Covid-19 Q & A Update
3/27/20
Q: Is it helpful to wear a surgical mask?
A: Almost certainly yes. It’s hard to find surgical masks right now, but if you have them, judicious use of the mask with good quality hand hygiene is probably quite effective against the virus. The most useful scenarios are in close contact with other people. The best time to use the mask would not be in wide open spaces where droplet and aerosol transmission is unlikely, but in tight enclosed spaces with other people, especially if these spaces are air conditioned. Here is an article written about the spread of Covid-19 on a Chinese bus. It is speculative and uncontrolled, but potentially instructive in regards to surgical mask utility and spread of virus on public transit.
Q: Can the virus be spread by people without symptoms?
A: Almost certainly yes. There are several medical publications that use known cases and their close contacts to demonstrate asymptomatic spread. Here is one of them. The logic of such papers goes like this: patient 0 comes from out of town and spends 2 days with family members and then leaves town again. On day 3, patient 0 becomes symptomatic and tests positive for covid-19. The family members are tracked down and subsequently develop symptoms despite no other known contacts. The only possibility is that patient 0 became infected prior to visiting and spread the infection during the asymptomatic period.
Q: How does the virus spread?
A: The primary method appears to be close contact with an infected individual. Infected individuals secrete viral particles in nasal mucous (runny nose, sneeze), expectorated sputum (coughing), saliva, and stool. When an infected individual blows their nose, coughs, or sneezes, tiny droplets of mucous fly through the air and can land on nearby surfaces, or your face or hands, or they can be directly inhaled. The virus can infect the nasal mucosa, the cells in the lungs, or it can get into your eye directly or by touching a droplet and then touching your eye. The eye itself does not become infected, but tears wash the droplet into the tear duct which drains into the nose where infection occurs. Direct droplet spread and self-inoculation are likely the primary methods of infection.
Surfaces
The viral RNA can definitely be found on surfaces such as cardboard, plastic, and metal, but to my knowledge, nobody has yet demonstrated that the presence of RNA on these surfaces is definitively infectious. Still, it is best to assume that any surface (including delivered packages) can be contaminated, and to disinfect them to the best of your ability.
Aerosols
The virus may also spread as an airborne aerosol in some circumstances, but this also has not been proven. Airborne/aerosol spread is different than droplet spread in terms of the size of the particle and how long it’s suspended in the air. Droplets usually don’t make it more than 6 feet away from the source before falling to the ground within seconds to minutes. Aerosols could stay airborne for hours and travel much further. Airborne transmission is probably minimal in most conditions – but is probably responsible for some subset of transmissions (this might be especially true in enclosed spaces with turbulent air flow, such as hospital rooms, and public transit.)
Q: What can you do to minimize chances of infection?
A: Wear a surgical mask, wash your hands, stay away from infected people. The WHO and CDC are not blowing smoke on hand washing. Fastidious hand-hygiene is important. I also strongly believe that surgical masks are very protective against spreading this disease. There is a “shortage” of masks, so you might have trouble buying them right now, but if you already have some, they are best used to cover the nose and mouth of infected individuals or to protect oneself in close-contact situations (think public transport, packed stores, etc.) IT IS IMPORTANT NOT TO CONTAMINATE YOURSELF BY TOUCHING THE OUTSIDE OF A CONTAMINATED MASK AND THEN SELF-INOCULATING. The reason for confusing mask recommendations is that some healthcare providers are running out, and a public run on mask supplies would make it even harder for healthcare personnel to get their hands on masks. So, authorities are recommending against masks to maintain supply chains. But, it looks to me like there was a run on masks anyway — people generally don’t trust a recommendation to not protect themselves. So, if you have masks, protect yourself. If you have a lot of extra masks, consider donating them to a major city that is struggling, or a local hospital that is running short. Call your hospital, they should have someone responsible for tracking down and obtaining protective gear.
Q: Are hospitals over-run?
A: Some are. At this point, everyone probably knows that many hospitals in and around NYC are over full-capacity. They are running out of equipment, ventilators, and ICU beds. If you live in or around a major city right now, there is a good chance that healthcare resources are scarce. But, hospitals in more suburban or rural areas have had two plus weeks to prepare and many of them have seen massive cuts to their usual volume. Elective surgeries have been cancelled nationally. Routine outpatient visits have been cancelled. And, anecdotally, it seems like people are avoiding hospitals as much as possible. So, some hospitals have far more capacity than usual, but those in many big cities are swamped, or they’re about to be. Even if your local hospital is well-prepared, this is something that could change quickly. It’s very easy for this virus to take hold in a nursing home or rehab facility and cause people who are already elderly and chronically-ill to all be infected in a short period of time. Several dozen of these patients becoming simultaneously ill would easily consume a major hospital system’s critical care resources. The bottom line is that hospital status is extremely variable right now and depends largely on your local population density and the preparedness of your local health system.
