What is Coronavirus?
The 2019 Novel Coronavirus COVID-19 is a new virus that causes respiratory illness in humans. Coronaviruses are a family of viruses that typically cause mild respiratory infections like the common cold.
Who is most affected by COVID-19?
Most deaths are primarily in older individuals with chronic disease especially diabetes while most young and healthy people seem to recover fully with hundreds of thousands already recovered. However, as with all viral infections, the virus does not discriminate and there are reports of younger people becoming seriously ill and dying. In addition, the young can asymptomatically infect their older relatives and the community at large. The goal is to prevent rapid spread to everyone at the same time overwhelming healthcare resources and thus everyone has to be involved in stopping the spread of the virus. This has affected the entire country with certain hot spots being much more affected than other places.
How Coronavirus Spreads
Person to person transmission usually occurs
- Via close contact of about 6 feet or less
- After contact with respiratory droplets from coughing or sneezing
- During the time people are the most symptomatic or sick
- COVID-19 has been identified in feces, so wash your hands
It is important to practice good hand washing and droplet transmission like you would do with influenza. Most people who are exposed to the virus become infected and usually show symptoms within five days. Symptoms are a high fever and dry cough, which is different than a stuffy nose associated with common colds and spring allergies.
Confirmed COVID-19 Cases
As of May 12, 2020, there have been ~1,386,000 confirmed cases in the United States (with ~82,000 deaths). Almost half of all the US COVID-19 deaths are in New York state and New Jersey and nationwide many are in elderly and nursing home residents
The US government on Jan. 31, 2020 first suspended the entry of foreign nationals with a history of travel to China and then issued travel advisories to high risk areas including Italy, Japan, Iran and South Korea. By March 14, 2020 the US stopped travel from Europe to the US for at least a month. Other countries are following suit and many have closed their borders. As of March 18th, the US-Canada Northern border closed for all non-essential traffic, not including trade and on March 19th the US State dept. urged Americans NOT to travel abroad. By March 20th the US Southern border was closed. on March 28, 2020 the CDC issued a Domestic Travel Advisory urging residents of NY, NJ, and CT to refrain from non-essential travel for the next 14 days. By April 22, 2020 immigration to the US has been halted.
National physical “social distancing” by the President and Centers for Disease Control to reduce the impact of this new highly infectious virus has been extended through April 30th based on expected peaks of US deaths in mid-April, but governors and mayors have been the ones making the individual decisions on specific business and activity closures. Most of our States have had shelter in place orders which are being lifted in a staged approach. Since most of the US cases are in New York, New Jersey and Michigan anyone who has traveled from these hot spots to other states have been advised to self quarantine for 14 days. Immigration from other countries is on hold during this pandemic. On April 3, 2020 the CDC suggested use of face coverings, scarves or home-made face masks when outside as persons may have virus without symptoms with some locales mandating this.
As of May 12, 2020 there have been ~4,273,000 cases reported globally. Of the confirmed cases, there have been ~288,000 worldwide deaths from the COVID-19 and this may be higher as it is not clear we have all the accurate data from China and Iran. Most of the initial cases were in China, Italy, Iran, Iran and S. Korea although based on our large population size, the US has the most reported cases now that testing is more wide spread; however, the denominator based on our large population makes the percentage of infected cases less than some other countries. Reported death rates are expected to rise and have been reported in many countries and the US is counting ALL deaths as from the virus if positive or suspected even if the person had cancer, heart disease, stroke etc. which makes comparing death rates between symptomatic, virus positive persons difficult. The infection-fatality ratio is decreasing as more widespread diagnoses are being made.
At Least Two Strains of the Virus
The good news is most healthy people infected are expected to recover hundreds of thousands have already recovered, and work is progressing quickly for a vaccine. There appears to be two strains of the virus: a weaker one and a stronger one (L and S strains) - as viruses are known to have antigenic drift. Good hand washing technique and avoiding touching nose, eyes and mouth prevents many viruses from infecting other people. DO NOT TOUCH your face, eyes or nose before adequately washing your hands thoroughly as the virus can survive on many surfaces!
Co-Testing or Individual Testing
Most respiratory viruses may not be from COVID-19 but rather influenza and RSV and initial testing involves co-testing in sequence however as of April 6th many have uncoupled testing. It is expected that most testing will be via drive-through testing stations and even self testing. There is some false negative testing, so even if you have a negative test and have reason to believe you had an exposure you still may want to self-quarantine after communicating with your treating physician. Anyone with acute respiratory illness should avoid contact with the elderly and those with chronic illnesses.
Nasal Swab Testing and New Saliva testing
Even though testing is available and millions of Americans have been tested, nasal swabs may limit the total number of persons tested so the worried well and those with mild symptoms need to stay home! Those with chronic diseases, cancer, diabetes, lung disease, kidney failure, suppressed immune systems and those over age 61 and under age 3 will likely be prioritized. Self swabbing to screen for infection may become available and point of care immediate test results may soon become available and allow more widespread testing and critical information. In addition, widespread serologic testing which has recently been approved will give us critical information about asymptomatic infection rates and immunity levels. On April 14, 2020 saliva testing for infection with the virus was approved which will be more comfortable than the nasopharyngeal testing.
