Our society and the medical establishment is being confronted with something that we have not had to face, literally within the last century. Our success against this challenge will depend on how well we can behave as individuals and as a species collectively.
I’ll be making a bit of a change from my usual format. First, I’d like to apologize to my patients. I was involved in a bit of a biking accident earlier this month. Injuries sustained have forced me to close the office for a short period. I’m making good progress and expect to be back fairly soon. I’ll be managing old and seeing new patients via telemedicine until that time. Thank you for your patience.
What we know about the coronavirus:
There is much conflicting information out there about the coronavirus. The following (in no particular order) will be a coronavirus fact sheet, containing what we know so far. The accuracy of this information may change daily.
How many of us will be infected:
Estimates range from 25-75% of the total US population. Whether we achieve the lower number will depend on how well we achieve social distancing and how quickly a vaccine can be developed. For now, social distancing is our number one line of defense.
Availability is community dependent. Hotbed towns like Bremerton, Wash., will have widely available testing. Areas with very low risk will have more restricted access to testing where patients will need to meet strict criteria to get one.
There are two possible sources for testing: 1) The Health Department, and 2) Private centers.
The health department continues to have limited tests, where very strict guidelines must be met to qualify for one (you must be hospitalized with pneumonia or had contact with a known positive person in a high-risk setting). Testing privately still requires authorization by a physician. Widespread testing of any symptomatic person is probably still two weeks away, therefore spread will continue unless STRICT social isolation is followed since we don’t know who the carriers are. If you have the slightest suspicion you are sick you must self-quarantine for 14 days, unless hospital care is needed, and be tested once available.
Time for results:
What used to take days can now be done within 45 minutes with new FDA approved testing.
Modes of transmission:
It is becoming apparent that this is perhaps less respiratory droplet related and more surface related, especially if the 6-foot rule is being followed (much greater separation required if someone sneezes). Airborne virus remains viable for up to 3 hours, but it’s uncertain how long it is actually infectious. The virus seems to need a contact surface to survive any length of time. It is shown to be viable on cardboard for 24 hours, a plastic surface for 3 days and a frightening 9 days on floors or surfaces that are not decontaminated. Recent data frighteningly has shown that viable virus was still identifiable for up to 17 days on the cruise ships. So, it appears acquiring the virus from surfaces is a much higher risk than from air. Here’s where hand washing, not touching your face and maybe sterilizing your mobile phone really pay off.
Incubation period: 1-14 days, which means people can be contagious for up to 2 weeks before they manifest symptoms.
Are they needed? They really only have value for healthcare workers, where in many instances desperate shortages have made their jobs life threatening. For the general public a mask offers no advantage over the 6-foot rule unless in close quarters such when using public transportation. The N-95 mask will filter particles down to .1-.3 microns (quality varies) at a 95% efficiency. That’s good but not perfect. The virus has a dimension of .1 micron but still does not readily pass. Too many particles will actually be competing for the same hole and cannot get through. The only devices offering complete protection are the PAPR (Powered Air Purifying Respirator) systems, which are reserved strictly for high risk surgical indications.
Symptoms vary and can be fever, cough, body aches, fatigue, shortness of breath, sore throat, headache, diarrhea and nausea. Interestingly, anosmia or loss of smell is very common around days 2-4 and may be the first indicator of infection. Any variation of these is possible and the severity is individual specific. These are also symptoms of the common cold which makes sorting out who is positive for coronavirus and who has any other garden variety virus very difficult. As already noted, it is anticipated that between 25-75% of the population will become infected to some degree, 20% may require some type of supportive care, 5% requiring ventilator assistance and an ICU setting. Expected mortality rate will probably fall between 3-5%. Unfortunately, of those requiring an ICU setting, even when they survive there is a significant risk of long term pulmonary or cardiac issues.
For those infected, you can expect the following approximate progression of symptoms:
- Incubation period 2-12 days
- Day 6: Symptomatic: As listed above
- Day 8: 20% May require hospitalization
- Day 10: Symptoms peak, 2-3% develop ARDS (requiring assisted ventilation)
- Day 13: Peak ARDS symptoms followed by 24-48 hours of improved symptoms
- Day 14: Resolution of symptoms
Medications that affect Corona viral disease:
Tylenol and cough preparations are fine, aspirin and other anti-inflammatories like ibuprofen are thought to make you more susceptible to this infection and should be avoided. Prednisone has a place in end stage complications, but none in the acute phase where it can prolong the disease process.
Plaquenil (hydroxychloroquine) the antimalarial drug, has been shown to decrease symptoms in the critically ill, the mechanism of effect is not known. It has no value in the early stage of the disease and has potentially severe side effects.
Zithromax – an antibiotic has also been shown to reduce the severity of severely stricken patients, but not considered an acute phase drug.
Nebulized Melatonin – seems to strengthen local immunity to the Coronavirus.
Antivirals – Some have shown promise, those being tested are Remdesivir, Lopinavir and Ritonavir.
ACE inhibitors, used for blood pressure, tend to make the disease worse and should be substituted with another antihypertensive if you suspect infection.
There are trials going on with various combinations of these drugs that are showing a fair amount of promise. With relaxation of normal FDA red tape, there will likely be effective treatments and a vaccine in far less time than is normally the case.
In concluding, each day we learn something new about this virus, ideally much of it will be of value to improve future treatment of those later stricken. This is a time to put aside all of our differences and realize that we are in this battle together. Only united will we triumph over it.