Q: When will this be over?
A: Weeks to months – best case scenario – 8 weeks (Starting on 3/27/20). At this very moment, if we stopped the spread of the virus, we would still have two weeks before we would even know that it was stopped, and likely another two weeks to see how existing cases will resolve. This means we have at least another month of uncertainty, and probably more. Many experts are optimistic that our “social distancing” and warmer weather will slow the spread of the disease, which I think is likely, but I think we’ll see throughout the year bursts of infection as this virus inevitably finds its way into nursing homes, group homes, etc. For the average person, I am optimistic that within 6-8 weeks, we will have a significant national slow-down in spread, robust healthcare responses and preparation, a solid and wide-spread understanding of prevention in terms of mask-wearing and hand-hygiene, and a private sector response in the way of manufacturing tests and supplies.
Q: Are there any useful treatments or preventive strategies?
A: Yes and No. If you’re not yet ill or only mildly ill, there are no treatments other than routine supportive care (antipyretics like acetaminophen, rest, and fluids). If you’re severely (requiring oxygen) or critically-ill (requiring a ventilator), there are several treatments being used. Medications – notably hydroxychloroquine and azithromycin are being used in hospitals to treat severe cases, but the data on these treatments are not promising at the moment. Life-threatening side effects of these medications are real, including sudden-cardiac-death from malignant arrhythmias. See below:
By BruceBlaus – Own work, CC BY-SA 4.0, Link
The top tracing is a normal heart rhythm. It’s called Sinus rhythm.
The waveform below that is called ventricular tachycardia (v-tach). The top rhythm reflects an organized firing of the heart’s electrical system, which causes each chamber of the heart to fire sequentially to maintain normal blood flow. The bottom rhythm shows v-tach, a life-threatening arrhythmia that in some cases can degenerate and cause sudden death if the patient does not receive defibrillation quickly. Below is what the heart looks like when it’s shocked out of v-tach into normal sinus rhythm.
It’s because of this potentially deadly complication from medications, along with the propensity of the virus to cause cardiac involvement and increase the risk of arrhythmia, that doctors are hesitant to recommend these medications in the absence of strong evidence that they work.
The mechanism of action of hydroxychloroquine is thought to be the blockade of endosomal acidification. The endosome is a membrane bound organelle within the cell that can harbor viral RNA.
Viral RNA requires certain conditions to travel within the cell and to replicate. One of these conditions is thought to be a particular pH. Hydroxychloroquine may inhibit viral replication by increasing the pH of the endosome, the tiny organelle that houses viral RNA within the cell. Essentially, the supposed mechanism of this medication is to prevent viral replication rather than effect the devastating downstream effects that occur when a patient is critically ill.
So, if the medication is going to work, it probably works best early in disease when the virus has not yet infected lots of cells. But, early on in the disease process, symptoms are usually very mild and the most likely clinical course is recovery (it’s possible that as many as 50% of infected people never develop symptoms at all; of the remaining 50%, only about 1/3 may go on to develop severe or critical illness). With odds this good, taking a dangerous medication is usually imprudent considering the potential side effects, which in some cases can be deadly.
Other treatments under investigation are: Remdesevir (unavailable unless you’re critically ill), and Kaletra (an HIV med that is very expensive, potentially dangerous, of limited availability, and of questionable efficacy). I’ve read that vaccines are already in clinical trials, but expert infectious disease physicians don’t think we’ll have an effective vaccine for 1+ years, and even then, the first to receive it will likely be healthcare workers.
So, essentially, there is no known safe and/or effective treatment that can be taken prophylactically or early in the disease course. Available treatments, though likely of limited efficacy by the time they are used, are best used in severely or critically ill patients. I hope this will change very soon, and it is what I am spending most of my time researching.
Regarding prevention, the best things you can do are to be fastidious about distancing, hygiene, mask wearing, nutrition, sleep, and exercise. Nutrition, sleep, and exercise are incredibly important for immune function. It’s clear that metabolic syndrome (diabetes, hypertension, obesity, fatty liver, and coronary artery disease) puts people at high risk of severe complications. It’s easy to binge on ice cream when you’re anxious and stressed at home, but don’t do it! You’re making yourself less fit and more likely to have a bad complication from infection in the case that it happens. The better thing to do would be to exit isolation in a few weeks in the best shape of your life.
