Keep Calm (and Wash Your Hands)

I had an encounter with a hysterical woman at Walmart on Monday. She was in a state of panic over the coronavirus. After getting home, I reached out to a good friend who is an MD, who has been training with me and others for years. I asked him if he could give his perspective and some advice.

I assume that most of you who first read this are already squared away, and not freaking out. But we all have friends who have friends that might benefit from this info, and it might help keep them from losing their minds.

— Jared

COVID-19 is the newest member of coronavirus family discovered in Wuhan, China in December 2019. The other two known coronaviruses since 2003 are SARS and MERS. Coronaviruses appear to originate from bats and are spread from the bats or an intermediary host. The intermediary host for SARS is civet cat, and for MERS is camel. The intermediary host for the newest virus discovered in 2019 is unknown. SARS has mortality rate of 10%-15% and MERS has mortality rate of 30% but they are hard to catch or transmit and therefore are not very contagious. COVID-19 is very contagious but seems to have lower mortality rate. The numbers for calculating the mortality is mostly from China which could not be trusted. If what they report is correct then their mortality rate was 2 to 3%. But this does not consider those with no symptoms or mild symptoms who never presented to the system which would make the mortality rate less. In contrast the mortality rate of Spanish flu in 1918 which killed 50-100 million people was 1.2%. Regular flu has 0.1% mortality in developed countries.

This virus appears to be essentially a respiratory virus and kills by causing a viral pneumonia, destroying the lung. But unlike other known respiratory viruses, it also spreads by touch. This is because the virus is able to survive on a typical surface for up to nine days at regular room temperature, and longer in colder temperatures, but only survives a few hours at temperatures above 80°. In addition, it has been reported to be present in feces, urine, blood, and saliva, therefore more easily contaminating surfaces.

It has been isolated and recovered from bathroom door knobs, sink knobs, toilet seats, and regular household surfaces. Touching these areas and introducing the virus to near your respiratory system (by touching your face, etc.) will cause an infection. It also appears to need a small number of particles to cause an infection unlike some other viruses that require a large amount of particles. The respiratory airborne route which appears to be the main form of transmission is by droplets. These droplets are about 0.05 µm in size and thought to be airborne and able to travel up to 6 feet away. Droplets are produced as expected by coughing or sneezing, however, they also can be produced by simple talking, laughing, crying etc. Therefore, a simple conversation at a close distance can possibly expose one to possible infectious particles, although coughing and sneezing is a much more common and efficient cause of droplet spread.

Avoiding touching one's face and keeping appropriate distance are two ways of decreasing the risk of acquiring an infection. Large gatherings where larger numbers of individuals are in closer proximity have a higher risk of spread. Getting the virus on one's clothing by coming in contact with a contaminant surface and then touching that part of clothing and touching one's face is another example of infection spread. Handwashing is one possible way of decreasing infection rate, and face-washing is helpful if exposure to droplets has occurred.

Hand sanitizers containing more than 60% alcohol also appear to deactivate or destroy the virus. Regular household cleaners appear to be effective for cleaning services. The most effective obviously is bleach – however, ammonia, Lysol, etc. appear to have significant benefits as well as does alcohol. Because of the easy method of spread by airborne particles or contaminated surfaces, it is advisable to isolate infected individuals to a specific room with the doors closed and minimizing common interactions as much as possible. It's best to clean possible affected surfaces on a daily basis. Typically, in healthcare setting gown, gloves, and N95 masks will be used and discarded after each use. N95 mask will filter particles of 0.03 µm or larger. The mask must fit correctly so that no air can enter from above or below the mask and therefore is a tight fit. There are two types of N95 mask, one is cup shaped and the other is folded duckbill shape mask. The second type is more appropriate for individuals with facial hair. Regular masks usually have poor fitting and easily allow air from above and below mask to enter behind a mask and typically do not have the required small particle filtration.

Frequent use of hand sanitizers when handwashing is not possible is effective. Due to hoarding of supplies, hand sanitizers are difficult to find. One can make his or her own hand sanitizer by using a clean, preferably sterile container. Fill two-thirds of the container with rubbing alcohol (91% alcohol content). Add a quarter of the container’s volume in aloe vera gel and fill the rest with distilled water (or regular water, if distilled is not available). Mixing this solution is as effective as any commercially available hand sanitizer. Due to shortage of N95 masks, as long as the mask is not visibly soiled, destroyed or compromised, the mask can be reused with careful attention not to touch the outside surface of the mask, which may be contaminated with particles.

In my 32 years of practicing medicine, this virus seems to be one of the most contagious, if not the most contagious virus that I have known. This also appears to be the view of other physicians in the field that I know of. In Wuhan, 1,700 Chinese health workers contracted the disease, presumably in spite of protective devices - although the level of skills and professionalism is unknown. This makes a pandemic very likely and the likelihood of most, if not all, coming in contact with the virus is much higher. The highly contagious nature as well as multiple modes of transmission (which is different than typical pathogens) raises the question of the virus being man-made or manipulated. At this point the evidence is not there.

