This is our first update since a month ago when I attempted to summarize and clarify the rapidly changing information on this new virus, Covid-19 (formerly called Coronavirus 2019-nCoV), which is steadily spreading throughout the world. We will try to give additional explanatory advice every few days to every week or so to our patients. Of course, there are many reliable public sources of information and you should stay tuned with them. In particular, follow the CDC website, which has the coronavirus information on its front page. You may also find a recent longer recap written by my Harvard Medical School colleague, Dr. Edward Hoffer, to be a good current read.
Summary of Covid-19 as of 3/1/20
This novel coronavirus infection is somewhat like annual influenza, in that it causes high fever (101-103F), often severe cough, and frequently respiratory impairment, but it is more serious for two reasons. First, we have no immunity and currently no immunizations, so everyone is susceptible. Second, the case fatality rate (which appears to be 2%, though it may settle down toward 1% as we better account for asymptomatic cases) is 10 to 20 times worse than that from the annual influenza virus, which has varied between 0.1-0.2%. Note, however, that the CDC says influenza this season has so far infected 32 million Americans, hospitalized over 300,000 and killed 18,000, with final death totals expected much higher.
Covid-19 is also different from influenza in that there appears to be a significant amount of asymptomatic infection, during which the affected person is an unwitting carrier and spreader of the infection. The incubation period can be as short as 4 days, but may extend to a full 2 weeks (which is the rationale for 2 weeks quarantine after exposure). Children are relatively less affected compared to influenza. We have no antiviral medication that has been shown to work (think Tamiflu for influenza).
Fortunately, a large portion of the infections are mild to moderate, and people can self-treat themselves at home with remote advice from their doctors. But a substantial minority are much more ill. Treatment so far is purely supportive, even for those ill enough to require hospitalization and respiratory support.
We almost certainly have a large subclinical reservoir of infection that is spreading in our Northwest. Why? Because this past week there were one or two cases in those states where the infected people had no record of contact with anyone who had a known Covid-19 infection, such as those returnees from that cruise ship in Japan. Given the known possibility of asymptomatic infection, the inference has to be that there is a reservoir of other asymptomatic infected individuals at least in the Northwest who have been spreading it in the community. We can reliably expect that northern California, Oregon, and Washington will shortly show a substantial increase in symptomatic cases over the next week or two.
What is our government doing?
Our federal government has done some good things, such as to restrict incoming travel from China (the epicenter of the infection) as well as from other severely infected countries (Iran, Italy, Japan, and South Korea), but others are showing rapid spread. Keep yourself informed on regular news sources. Travel to such countries would not be advisable at this time.
The government, however, has not offered any practical guidance about dealing with school attendance or other large congregations of people (theaters, conferences, and so forth) where contagion can easily be spread. And it has done little so far to facilitate mass testing of our population by the medical community. Up till a day or so ago, testing for possible Covid-19 infection could only be done if people were clearly symptomatic and febrile and had visited countries with known disease, and all samples had to be sent to the CDC for testing. Ultimately, few people were tested. Without easy specific tests for the disease, medical professionals are at a severe disadvantage.
What we need to do, as others have pointed out, is to have readily available rapid tests to detect Covid-19 in people who may be minimally symptomatic, or in contact with others who were, in order to detect those with latent infections so they can be treated or isolated. We have to do this aggressively if we are ever to contain the spread of the infection. While greater availability of testing is coming, and Mass DPH will shortly be able to do the tests, to be truly effective the government should facilitate the distribution of test kits to every hospital and lab and for point of care tests in physicians’ offices (as we have for influenza A and B). Pharmaceutical companies are working hard on drugs and vaccines, but drug treatments or preventive immunizations are unlikely this year.
What can you yourself do to protect yourself now?
These practical behaviors will help protect you and others:
- Basic careful hygiene is really important. Wash your hands with soap and water frequently. Do this for at least 20 seconds and then carefully dry. Both the duration of the washing and the drying with a cloth or paper matter in germ removal.
- Use an alcohol-based hand sanitizer (think Purell, also Zep at Home Depot) frequently when you are out and about or in your office or go to a store. Clearly hand sanitizers are already hard to get, but keep trying. You don’t need to buy out the store. Frequent soap and water is sufficient in lieu of Purell.
- Purchase disposable sanitizer wipes to take with you on a trip, on the plane, etc., to wipe off public surfaces that you may need to be in regular contact with. These surface wipes seem to be available now. Again, don’t buy out the store.
- Consider getting and using proper surface sanitizers in the kitchen. These are used by restaurants as dilute sprays after physical cleaning with soap and water. One brand is Q-San-10, but others available on the web.