That’s all for now – please feel free to send me questions and I’ll do my best to answer. The best place to contact me and to see what I’m reading is my Twitter account.
Steve – 3/27/20
Developments in the past Week
3/19/20
Spread of Disease
Despite social distancing, the threat seems to remain high. What is notable, however, if you look at the Hopkins Map of Covid-19 cases, is that major metropolitan areas such as NYC and Seattle are really suffering, whereas other areas don’t seem to be. South Carolina for instance, where I live, still only has 60 cases as of this morning, and only 1 in Spartanburg County. It appears, at least for the moment, that those of us who live in more suburban or rural environments may be spared an extremely rapid spread of this disease.
That’s not to say, however, that a few unfortunate events, such as the spread of the virus within a nursing home or similar facility wouldn’t place undue strain on a particular local health system. Overall, I am cautiously optimistic that the spread of this virus within the majority of the country will be attenuated by social distancing and by our relatively low population density and personal interactions as compared perhaps to Wuhan or Milan.
Healthcare Readiness
Much has been said over the past week about “flattening the curve” so that health care resources can meet demands. Based on discussions with colleagues, it seems as though many health systems are in an aggressive preparation stage. I believe that within the next 2-8 weeks, most health systems will likely be far better prepared than they were 1-2 weeks ago, and that in areas with less dense populations, it seems quite possible that there will be adequate resources to take care of sick patients. Many epidemiologic models predict that the nation’s # of ICU beds and # of ventilators will fall far short of critically ill patients in the coming months, but my analysis is a bit more nuanced. I may turn out to be wrong, and I am certainly not an expert in this area, but I think that rather than an even distribution of scarcity of resources, what will more likely happen is a regional resource mismatch.
What I mean is that, as mentioned above, areas like NYC may struggle to care for a huge spike in critically ill patients, whereas a more suburban or rural area may have excess ICU beds and ventilators. Perhaps these resources will be redistributed over time, or patients will be moved around by the voluntary cooperation of health systems, but my feeling is that small communities will have smaller outbreaks, which occur slower, and may be adequately cared for.
Prevention and Treatment
There is no specific medication or vaccine yet developed for prevention. The actions I am taking at this time are to avoid close contact, perform maniacal hand hygiene, avoid self-inoculation (by touching the mucous membranes of the eyes, nose, and mouth), and to obtain adequate sleep, nutrition, exercise, and stress management (see previous post below for specific suggestions).
Medications have been discussed in the news and by the president today – most notably, Chloroquine and Hydroxychloroquine. Based on the data I’ve reviewed (which can be found here), I have no reason to believe that either of these medications (or other experimental treatments that are being used in other countries) is going to make a huge difference in this disease. These data are low quality and premature, but I wouldn’t be relying on these drugs as a cure by any means. The best plan at this point remains avoiding the disease. Given a limited supply of the drug, its side effects, and that it is an unproven therapy for Covid-19, doctors, especially at first, will be unlikely to prescribe this for prophylaxis or for treatment of mild cases in “low-risk” individuals.
Some Optimism
Despite the overwhelming feeling that the world is coming to an end, there are a number of silver-linings here.
- The virus and the disease it causes are being aggressively studied and are becoming better understood. Even if we are months or years away from better treatments or a vaccine, supportive care will improve, and I believe morbidity and mortality along with it.
- Doctors and nurses have a lot of skin in the game. This virus is a threat to us all, even relatively young healthy people. Doctors and nurses always want their patients to do well, but this is even more the case on an emotional level when the disease that threatens the patient is also a threat to the doctor or nurse.
- Because this disease is a pandemic, and there is a national emergency, people are getting out of the way. The normal rules and regulations that hamper health systems, scientists, pharmacology companies, doctors, and nurses are being withdrawn so that brilliant people can fix this problem. Medical licensing regulations are being relaxed, the FDA is fast-tracking medications and vaccine trials, and CMS is making exceptions for telehealth to operate the way that it should. It’s more likely than not that geniuses will bail us all out of this mess if we let them, and we should thank them for it endlessly.
- I’ve spoken to many friends and family who report that this time period, though scary, is one of the most relaxed, still periods they’ve had in their lives.
- The next phase of this situation is likely coming as the availability of testing increases. My hope is that, once we have the ability to test people at will, including antibody testing to identify those who may have immunity to the disease, we’ll be able to identify those who need to self-quarantine and those who can resume their daily lives. This should happen quickly, and as it does, we can get back to doing what we all do best.
As always, please feel free to contact me with questions, comments, corrections, or disagreements.
