All the Covid-19 numbers get outdated almost as soon as we write, but the United States yesterday passed 258,000 cases with over 6,600 deaths, with Massachusetts just under 9,000 cases and 154 deaths. The graphic from today’s NY Times clearly shows exponential growth. Quick arithmetic gives unadjusted death rates of 2.6% nationally and 1.7% in our state. Remember that annual U.S. influenza death rates are 0.1-0.2%, ten times lower. The only consolation is that many other countries’ death rates are substantially higher (but we have to allow for wide variations in how effectively all the milder cases were enumerated).
By most all estimates, the worst part of the epidemic will evolve and peak later this month, more or less 2-3 weeks from now. A decline after the peak is not guaranteed. A plateau of sustained high cases and mortality is possible. We will all learn the accurate answer later in the month.
What is the medical situation now?
Our inpatient systems are still struggling, with rapidly expanding numbers of patients and still inadequate personal protective equipment (especially N95 masks for clinicians directly dealing with infected patients), and of course respirators for unfortunate people/patients whose immune systems are overwhelmed by the infection that extensively infiltrates and inflames the lung tissues.
The few bright spots in last day or two include the impending arrival of a new sterilizing machine that will enable the reuse of large numbers of N95 masks in the Boston hospitals, being brought in by Partners from a nonprofit firm that just developed the technology in the mid-West, and the Patriots sending their team plane to China to purchase and return with thousands of masks. Certainly good news, but these supplies should of course have been amply available.
What about drug treatments?
We have no demonstrated effective medical treatments for severe Covid-19 infections as of today. Several anti-AIDS treatments have been tested and failed with this virus. We have hope-and-a-prayer treatments based on hydroxychloroquine and azithromycin that are touted based on largely anecdotal evidence with tiny trials presented as strong evidence. These drugs can have meaningful toxicity, especially in combination. These are not antiviral agents, so their mechanism of action for a severe viral infection remains to be elucidated. These treatments were also proposed before the explained mechanism of action. Fortunately, enough groups are studying the situation in clinical trials that we may have meaningful data by the end of the month, more or less light speed in such situations. We are not planning to prescribe anyone any of those drugs for preventive purposes. That is even more tenuous.
Also, there is now no technical consensus whether certain hypertensive drugs (such as ACE inhibitors like lisinopril or fosinopril) or ARB meds (such as losartan or irbesartan) are harmful or instead beneficial in the context of a Covid-19 infection. We are tracking this issue carefully, since many of our members have hypertension and these drugs are fundamental to treating blood pressure issues. For now, we will continue exactly as we have been doing, since these drugs are exceedingly effective to keep your blood pressure in check.
Prevention works: Stay in your circle of safety
As we end our third week of self-quarantine, only a small handful of our members appear to have gotten Covid-19, and only one seriously (that was documented). Those infections all predated or were early in our Week 1 timing. I think this represents the rigor with which most all of us practiced self-quarantining. Everyone who remains in his or her circle of safety and has been safe so far should be safe going forward, providing you are vigilant and keep to your circle of safety.
- We will need to keep “social” distancing for months into the future. The epidemic will be worsening over much if not all of April.
- Do not congregate outside your circle of safety for social events, even important ones like Easter and Passover. Dr. Sobel and I feel strongly that it is far too early to break your circles of safety to merge for any social gathering, even if they are all apparently healthy. Use Zoom for social gatherings among groups, even though Zoom apparently is selling your personal data to advertisers (reports today in NY Times).
- Do go outside and walk around (when the rain stops) and enjoy the spring. You don’t have to distance yourself from trees or plants.
- Do break down social distance and call and FaceTime others and keep in contact. Stay socially close but physically distant except in our circle of safety. We’re all in this together.
- Continue to keep to physical distancing of at least 6 feet when outside or inside; more may be better. That is being argued.
- Wear a mask of any sort whenever out. Buy standard surgical masks if you can get one (eventually they’ll become available). Or improvise a cloth mask (directions appearing online from various sources). Again, it’s an embarrassment that such health supplies are not routinely available now and two months ago. Perhaps by June we’ll begin to get enough.
Safe and sane: reminders on other details of self-protection
Here are some behavioral suggestions that I believe reflect a proper reading of the current science on transmission of Covid-19 virus that will enable you to function smoothly and to be safe in the practical activities of daily life. Our family is following these guidelines.
- Try to get your food delivered (Instacart for local supermarkets like Market Basket and Wegmans), even though there may be a 4-5 day advance notice for a delivery time. More supermarkets (Donelan’s in Lincoln and Verrill Farm in Concord for great produce) will take your order by phone or fax and put your groceries into your car without direct contact.
- If you need to go to a food store, do wear a mask and use antiseptic wipes on your carriage if possible. Treat your grocery bags like packages. Leave bags with nonperishables sitting in your garage or outside for 36-48 hours. Any surface virus will be neutralized by air exposure in that time (people argue, but that’s about right). If you are especially worried, you can wipe down or spray the boxes with viral disinfectant (Chlorox spray and others, CDC offers list) but that should not be needed if you wait. For perishables, take them out of their bags, rinse the vegetables, put in fresh bags, and put in fridge. Wipe down milk bottles with disinfectant wipes. Wash your hands after. Be thorough but not crazed.
- Seek out a pharmacy that delivers. Many do. Ours is West Concord Pharmacy. Others have drive throughs (CVS in Bedford).
- Open packages outside, leave the cardboard in your garage, wipe down inside purchases with disinfectant wipes or approved Chlorox sprays or equivalent. Then wash your hands off carefully (Happy Birthday, Happy Birthday, remembering to interlace your fingers and wash around your thumb and the outside of your hand). An alternative to disinfecting the inside box is to leave it sit for 24-48 hr (exact timing being argued) by which time any residual virus will be neutralized by air exposure.
- You can take your mail from your mailbox (gloves not really needed), throw out the usual 2/3 and then let the rest sit in a paper bag for 24-48 hr to neutralize any conceivable surface contaminant of Covid-19. You usually let it sit for days anyway, right? Doesn’t really matter. Wash your hands carefully after you handle the mail.
- Enjoy your takeout food delivered. Handle the outside boxes and bags like a package. Wash your hands carefully after opening and removing the tops of the inside containers. Enjoy your food. Covid-19 does not survive in cooked food.
- Overall, you can be vigilant without being crazed.
Major risk is exposure to infected person not objects
Finally, we must emphasize again that the overwhelming portion of documented cases occurs through person-to-person contact, not from environmental exposures. Circles of safety work. The number of people infected in Massachusetts is growing rapidly and will almost certainly continue to grow throughout April.
We urge you not to congregate outside your circle of safety for upcoming holiday events. Celebrate Easter and Passover with FaceTime or Zoom.
Nuclear families who were quarantining separately for 2 or more weeks waiting to rejoin in to a single circle of safety can do so by now, assuming everyone is healthy, and then continue to quarantine together. That should be safe.
Otherwise, we urge everyone to wait until at least the end of April even to consider consolidating existing circles of safety larger than nuclear families. We will have a better idea of the lurking community risk and may even have some ability to test people by that time. The unknown and perhaps unknowable risks are what worry us.
If we are safe, we are winning. Don’t mess it up now.