- Don’t shake hands. Use elbow bumps or be Japanese and bow (we liked that tradition when we visited Japan last year). Don’t kiss on the cheek with family. Be French (or New York) and air kiss if you must. Or just wave.
- If you get any respiratory illness, stay home. Practice careful hygiene. Cough into your sleeve or a disposable tissue. Avoid touching your face or nose, which facilitates virus spread.
- If you are sick, obtain and wear a standard surgical mask to protect your family (if you can find one). Ordinary surgical masks are effective in minimizing spread of droplets from a person’s cough and protect other people from your illness.
- Normal surgical masks do not protect you from another person’s cough. Do not try to buy large quantities of masks nor wear them unless sick. Masks are made largely in China, supplies have been rapidly depleted and few masks are available even for health care facilities and doctor’s offices, where they truly are needed.
Consider reducing travel
Travel is also getting riskier. All public travel and common meeting areas raise the risk of incidental and unknowing exposures. Consider that risk in your plans. I would think:
- Don’t go on a cruise ship for the foreseeable future. They are potential incubators of disease and then can become a public-health prison.
- Obviously don’t travel or plan to travel to any country or location (think Italy) where there are large outbreaks of Covid-19.
- Think hard about attending any international convention wherever located since the risk of innocent contagion from asymptomatic attendees is clearly real and likely growing over time.
Prepare for 2-week quarantines
Any mild or moderate or asymptomatic case of Covid-19 requires treatment and isolation (self quarantine) for at least 2 weeks. It is also possible that regional quarantines may become a public health mandate at some point in the epidemic if it continues to spread aggressively. That is not true now in the US, but it is certainly a concern as we look to this spring and summer. Also, some drug supply chains may be jeopardized given how much primary drug production occurs in China. While there is no indication for panic buying or hoarding (and lots of reasons not to), it would be prudent to:
- Check your freezer and pantry to confirm you have adequate supplies for and your family for 2-3 weeks self-quarantine without extra food shopping, should one of you come ill with Covid-19. For most of us, adequate back up food in the freezer is not going to be an issue.
- Try to assure that you have a month or two supply of any critical medicine, such as insulin and biologicals such as Enbrel, to allow for a significant shortage. Talk to your pharmacy provider about getting extra supply. We will authorize such additional medication if need be, though there is no assurance now that the drug intermediaries will pay for such early refills. For most standard drugs (for blood pressure, cholesterol and so forth) cases, shortages seem unlikely and we should be able to identify alternatives with your pharmacy.
If you get ill with fever and cough
We are modifying our office approach to acute respiratory illnesses with the intention of giving everyone proper care but providing better protection to patients and staff in the office. We will of course be available for anyone with acute illness, as always, and to give remote advice at any time. We will work as follows:
If you get any respiratory illness, stay home but then promptly call our office for advice.
- If you need evaluation and are without clear risk for Covid-19, we will see in the office, but will give you a mask at the entry door and have you come in through our rear door and go directly into an exam room to minimize your contact with others. We will use protective N95 masks during your evaluation.
- If our telephone screening suggests a high likelihood of coronavirus infection, we will direct you to the emergency room (and call in advance for you), where they have the proper exam facilities (such as negative pressure rooms) and direct availability to the key diagnostic tests and X-ray.
- If our telephone screening suggests influenza, and you are not seriously ill, we may now prescribe Tamiflu for you and close contacts on a presumptive basis rather than having you come to the office. That may be safer practice for the duration of the flu season.
I hope this update and review is helpful to you in understanding what is developing with the Covid-19 infection as it approaches pandemic (all over the world) status. It is more serious than influenza but fortunately much less dangerous that SARS or MERS were, which most of us were never directly affected by. The self-care suggestions reflect pretty universal advice from infectious disease specialists. Keep listening and reading.
We are available for questions about Covid-19 on this blog, which we encourage and I will try to answer within a day. Use the comments field below. I suggest checking this Orchard Health Care blog every few days for the moment to keep current (along with other sources, of course). We are emailing this post to members of the practice, given its importance, to get this information stream started.
However, if you have a personal health question on Covid-19, please email to firstname.lastname@example.org or call us in the office for prompt personal attention.
Brief Update of Covid-19 as of 3/3/20
In the past two days, we have just heard the public announcement of substantial expansion of Covid-19 test-kit availability around the country. That should make possible screening of people with indeterminate contact or mild symptoms to detect mild Covid-19. That will vastly improve our ability to contain spread from original cases. The details of this test-kit distribution, timing and effect are unclear but should evolve over next few days.
We also now have evidence of new infections in New England, specifically in Rhode Island and Maine. This is hardly surprising. We all need to pay attention. Wash your hands! Again!