-Steve 3/19/20
Current Risk Assessment and Action Items
3/16/20 Update
I am Still in favor of Distancing for 1-2 weeks
It seems as if most voices in the general media, government, and social media have caught up with the recommendations of medical professionals from ~ 1 week ago to enact “social distancing,” and to minimize gatherings. There is a 1-2 week lag time between infection of Sars-CoV-2 and manifestation of severe symptoms, and another 1-2 weeks before development of respiratory failure, need for ventilation, and then subsequent demise or “recovery.” We might not be able to stop our lives for much more than a few weeks, but being exposed and getting sick later is better than being sick now. I believe that even a short delay will give medical professionals the time they need to become accustomed to treating this illness and will give people a better chance at survival. To my knowledge, there is no ground-breaking treatment or vaccine on the way any time soon, but every day that passes, at least those who are working on these solutions will have more time to do so.
Severe and Critical Illness in the US
We are finding out this week and next how many people are infected and how many of them will become critically ill. We’ll also learn if we’re able to achieve better outcomes here than have been achieved in other countries. Based on reports from the medical community in our country, the presence of severe disease in the US is appearing just as it appeared in China and Italy. Exactly how these numbers will shake out is an unknown, but one thing is certain, this is not a cold virus or an influenza. I don’t have any good reason to believe that in the past 1-2 months, we’ve learned enough to stop the 0.5-5% case fatality rate being seen elsewhere. Currently, as of this writing, there have been 769 cases in Washington State with 42 deaths for a CFR of 5.5%. From unofficial reports that I’ve heard, the majority are 60s-80s+ in age, but 20s-50s are not exempt from severe illness, even if previously “healthy.” These reports are lacking in detail, but are sobering for me as a medical professional, to say the least. The last thing to consider is that I’ve seen no reports of what it means to “recover.” The people who are making it out of the ICU and off of vents may not recover normal heart or lung function afterwards. It’s too soon to tell. I am taking this disease quite seriously and trying to buy as much time as possible.
Corrections and Updates to Prior Posts
- I removed my initial video to prevent any confusion. Most of it was accurate, but there were a few things I thought at that time on 3/4 which are now less certain. It’s also redundant content given how much time has passed and how much content is now available.
- Fecal-oral spread is a theoretical possibility. Avoid putting contaminated hands in your mouth. Though I still think this is a less likely route of transmission, it’s certainly not worth it. Avoid touching eyes, nose, mouth, face with infected hands.
- Risk to the young – seemingly remains quite low. Age 20 and under seem to be almost untouched in terms of critical illness and death. There are reports of critical illness in people aged 20-40, though still low. The older (50s-80s) and those with metabolic syndrome or its constituent elements (obesity, hypertension, diabetes, coronary artery disease, etc) seem to remain at very high risk.
High Yield and Trusted Resources
Action Items (This is what I am doing)
- Storing 2-3 weeks worth of non-perishable foods and water – (beans, legumes, rice, pasta, oatmeal, frozen meat/fish/vegetables, nuts, seeds, energy bars).
- Getting delivery of 1-3 days worth of fresh foods – meat, fish, vegetables, fruit.
- Maintaining a low-moderate intensity workout program which includes body weight movements such as pushups, pull-ups, burpees, planks, and air squats.
- Maintaining a normal sleep and work schedule which includes minimum 7 hours of sleep (8 hours in bed), and focused work during the day.
- Eating a healthy diverse diet with a full complement of nutritious foods, and a focus on maintaining my weight without developing any additional risk factors for metabolic syndrome.
- Maintaining a positive outlook and preparing to live and prosper post Covid-19.
- Preparing mentally for the likelihood that myself, a friend, an acquaintance, a colleague, or family member will become sick or even die. If Rose Schindler can make it through Auschwitz – we can make it through this.
- Afraid you could die? Me too. But, almost all of us will live. Ric Elias taught me how to make this a positive experience when he shared his story of almost dying when his plane landed in the Hudson River.
- Avoid spending much time on social media, or watching or reading the news. You already know what you need to do.
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Social Distancing for 1-2 Weeks and Then Risk Reassessment
3/13/20 Update
If the average incubation period is 7 days, then each of the roughly 1,000 new diagnosed cases in the US in the past week had the potential to spread disease for 7 days prior to diagnosis. There are debates on the transmissibility of the virus from asymptomatic carriers, but there is convincing data that it is occurring. Out of the people diagnosed 7 days ago, a portion of them are in the hospital. There is a 1 week time period from symptom onset and hospitalization until shortness of breath, and another week until ICU admission, and yet another until recovery or death. These numbers are averages, they’re from China, and they may not be perfectly accurate or representative of what’s happening here, but it’s the best I can find. If these numbers are close to representative of our situation, you can see that, the new cases diagnosed in the past week are potentially a small reflection of the true case load, and critical illness and death has yet to manifest. Minimizing your risk of exposure for 1-2 weeks should allow us to see how the numbers are going to shake out, and will give people a chance to get a better handle on the risk. During this time period, hospitals, doctors, and nurses will be able to better prepare. Buy some time and stay safe.
