We have lots to cover. I will try to make it simple and concise, but this nevertheless is likely to be a lengthy piece on the Covid-19 epidemic. Let’s start with the items that immediately affect everyone.
Social distancing and community spread
Even before the belated Sunday night announcement by Governor Charlie Baker to close schools and restaurants, most of our regional communities had already taken comparable action in parallel but not in concert. You knew that. We had been urged to keep “social distance” but had not had coherent national or even state leadership on really important details, such as whether schools should be closed now and whether all locales where people gather in smaller groups, such as restaurants and bars among others, should now be closed for in-location service. Governor Baker’s action I hope will mean more effective public guidance from state and national governments going forward.
All schools are now closed for at least the next two to three weeks, and likely longer. This of course profoundly affects all families with children and many others. The children are critical because they are known aggregators and spreaders of many viral illnesses, such as influenza as well as Covid-19, which they then take home to infect their parents and grandparents, even when the child may not show much in the way of illness.
We have been urged appropriately to keep “social distance” from others and to cancel or avoid larger gatherings (last week over 100 people or 250 people depending on who is talking, then 25, now over 10 people), because the Covid-19 infection has spread sufficiently, under the radar screen, that community spread is likely through infected people who are not symptomatic yet but who are or will rapidly become contagious. Social distancing is the most effective defense we have against such spread. These restrictions have serious public economic consequences but are clearly the right course at this time to mitigate the spread of Covid-19 infection while we can still hope to modify its trajectory.
Personal implementation of social distancing
Dr. Sobel and I fully support social distancing for everyone’s protection from Covid-19 and to prevent its propagation. What exactly does that mean? Let’s give some examples.
- Stay at home, in general, and venture to public venues only to obtain food, medication, or possibly to your physician’s office for urgent problems that require direct examination. Do not go to the movies, theater, to the hair or nail salon, to group gatherings of friends, to restaurants for eat-in service. Do not go to medical laboratories for routine lab tests. Work remotely if you can or talk to your office about what to do. In reality, most theaters, museums and sports events had already been canceled for the spring before the governor’s edict, and most offices have been setting up remote access or requiring it. This is good.
- When you venture out, keep a physical distance from others of at least 6 feet. At the pharmacy, if there is a line, hang back. Ditto the supermarket. Whenever possible call ahead so you can arrange a quick pickup and not stand in a line. Order food supplies for delivery from Peapod, Whole Foods, Instacart or any of the many food services that will deliver to you. Check if your favorite restaurant is offering food to go now. The reason for 6 feet is that the Covid-19 virus is largely droplet spread, and after a sneeze or cough the virus droplets are relatively heavy and are believed to fall to ground before 6 feet. By contrast, measles virus typically exists in more of a fine mist that hangs in the air for hours and can infect you when no one has been in a room for several hours. Really impressive.
- Define a “circle of relative safety” [my term, but I haven’t heard any other proposed], namely those family members and friends with whom you have been in close contact and mean to be in close contact over the next month. That means you all share the same risk. A prerequisite should be lack of known exposures of any members (to be obvious, none of your inner circle should have been at that Biogen meeting at the end of last month). And should anyone develop persistent sore throat, fever over 101F, and dry cough (cardinal symptoms of Covid-19 infection), they should immediately isolate themselves and let everyone know in your circle. That would be a cause for Covid-19 testing for members of your group.
- To be even more specific, everyone in your circle of relative safety must restrict any close contact with other people (outside of the needed food or pharmacy run). That is the only way for you to keep out unknown risk for the next few weeks (or longer). That is especially relevant for children in the group, who cannot be allowed to play with other children who are not in your circle of relative safety. And a family baby sitter must only work for your family or one in your group and restrict her own circle. And children should not visit their grandparents unless they are all in their circle of relative safety.