An unknown portion of infections are asymptomatic and these individuals are able to infect others. There was a report of a Chinese woman who had a meeting in Germany where she had no symptoms until a few days later, when she was back in China. She infected everyone who had shared the conference room with her in Germany.

Another, larger percentage of individuals tend to have mild symptoms. A small percentage, approximately 15 to 20%, will have significant fever and respiratory symptoms, with 10% requiring hospitalization and half of those have required ventilator support. Children appear to be least susceptible to the virus and have the least amount of infections. It's not clear why. Since mass testing has not been done in children it may be that they have a higher rate of asymptomatic infection and are spreading the virus without realizing it. Most of the individuals with severe illness are in their 50s or older age. However, individuals in their 20s and 30s who were healthy have died because of the virus (as recorded by the Chinese), including two physicians with good health in their system.

Individuals with significant lung disease or heart disease or other significant medical history tend to be at higher rate of dying. Individuals who have immune-suppressed status, either due to medication, transplant, or other causes are also at high risk of dying. Elderly with extreme age seem to have very high rate of death and therefore all these classes of individuals would need to be protected from others who could spread the virus unknowingly.

If humans are the main reservoir of the virus, then theoretically, once either everyone is infected, or immune, or has succumbed to the virus, then the virus should disappear, since it would not have any host to survive in. However, the Chinese claim that they have evidence of mutation in the virus and therefore they have isolated two different viruses. If this is correct and the virus can mutate the same as the flu virus, changing year to year, then this problem could be with us for many years and will change our way of life drastically.

Avoidance of contact with infected individuals or surfaces is the best way to avoid contracting the infection. However, this may not be possible for most, especially those in service employment. Once one has contracted the infection, the best action would be avoiding other individuals to limit the spread by isolating oneself in a specific room in the house. Visiting your physician or healthcare facilities would not be of any benefit since there is no good treatment at this point, although some drugs are being studied. If the patient has significant respiratory symptoms, mainly shortness of breath at rest or air hunger, then that's the time to present to the emergency room for more aggressive treatment.

Not every respiratory illness is from coronavirus, so if you are feeling significantly ill, then always call your physician to obtain his or her advice. Ignoring self-isolation, either because you have to do your job or nobody else can put food on the table or another reason, is only going to increase the spread of infection and affect someone who may be susceptible to it, resulting in death.

The incubation period for the virus appears to be 14 to 18 days in most people, however, it has been reported as low as one day and as high as 23 days. Most people, once they have symptoms, tend to progress to shortness of breath on day 6 to 9, if they're one of those with more severe symptoms. The initial symptoms seem to vary, however, the most common are fever (which may be low grade) followed by cough as the next most common symptom, which is usually a dry cough. Sore throat is the next most common symptom. Achiness, as well as diarrhea, may be present. However, these tend to be 20% or less of cases. There have been reports of individuals being infective to others within one day of exposure to the infection and individuals being infective as late as 23 to 25 days after infection. Some seem to have very little symptoms, indicating mild disease and progressed to death within few hours. Others have a slower process with respiratory failure 8 to 10 days after start of symptoms on average.

There is an intravenous medication named Ramedisivir that appears to be effective and is being studied. A medication in Japan called camostat mesylate appears to block the virus from attaching to lung cells to destroy or infect the cell. This can be purchased online, apparently. The dosing I guess to be one pill 3 times a day for 10 days. There are other medications that are Protease inhibitors, which may be beneficial in stopping the virus. Virus uses Protease in order to infect the cell. Studies are ongoing. Vaccines will be developed, however, these are 6 to 12 months away. The virus is an RNA virus. However, it's not clear if some of the medications which are effective against RNA viruses are of any benefit in this virus. One example may be opuntia streptocanta, also known as Prickly Pear cactus, which in laboratory studies by National Institute of Health, has been shown to stop influenza virus and other similar viruses. Vaccines developed for other two coronaviruses do not appear to be protective against the new one.

The above information is based on scanty preliminary information from initial infections and sometimes unreliable sources, such as China. Some info is speculation and not necessarily advice. We have yet to learn much about the virus and its function and long-term effect. However, what is clear is that avoiding large gatherings, frequent handwashing and use of hand sanitizer, effective hygiene, frequent cleaning of surfaces, as well as correct covering of mouth and face with one's elbow while sneezing or coughing, etc. can decrease rate of infection. Protect the vulnerable and remember that lack of symptoms does not mean lack of infection, therefore, lack of spread of infection.

— Doc N
March 9, 2020