Sources
Revised Risk Reduction Thoughts
3/11/20 Update
I think there’s been sufficient spread of the virus in the US and enough evidence of community spread that I am revising my thoughts. I am personally limiting my public exposure to essential activities only, and I am making the same recommendations to my friends, family, and clients. I will of course be working in the hospital, but other than this, I plan only to go to my home until there is a better understanding of the rapidity of spread and the severity of disease in my community. I am taking a proactive and cautious approach rather than a reactive approach, which right now might make me look like an alarmist. I hope I am wrong, but the opposite choice seems like it could be too costly. I think, based on available data, the chance of a young person, roughly age 20-40 who is otherwise healthy, becoming critically ill or dying is still quite low, but definitely not 0. For this reason, I am comparing this very unlikely, but catastrophic outcome, to its alternative. And for me personally, there is nothing I’d rather do than keep living. I am also sensitive to the fact that as an ER doctor, I am at an increased risk of exposure, and given the average of 9 days of asymptomatic viral shedding that is theorized to take place, I do not want to expose friends, family, or members of the public. Given that there is no vaccine and only experimental treatments, the best strategy I can see for individuals is to reduce the likelihood of becoming infected at the same time as many other people, and to reduce the chance of multiple family members becoming infected simultaneously as well. Giving yourself more time means that the medical community has more time to learn how to best diagnose, prognosticate, and treat this infection. You’ll also give yourself time to benefit from any pharmacologic achievements, of which we are sorely in need. Lastly, I’ll leave you with this quote:
“We do not think that tragedy is our natural state. We do not live in chronic dread of disaster. We do not expect disaster until we have specific reason to expect it, and when we encounter it, we are free to fight it. It is not happiness, but suffering, that we consider unnatural. It is not success but calamity that we regard as the abnormal exception in human life.”
http://bit.ly/2xqqCEF
Original Post from 3/4/20
As an ER doctor, I am probably going to contract Covid-19. I am slightly worried about this, but all evidence at this time points to an over-estimation of the severity of the disease. There is likely reporting bias in favor of recognizing and reporting only severe cases. Most of the mortality is in older individuals with pre-existing cardiopulmonary problems. That said, this does appear to be more severe than current strains of influenza, so some precautions are reasonable. Follow my twitter feed for updates, and see the bottom of this page for links to high-quality sources and primary literature on the topic.
In the video I reference airborne spread of disease, but I did not elaborate on this. Sars-CoV-2 can spread in droplets that settle 3-6 feet from where they were originally generated – usually from a cough or sneeze. I also mentioned N95 masks – N95 masks filter 95% of particles above 0.3 microns.
Overall, I agree with Amesh Adalja @ameshaa who thinks that containment is not a viable strategy at this point. It’s likely that many if not most people will be exposed to this virus at some time. The only good reason I can think of to actively try to avoid exposure now, is that this virus may be less robust in a month or two when weather warms. If you are able to avoid infection this season, there is a chance of being vaccinated (if it is developed in time) before next season when this virus is likely to return.
Lastly, if you do have a history of cardiopulmonary disease such as heart failure or COPD, attempting to avoid infection to the best of your ability is a very good idea. Anyone who begins to feel short of breath should seek immediate medical care.
My goal here is to provide distilled, accurate, and timely information. Please feel free to leave feedback, comments, or questions below and I’ll do my best to respond. You can also contact me using the contact page.
See this post for help with symptomatic management (pertains to upper respiratory symptoms only) and info on the specific zinc lozenges that I use for acute upper respiratory infections. This is the supplement I use for routine zinc repletion. (Update 3/16/20 – It’s true that there is no published evidence to suggest that taking zinc will prevent or treat infection with Sars-CoV-2 / Covid-19)
Embedded Twitter Feed
Sources
Disclaimer: As always, none of the material on this site constitutes medical advice or a medical recommendation. The information on this site does not constitute the practice of medicine, nursing, or other healthcare profession. No doctor-patient relationship is formed. The use of the information on this site is at the user’s own risk, and you should not delay or neglect to obtain medical care. These opinions are my own and do not represent those of my employer. See my full disclaimer here.