Coronavirus /CoVID-19 Infection
March 19, 2020 – by S. John Guha, MD, Medical Director, USADoctorConsult.com
Basic Knowledge About Coronavirus
The main point to remember is DON’T PANIC, and remember that most people who test positive for Coronavirus don’t get sick or have very mild sickness (about 80%). They tend to get better on its own.
However, it is also worthy to note that in recent days, the current strain of coronavirus, called “CoVID-19” (started in 2019), has been shown to cause a higher incidence of death in certain “high-risk populations”, and less likely in healthy adults and children.
Although coronavirus is not as common as the influenza viruses, it is still “worse” in some ways because it is more likely to cause death, and like the influenza virus, it is highly contagious. One major differentiating factor that makes it more dangerous is the fact that no vaccination or treatment has been currently developed, and the incidence of cases are accelerating worldwide.
Since the virus has only been identified a few months ago, we don’t know as much about it as we do other major viruses such as influenza. This uncertainty also makes coronavirus Covid 19 potentially more serious than influenza.
As you read this article, please remember that this is a fluid situation, and we are learning more and more about coronavirus with each day that goes by. Hence, the recommendations a week from now may be slightly different than the recommendations in this article, as we learn more about the virus.
Per the World Health Organization, “Coronaviruses (CoVs) are actually a large family of viruses that cause illness ranging in severity from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV).
A novel coronavirus infection (CoVID-19) is the new strain that has not been previously identified in humans. This strain is the one we are focused on, and unfortunately, it seems to be mutating as we speak. This means that “sub-strains” with different characteristics are developing rapidly, and these may cause different symptoms.
Coronaviruses in general are zoonotic, meaning they are transmitted from animals to humans via airborne or droplet spread (coughing/sneezing) and/or direct contact (touching). Several known coronaviruses are circulating in animals that have not yet infected humans. As stated, this article only applies to the current coronavirus pandemic with Covid-19 (a pandemic being defined as a highly contagious, potentially serious infection occurring in large numbers of people across the globe.)
Even if you have no symptoms, you can still spread the virus to others. In general, CoVID-19 tends to “live” in the nose, throat, and respiratory tract/lungs. Unlike influenza, which tends to be seasonal, that is, more prevalent in the colder months and decreasing substantially in the warmer months – at the time of this writing, we do not know if coronavirus will be seasonal or not.
Since about December 2019, it is been accelerating through the winter, and currently (as of March 19, 2020), there have been about 157,000 cases reported worldwide, with nearly 6000 deaths, which equates to a 3.8% chance of death. However, it is important to realize that most of these deaths occur in “high-risk populations”, such as certain healthcare workers, senior citizens, patients with certain chronic illnesses (hypertension, heart disease, lung diseases such as COPD/asthma, diabetes, etc), patients with cancer, patients on chemotherapy, and patients with certain auto-immune diseases that are being treated with medications to intentionally reduce their immune function. (These “immunosuppressive” medications are frequently used to target certain “autoimmune diseases”, in which the patient’s own immune system attacks the body’s normal tissues – diseases such as rheumatoid arthritis, lupus, and the like).
In the past week or so, we found that the virus also can attack the very young, we initially thought were relatively immune. We have also recently found that young adults who seem to have recovered, actually may have decreased lung function several weeks to months after the infection. It is unclear as to whether this is permanent lung damage or not.
Whether CoVID-19 infection will decrease in the warmer months as spring approaches, is uncertain. As of yesterday, March 18, 2020, Pres. From is unveiled a federal plan devoting massive federal resources to fighting the COVID-19 infection over the next ”18 months”. That is to say that the federal government is not assuming that the COVID-19 virus is seasonal like the influenza viruses. Everyone, of course, hopes it does slow down.
What follows are facts about CoVID-19, and my some of my own personal opinions as a practicing Emergency Room physician. I will try to differentiate these clearly.
How is Coronavirus spread?
CoVID-19 is generally transmitted from person-to-person, and the two most common types of person-to-person transmission include airborne/respiratory droplet transmission, and direct-contact Transmission.
Airborne/Respiratory Droplet Transmission: Airborne/respiratory droplet spread is the most common. This includes standing close to someone who coughs or sneezes without covering up. When someone coughs or sneezes into the air, tiny respiratory “droplets” float in the air for potentially several hours, just as tiny droplets of as a sprayed aerosol would remain in the air for a while. Someone else standing nearby, such as in long lines at airports or train stations where people stand in close proximity to each other for extended periods of time, can breathe in these droplets and become infected.
