  Will we be willing to give up our individual freedoms until there is a vaccine or quick accurate antibody testing for the coronavirus?  That would be the fastest way for us to return to work.

There may be other ways that are not as restrictive.  For example, if you live in a state which is over the peak of the deaths then we can assume that the hospitals have some capacity in case more people get sick when they return to work.  We would need sufficient testing available in case there is an uptick of new infections.  Working from home may be possible for certain professions. 

Others may consider returning to work if they are younger and healthy which makes them a low risk to get severe or critical COVID19.  Obesity is a risk factor for getting the more severe form of COVID19.  Various vaccine trials are being considered.  Blood antibody tests may be another option but

 The first to return to work would be those under age 65 with no medical conditions (and not obese) who have demonstrated immunity or have had a positive COVID-19 test in the past.  We may have to accept a certificate on our phones on an app that we are virus negative (and we may need to accept repeat testing if we are COVID-19 negative).  This certificate may be required for airline travel, restaurant dining, or even socializing.  We may have to work in shifts.  We would need to continue social distancing, wear masks and not shake hands or share utensils.    

Ethical Dilemmas

There are so many ethical issues to consider with COVID-19.  Can we ethically bring people back to work and school and begin to resume things gradually even when we know that these actions may cause people to die?  But if we don’t restart the economy then people won’t be able to pay their bills and may lose their homes, businesses, etc. 

We will have to give up some of our freedoms if we want to return to work sooner rather than later.  We would most likely have to accept aggressive testing and accept quarantine measures if someone within our contact tests positive.  We need rapid results from these tests akin to the results from strep throat which is available within minutes.  The CDC Director on April 10, 2020 said, “We can’t afford to have multiple community outbreaks that can spiral up into sustained community transmission – so it is going to be very aggressive, what I call ‘block and tackle,’ ‘block and tackle.’”  For context, in February, the World Health Organization reported that in Wuhan, China, to contain that outbreak, “1800 teams of epidemiologists, with a minimum of 5 people/team, are tracing tens of thousands of contacts a day.”  I have faith that in the US we will be able to harness technology to do this more efficiently so may not need as many teams. https://www.npr.org/sections/health-shots/2020/04/10/831200054/cdc-director-very-aggressive-contact-tracing-needed-for-u-s-to-return-to-normal

Chapter Summary/Key Takeaways

Once we have enough test kits for either coronavirus infection (nasal swab) or antibody (finger prick for blood) then we will be able to discuss pros and cons of returning to work for the low risk population if we are willing to give up some privacy so aggressive contact tracing (i.e. old school detective work to find each sick person and figure out who they recently interacted with).  But will we as Americans voluntarily share with public health officials where we have been and who we have been in contact with?  The only way to break a coronavirus death grip is to cut the circle before it gets complete.  If a person tests positive for an active infection, then their recent contacts will be tracked down too.  The process continues until everyone who has been exposed is out of circulation (i.e. quarantined).  That stops the virus from finding another human to infect. 

On April 10, 2020 Google and Apple announced they will collaborate on an app using Bluetooth data to track when they’re near each other.  If someone tests positive for the virus, they could tell the app which would then notify all the people whose phones were nearby.  But then everyone within this contact list would have to voluntarily agree to be tested and/or be quarantined.  

Epilogue/Conclusion

From a medical standpoint the United States is doing better than originally anticipated when this pandemic began.  We have serious issues we need to address for the future including shortages of medical supplies and ensuring a plethora of test kits.  But many may recall that the initial analysis published on March 16 2020 was that “In total, in an unmitigated epidemic, we would predict approximately 510,000 deaths in Great Britain and 2.2 million in the US, not accounting for the potential negative effects of health systems being overwhelmed on mortality.”  DOI: https://doi.org/10.25561/77482

Another site began tracking death rates within the US, and based on government mandated social distancing (e.g. stay at home, educational facilities closed, non-essential services closed, travel severely limited) estimated that these measures may result in 61,545 deaths (and this is down from around 90,000 deaths a few weeks ago – these numbers are constantly adjusted based on restrictions put in place).  https://covid19.healthdata.org/united-states-of-america

The Federal and State Governments are trying to help but the coronavirus pandemic has placed severe strains on our health and economy.  The big question now is how to continue these measures that work to stop the spread of this virus and deaths but how to restart the economy.  Many of my friends see salary reductions or bankruptcies in their future if the situation does not improve.   Scary health numbers have now been joined by some scary economic numbers.  The collapse has been instantaneous, faster than even during the Great Depression.  We are facing an emergency and I hope you do your part to reduce your risk of getting coronavirus.  As Dr. Anthony Fauci, the director of the national Institute of Allergy and Infectious Diseases, put it, “You’ve got to be realistic, and you’ve got to understand that you don’t make the timeline, the virus makes the timeline.”  But you, my friends, can help show the virus the path to its own self-destruction by doing the right thing:  keeping physical distance of 6 feet, frequent hand washing and not touching MEN (mouth, eyes or nose).      

Bibliography

Internet Documents:

These have been referenced next to graphs etc.  I used a lot of CDC, WHO, FDA websites. 

Online Periodicals:

Again, these are in the text.  I used mostly peer reviewed articles

Acknowledgments

Thank you to my patients, colleagues who are risking their lives, and also you my readers for your trust in me over the years.  These opinions are my own and please forgive me if I have overlooked a good resource.  You can reach me via my website https://sheilaregemd.com/

About the Author

I am a radiation oncology physician within WA state.  I founded Northwest Cancer Clinic and am currently Regional Medical Director.  I was honored as the recipient of several research awards and also the Top Doctor and Oncologist Award.  I am currently Chair of the Washington State Health Technology Clinical Committee and Clinical Associate Professor at WSU Elton S. Floyd College of Medicine.  I am the President of the American College of Radiation Oncology and Board Member of the Washington State Medical Association.  I also volunteer on an AMA committee whose goal is to improve US healthcare delivery.

I have been fortunate to have many mentors who have helped guide me to these leadership positions.  Most importantly, I have been blessed to live and work in a wonderful small community and make a difference. 

Thank you!

Sheila Rege MD


 [A1]Heartbreaking??

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