Over 200 Countries and Territories have reported COVID-19.
Coronavirus Symptoms and Complications
Symptoms of COVID-19 appear to include:
- High Fever or no fever
- Dry cough
- Difficulty breathing
- May have some gastrointestinal distress and myalgia/muscle pain
- Loss of smell and intense fatigue are other reported symptoms
- “COVID” toes
- Shivering off and on
- Kawasaki like inflammatory syndrome in children
Previous coronaviruses have been known to cause mild to serious illness. At this time, it is unclear the true mortality rate of COVID-19. With more data and more testing, we can more accurately calculate this. Many think it is 1% or perhaps as low as 0.2 or less with Diamond Princess fatality rate of most older persons 0.5. Many initial models calculated over 200,000 US deaths and others well under 100,000. The initial models were clearly off. It is believed that infection can present with mild to respiratory symptoms that progress to pneumonia later and a “cytokine storm” about 5 days later and many persons may have infection with no symptoms. Widespread antibody testing may show that asymptomatic infections are more widespread than realized and thus deaths per million population may be less than predicted.
Individuals with a compromised immune system and the elderly are at a greater risk of serious illness if infected with COVID-19. But younger and middle-aged people have also required hospitalization and can die, so everyone has to be “all hands on deck” to flatten the curve of infections to avoid overwhelming hospital resources in the counties and locales with the most cases. Certain urban areas appear to be more affected than other US areas.
Prevent the Spread of the Virus and other infections
- Wash your hands. Frequently cleaning hands with soap and water for a minimum of 20 seconds. If soap and water are unavailable then clean hands using an alcohol-based hand sanitizer with a minimal alcohol content of 60%. Keep your home adequately humidified to prevent nasal passage dryness.
- Avoid the sick. Avoid close contact with those who are experiencing symptoms of a viral illness.
- Do NOT touch mucous membranes. Avoid touching your eyes, mouth and nose with unclean hands and before washing your hands for 20 seconds.
- Cough into sleeve or tissue. Be sure to wash clothing after coughing into sleeve and dispose of tissues immediately after coughing into.
- Keep immune system strong. Ingest adequate vitamin D3 and vitamin C, zinc and eat a healthy diet rich in natural antioxidants like quercetin and get enough sleep all of which helps your immune system. Do NOT overdose on mega doses of vitamins or take substances and drugs that are NOT recommended by your physician.
- Practice social ie physical distancing. The elderly and those with serious, chronic diseases should avoid crowded, congested spaces similar to what one would do during flu season and follow the advice of your local authorities which in many states has escalated to shelter in place. Most schools, events, church gatherings, national sporting events and local bars and restaurants have been closed, canceled and/or put on hold. Grocery stores and carry-out food from restaurants remain available.
- Listen to stay-at-home orders and then staged re-opening rules. The CDC and the President have advised no more than 10 person gatherings. Individual states are handling closures and orders to shelter in home individually.
- Know the facts. In times of emergency, it is important to not panic and seek information from reputable sources. Beware of telephone and internet scams.
- Be smart with supplies. It is always a good idea to have several weeks of chronic disease management medications on hand. Plan ahead. Food supplies and toiletries are NOT affected so people are encouraged not to hoard. Medical grade masks in general should be reserved for health professionals and front line workers.
What to do if You Feel Sick
- Cover your sneeze or cough with a tissue and avoid coughing or sneezing into your hands. Discard all tissues in the trash.
- Clean hands regularly and disinfect items and services that have frequently been touched.
- Avoid close contact with others and stay home from work/school and all elective activities.
- If you are coughing, wear a face mask if close contact with others cannot be avoided. However, regular face masks in general do not prevent the healthy from being infected and general face masks should be worn by those coughing and sneezing to protect others. Specifically fit medical face masks are for preventing highly infectious airborne infections like TB and measles to protect the healthy. Health care workers doing close medical procedures may need a specially fitted N95 mask as well as Personal Protective Equipment (PPE).
- If you or a loved one experience any of the COVID-19 symptoms listed above, seek medical attention and contact your health care physician, hospital or local public health department in advance to prepare for your arrival.
- If you have traveled to any high risk area or “hot spots” in the US or known positive contacts within the last several weeks or any other locales with reported outbreaks and or if you are experiencing symptoms of COVID-19, please contact your healthcare clinician via phone or electronically. It is getting much easier to get telephone/distance/virtual care. Now that community spread has been documented high fever, dry cough and flu like symptoms have to be initially considered as possible COVID-19, so isolate yourself and CONTACT your physician regarding testing and potential treatments.
- Your health care clinician can instruct you on how to receive care perhaps virtually while going to a designated testing area and importantly minimizing risk and exposure to others.