Wearing certain types of face masks have been shown to reduce the chances of breathing in these droplets. In my opinion, if you absolutely must go to a place that is crowded with multiple people standing near you, it is prudent to wear a mask of some sort.
One should note however, that there are different types of masks. The classical “surgical mask” is soft, looser fitting, and does not completely prevent the spread of virus. The tighter and slightly more rigid “respirator” masks (e.g., an N95 mask) are more effective in preventing the spread of the virus. But when in close proximity to other people, any mask is better than no mask. It is recommended that the mask be changed frequently. For healthcare workers, it is supposed to be changed with each new patient interaction.
Direct contact spread: The best example of direct contact spread is holding the hand of somebody with live virus on their hand, and then rubbing your own nose or mouth, which everybody does at least a couple of times per hour without thinking about it.
Other ways of transmitting the virus through direct contact include drinking out of the same container, or eating off of the same silverware. This should always be avoided. The section on Prevention below will delineate in more detail how to minimize direct contact spread.
Surface Spread: Many bacteria and viruses, survive for some variable amount of time (ranging from minutes to hours) on surfaces (frequently hard surfaces such as hand railings, door knobs, elevator buttons, the soles of your shoes, etc.) that have been touched by an infected human and not wiped with an alcohol-based (60% or higher) antiseptic.
If someone touches such a surface with live virus still on it, and then touches their own nose or mouth, which everyone does commonly without even thinking about it, they can become infected. Wearing latex gloves while out and touching things, then discarding them carefully when you get home can minimize the risk of contracting the virus from touching surfaces where the virus has survived.
It is recommended to take off your shoes before you enter the house and to immediately wash your hands. Food that is well cooked should technically not transmit the virus. Uncooked foods such as fruits and vegetables frequently, should be rinsed thoroughly before being eaten since they may have been previously handled at the grocery store.
Frequent handwashing with an antiseptic or at least soapy water with extensive “irrigation” (rinsing) of the hands (or wearing gloves that are quickly discarded after each use) is also recommended. It is also important to know that after washing/rinsing off your hands, you should use a disposable paper towel to them and then turn off the faucet with the paper towel so that your skin does not directly touch the faucet. Remember also that touching the doorknob on the way out of the bathroom can re-contaminate your hands.
Hence if you can use the paper towel to turn the doorknob as you open the door, and toss the paper towel in a trash receptacle, this would be best.
Symptomatic illness versus “colonization”
It is important to realize that “being sick/symptomatic” and being “colonized” are two different things. Many viruses cause “colonization of the “host”, which means that you have the virus in your body but are not sick and so don’t even realize it’s there.
Colonized “asymptomatic (not sick) carriers” can transmit the disease to uninfected people (by the mechanisms delineated in the section above, “How is coronavirus spread?”), most of whom will also not realize they had contracted it. This is how an infection can become highly contagious, and spread through large populations of people fairly rapidly and silently, until someone becomes symptomatic/sick, such as with a fever, cough, shortness of breath, fatigue, etc., (more on the symptoms below).
This is when quarantine with “supportive measures” (such as good hydration, controlling fever with medications, and plenty of rest) may be effective in reducing transmission and improving the outcome of most cases of proven Coronavirus infection.
Currently there is no vaccination to prevent coronavirus and no effective antiviral medication to treat it once it has caused symptoms (see below).
Vaccination versus treatment:
It is also important to know the difference between a vaccination before an illness occurs, and treatment of the illness after symptoms appear.
A vaccination is an injection given with a tiny needle, usually in the muscle, that can be given to populations of well people to prevent them from ever contracting the illness. The influenza and pneumonia vaccinations are two of the most famous such cases. Many of the childhood illnesses, such as mumps, rubella and polio have all been virtually eliminated due to extensive childhood vaccinations.
When symptoms occur, most likely in unvaccinated people, it is too late to get vaccinated for that disease during that same season. It is worth repeating that most people who get symptoms from CoVID-19 coronavirus infection will have relatively mild symptoms such as runny nose, sore throat, cough, and fever.
More severe illness, such as pneumonia (which frequently causes persistent cough and shortness of breath) occur in a minority of cases, usually but not always in the “high-risk populations” mentioned earlier. However, children and some young healthy adults have recently been reported to get quite ill with the virus. It is not yet clear why.
Smoking cigarettes may also be a risk factor, since smoking decreases the ability of the lungs to fight off infection. (Remember that one of the places that coronavirus likes to “live” is in the lungs and upper respiratory tract.)