- Finally, every older person (read over 60 or so, and certainly over 70) is at higher risk of serious illness from a Covid-19 infection. That is especially true of any older person with important underlying disease, especially pulmonary disease including smoking, significant diabetes or heart disease, or immunosuppression from rheumatoid arthritis, Crohn’s disease, multiple sclerosis or cancers or the biological agents used to treat such diseases. All these people should be especially vigilant about self-protection and staying securely within their circle of relative safety.
Medical social distancing, remoting our office visits
We have modified our office practice to help and serve you primarily remotely. Our office is open and staffed with our nurses on site and others working remotely with good communications so that we can directly answer phones and emails. Dr. Sobel and I, with help from our nurses Pat Potenza and Anna Cherkassky, will answer phones and emails in real time during normal office hours 8 a.m. to 4 p.m. weekdays. We will help with evaluation of new problems, advice on long-term problems, prescription refills, and whatever as we normally do, as well as questions on the epidemic. We have canceled essentially all scheduled and hence routine office followup visits as well as annual checkups for the next 3-4 weeks. That may well be extended. Where appropriate and useful, we will substitute remote phone or video visits between doctor and patient at scheduled times.
In the event one of you has an urgent problem that is not respiratory (e.g., a substantial skin infection) and where you have no important environmental risks for Covid-19, and also where physical examination is important, we may arrange for you to come to the office. We will have appropriate environmental protections in place. So far that has not been needed, but we are prepared to do so.
In the event that a member develops a serious respiratory infection and fever, which on telephone screening suggest real Covid-19 possibility, we will send you to the local emergency room.
If a member develops a more modest respiratory syndrome that could be Covid-19 by virtue of significant symptoms and exposure, we will refer you first for Covid-19 testing to the just-being-activated drive through testing at Newton-Wellesley (and perhaps other places shortly) for such testing. Our office needs to make the referral. That may be accompanied by antibiotic prescription if appropriate. Regardless, we will keep close tabs on you by phone during your illness.
We ourselves tested last week for Covid-19, taking samples from two patients and seeing several others in the parking lot. That required my donning protective gown, gloves, goggles and N95 mask, and careful decontamination after (and before). This is complex and time consuming. The tests were sent to Quest and fortunately both were negative. We hope the drive-through arrangements starting up at the hospitals will make it easier for the patient (and us) for Covid-19 to be done with less risk.
Such drive-through testing should have been routinely available two months ago at the beginning of this epidemic. I am talking about the ability to do 10,000 tests a day, as other countries have done, not a few hundred tests a week as we still are doing. This is a major fail on our country’s part. The exact capacity of our drive-through testing is not yet publicized.
Continue to wash your hands with soap and water, regularly and thoroughly. It is more effective than hand sanitizers, which are intended to be used if soap and water are unavailable. Wash thoroughly by interlacing your fingers, and being careful to clean the sides of your hands (by your little finger and side of your thumb). Do say or chant or sing Happy Birthday all the way through two times. That amounts to 20 seconds. That is roughly twice as long as most people (including me) were scrubbing their hands before. The duration matters. Wiping your hands vigorously with a disposable paper towel matters as well.
When you are out and about, plan to use sanitizing wipes in the supermarket on the handle of the carriage. Sanitize your hands on leaving, and wash them when you get home. Covid-19 virus appears to survive on hard metal or plastic surfaces for many hours and perhaps up to several days. Virus survival on cardboard boxes is likely shorter, but not clear. If you receive packages, certainly wash your hands after you open the package and dispose of the cardboard. But droplet spread from prolonged close contact (such as over 10 minutes under six feet from a symptomatic individual) remains the greatest risk according to all authorities. You are not at meaningful risk from speaking to the brother of the woman whose father may have had Covid-19 last week.
Epilogue for today
We will all get through this. The times are extraordinary. Concern remains appropriate. Panic is not. Establish your circle of relative safety and stay in it.
I intend to update this blog with new information at least every 48 hours. Please enter comments and questions at the end of this post if you want, and I will reply within 24 hours.