This is an evolving situation and new evidence/recommendations may present daily and may be handled differently depending on the region of the country that you reside in as risks vary depending on your physical location.
Coronavirus Treatment Options
- Treatment for COVID-19 is geared generally toward relieving symptoms, including controlling fever, cough and adequate fluid intake to avoid dehydration.
- There are no available current human coronavirus vaccines but trials have started and several therapies including the anti-malarial chloroquine and hydroxychloroquine appear promising when used early along with oral zinc and other anti-oxidant therapies and potentially an antibiotic with anti-inflammatory activity like azithromycin with the caveat prolonged QT prolongation cardiac effects can rarely be seen. Quercetin like hydroxychloroquine and chloroquine May help to get zinc into the body’s cells to weaken the virus. Hydroxychloroquine was approved for emergency use in COVID-19 however, some Governors issued orders prohibiting use in COVID-19 and while these orders have been rescinded some states unfortunately still regulate physician’s prescriptive authority to include use only in clinical trial or in critically ill persons.
- There are preventive trials on the use of hydroxychloroquine in high risk health care workers that are enrolling. It is important to have adequate zinc.
- Melatonin, which declines after age 65 may have some anti-SARS2 viral activity. Anti-oxidants like glutathione and NAC (N-acetyl-choline) a glutathione precursor and alpha lipoid acid are being looked at as supportive therapy.
- Physicians are looking at IV therapies and on May 1st Emergency Authorization Use of anti-viral Remdesivir which appears to shorten ICU stays by 4 days in severe cases. Other IV anti-viral combinations in hospitalized patients and additional clinical trials are in progress. Actemra, an agent approved for cancer related cytokine storm has been used experimentally. Cyclosporine, an anti-rejection transplant medication is being looked at along with other agents with anti-viral activity like ivermectin and many others in clinical trials.
- Pepcid (famotidine) an antacid and antihistamine may have anti-SARS-CoV2 Enzyme activity.
- Those with low oxygen levels may need prescription high flow home nasal O2. Sleeping prone on your stomach appears to help the lungs function better.
- We are optimistic that anti-viral studies and other especially promising lines of research like using convalescent plasma of those persons who have recovered and recombinant immunoglobulin therapy are underway that will provide critical evidenced based therapies. One person’s convalescent serum may help several persons and is matched to blood type. It has been suggested that blood type may have influence on susceptibility to COVID-19 with type A higher risk and type O lower risk but this has not been confirmed in larger databases.
- Use of over the counter Levocetirizine/Xyzal and a prescription asthma medicine Montelukast/Singular is also being looked at to modulate the immune system in study protocols as well as several other promising agents like Complement C2 inhibitors are in progress.
- It is important to remember all the great strides we have made treating many viruses including HIV and hepatitis C.
Ibuprofen vs Acetaminophen
Initially, it was anecdotally reported from France that ibuprofen use in persons with COVID-19 may have worse outcomes than with acetaminophen use for fever; however, this has NOT been confirmed by others. Do not stop or start therapies without speaking to your physician. Acetaminophen reduces glutathione levels which is an important anti-oxidant so this has to be considered in persons with either liver disease and/or lung infections.
Information changes rapidly. Please discuss any and all prescription AND non-prescription therapy with your physician and have your bottles with you when seeing your physician or advanced practice clinician virtually or in person. As far as chemo-prevention and treatment of COVID-19, we have anecdotal clinical reports. Importantly, large clinical trials are in progress and will provide needed information. Some states have regulated whether physicians can prescribe medications unless in a clinical trial.
What you Can Do: Stay Up-To-Date About the State of the Novel Coronavirus COVID-19 and Please Stay Calm
If you are healthy consider donating blood as blood shortages have occurred. If you have recovered from COVID-19 please consider donating your plasma antibodies to help others. Check on the elderly and infirm and bring needed food and supplies to their homes. If you can donate time, money, and/or other needed resources to your health care facilities and our front line workers it will be much appreciated.
- Novel Coronavirus (COVID-19) and You
- What to do if you are sick with COVID-19
- Travel Health Notices
- Health Alert Network: Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus
Be Strong. Be Healthy. Be in Charge!
Oluwatosin Goje, MD and Taryn Smith, MD, NCMP
Walk-in Mammography at Cleveland Clinic is currently suspended as of March 11, 2020 until further notice. If you can obtain your medical care via telemedicine/distance care now is the time to get familiar with this emerging, convenient medical practice. Please read about distance medicine and virtual visits in the links below.
Oluwatosin Goje, who leads the Reproductive Infectious Diseases Program at Cleveland Clinic, is an Obstetrician Gynecologist fellowship-trained in Infectious Diseases at the Medical University of South Carolina, Charleston, SC. Dr. Taryn Smith is a Fellow in the Cleveland Clinic Specialized Women's Health Fellowship Program and will be joining the staff at Mayo Clinic Jacksonville in the fall 2020.
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- Virtual Appointments with Dr. Holly L. Thacker are Simple and Convenient for Out-of-State Patients
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