As a practicing Emergency Room and now telemedicine physician, I recommend that if you have some combination of 2-3 or more of the following symptoms: fever, chills, body aches, severe fatigue, headache, cough, shortness of breath, and possibly nausea/vomiting – YOU SHOULD CONTACT A DOCTOR TO CONSIDER GETTING TESTED FOR CORONAVIRUS (a swab or blood test) and/or INFLUENZA (swab or a blood test), and get in quickly (before 48 hours after symptom onset), especially if you are in a high-risk group.
This does not guarantee that you will be tested. It has been shown that in some cases you can get both influenza and coronavirus at the same time. I admit that my recommendation is more conservative and cautious than many medical authorities would advise.
This is my rationale: having influenza diagnosed and treated early on makes the chances of successful therapy with its “antiviral antibiotics” (oseltamivir and zanamivir) more likely. And since some of the symptoms of influenza infection and coronavirus infection overlap, it can sometimes be hard to tell which, if either, infection you may have.
Viruses other than coronavirus or influenza viruses can cause similar symptoms. At the time of this writing (March 19th), influenza still seems to be more common than coronavirus. Last season (2017-2018) in the United States, approximately 37,000 to 60,000 people died of influenza. This season (2019-2020) so far, less than 150 people in the United States have died from coronavirus, but this season is not over, and coronavirus may not be seasonal in the first place. It is definitely still accelerating.
It’s hard to be certain of the number of people that are actually carrying coronavisus (with or without symptoms), because the testing is woefully inadequate as compared to the flu, and as stated, coronavirus has no vaccination to protect large populations of people before they get sick. This is why the rapid spread of the virus is so concerning. Many large medical centers and university-affiliated hospitals will probably get large quantities of the rapid screening tests first, but some smaller community hospitals should eventually also get them.
Note that if you show up to a hospital simply to get tested for coronavirus, and you are not having symptoms, you will probably not get tested. This is simply because there is such a scarcity of test kits available right now, and symptomatic patients and high-risk patients, will and should take priority in getting tested.
Further, the result of the test may not be available immediately, although a company called BioMedomics claims to have developed an accurate, rapid-result, swab test. This test is used for quick screening results in many countries, including China, where coronavirus began. Other companies such as Roche and LabCorp also have their version of the test, but these are also scarce in supply. President Trump is currently mobilizing resources to increase testing capabilities in the United States. China and South Korea have been doing a much better job in testing and has the United States. Simply testing for a fever is not accurate, although you may have seen certain drive-by centers or other screening sites for coronavirus that check for fever first. Again, call a doctor if you have the overlapping symptoms of influenza and coronavirus.
The reason I recommend this is, again, because influenza can be treated successfully if caught early on with an antiviral agent, and you won’t know for certain unless you get tested or at least consult with a physician about the need for testing. Now having said this, many physicians will opt to treat for influenza based on the symptoms alone, realizing that influenza symptoms may overlap but are somewhat different than for coronavirus. For instance, coronavirus is more likely to cause fever, cough, and shortness of breath 3 to 14 days after exposure (that is, a 3 to 14 day “incubation period”), whereas influenza usually causes fever and chills, cough, sore throat, runny or stuffy nose, and body aches 2 to 5 days after exposure (a 2 to 5 day incubation period).
Headaches and severe fatigue are more likely with influenza and the onset of symptoms is more rapid (1 to 2 days) whereas with coronavirus they can be more gradual (2 to 6 days) and frequently not as severe. Realize that this is a rapidly evolving situation, with more details about coronavirus becoming apparent every day, especially as it mutates into different sub-strains.
I am hopeful that there will be a vaccine or an anti-viral antibiotic soon for Coronavirus CoVID-19 as well, but for now most people proven to be infected should stay at home, drink plenty of fluids, control fever with acetaminophen, or take multi-symptom over-the-counter medicines – and if not well in about 7-10 days, consult with a doctor.
If however, you have severe uncontrollable fever or significant shortness of breath, then you should see a doctor quickly to prevent dehydration and check for pneumonia or sepsis. Sepsis is a spread of infection that can cause major organ damage (kidney, liver, etc.) and death.
For those who die due to coronavirus, respiratory failure with or without sepsis is usually the final event, and it is worth reiterating that this is primarily in “high-risk populations”, though there are exceptions. Once an antiviral agent for Coronavirus is developed, assuming the supply equals the demand, significantly symptomatic people at high risk for respiratory failure and sepsis should be treated.
Young healthy people with mildly symptomatic coronavirus infection, even without treatment other than supportive measures, will usually get better on their own, although there are exceptions. Within the past week of this writing, some experimental treatments using malaria antimicrobial agents and zinc have shown some promise in treating CoVID-19, but no definitive conclusions have been reached as of yet.
As stated above, common signs of CoVID-19 infection include respiratory symptoms, fever, cough, shortness of breath and breathing difficulties. In more severe cases, infection can cause pneumonia, severe acute respiratory syndrome, kidney failure and even death. This does NOT occur in most people, but is more likely in “high risk populations – such as the elderly, people with multiple other illnesses such as COPD/emphysema, certain immune disorders, and cancer patients who are on chemotherapy. Smoking may be a risk factor.
Prevention – what you can do to avoid and/or not spread the virus:
To summarize preventative measures, standard recommendations to prevent spread include regular hand washing, covering mouth and nose with a tissue or handkerchief or at least with the inside of your elbow (but not your hands) when coughing and sneezing, -Ddo not shake anyone’s hand (instead, tap elbows), thoroughly cook foods such as meat and eggs. Previously frozen food should kill the virus, and hence be safe to eat. Avoid close contact with anyone showing symptoms of respiratory illness such as coughing and sneezing.” – adapted/modified from the World Health Organization, 2020.
Antiseptic Wipes and Gels: Other precautions you can take are to carry antiseptic wipes or gel (made of a minimum of 60% alcohol) with you whenever you are out and use these extensively, especially on surfaces that many people commonly touch right after one another, such as railings, toilet seats and flusher handles, shopping carts, and the like. Wearing a mask is more important for an infected individual than it is for a well individual, but people in high-risk groups should consider this as well.
As an emergency physician, I at least where a surgical mask if not an N95 respirator mask while at work. “Social/Physical distancing” is another means of reducing the chances of getting or spreading an infection. This basically means staying away from other people unless absolutely necessary, and never sharing drinking containers, silverware or toothbrushes. If you must be exposed to people outside your household, wearing gloves, and using masks (especially if you are a healthcare worker), should be options to consider.
Remember that if one person from the household is exposed to CoVID-19 and then comes home, he/she may infect the other people in the household who have not gone out. Physical distancing does not necessarily mean that you cannot go outside if you need to, but you should try to minimize getting into close proximity with other people if at all possible. The most recent recommendation is to try to stay at least 6 feet away from everyone when you’re out.
Many states within the United States are now prohibiting gatherings of more than 10 people, closing restaurants or bars or some public beaches. I believe that more beach closings are forthcoming. As of this writing, CoVID-19 has been reported in all 50 states of the United States, especially in more metropolitan states with international airports. Hence, I would recommend avoiding public beaches or any other public gatherings of more than 10 people, and even in these situations, trying to avoid getting closer than 6 feet from everyone else.
It is not known if the most recent outbreak of Covid-19 will subside as the warmer months approach, such as is the case for influenza, which does not go away but tends to decrease in the warmer months. The United States federal government has just declared coronavirus infection to be a national emergency, with Pres. Trump invoking massive resources to test for the virus and combat its spread.
It is important to remember that although approximately 80% of people contracting Covid-19 either do not get symptoms or get very mild symptoms and recover on their own, a significant percentage of them have been shown to have decreased lung function even after “recovery”, which poses the question of whether coronavirus can cause subtle, long-term damage to the lungs.
This decreased lung function has been shown to occur even in younger people, and not just the elderly. Recently, a substantial number of children have gotten infected. Hence, young people should be just as vigilant as older people regarding transmission of the virus. A general rule of thumb is to act as if you already have the virus in your system. If you do this and take the appropriate preventative measures, you’re less likely to spread it to a family member or friend who may not fare as well as you have.
CoVID-19, like many viruses, can also mutate or change its genetic structure fairly frequently. This means that new strains or sub-strains can come out periodically and cause different types and severity of symptoms. Some of the strains are more virulent, which means more likely to cause severe disease, and other mutated strains can be more benign.
The bottom line is that CoVID-19 is a type of coronavirus that spreads quickly, but generally does not make most people ill unless one is in a high-risk population described above.
It can however cause long-term lung dysfunction, even in younger people who have apparently “recovered”. As a percentage of people with known coronavirus CoVID-19 infections, the death rate/percentage is higher as compared to influenza.
The test for Covid-19 is in short supply, but efforts to ramp up production are underway. Vaccination and anti-viral antibiotic therapies have not yet been developed but intense research is being conducted on both fronts.
I am hopeful that a successful preventative vaccination and a treatment for symptomatic individuals will be developed within the next few months. For the time being, you can take multiple preventative measures as delineated in this article to minimize the chances of contracting the virus were transmission to other people. We all must be vigilant, but again, don’t panic!
Dr. S. John Guha
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