The 2019 Novel Coronavirus

March 15, 2020 UPDATE

Note: The disease terminology of the original post below has been changed to COVID-19, to reflect the official nomenclature.

As we watch Italy, (also beginning in the US Pacific Northeast and spreading), deal with significant COVID-19 outbreaks we are now getting a sense of what this virus is actually doing.  I think everyone is engaged and understands what is being reported.  For clarity’s sake, I will reiterate what I know here.

1.       The proper name of the virus is SARS-COV-2, the disease it causes is termed COV-19. 

2.       The virus affects different people differently.  It’s a big mixed salad of outcomes.  We definitely are seeing older people with immune compromise getting very sick and dying.  But it doesn’t take much to have a suppressed immune system.  Obesity, actually, is a significant player here and it’s a major problem world wide, not just in the US.  As the virus has moved out of China we are getting reports that middle aged populations are being hit hard as well.  Children statistically are doing the best with COVID-19.  But the other side of this coin is that they, as children always are, act as vectors and can spread it efficiently.  In fact, preliminary research is demonstrating that totally asymptomatic people are able to shed and transmit the virus.  And as with most viruses, detectable shedding can be found up to several weeks after the person has recovered.

3.       Most people are not dying from this.  Its the socioeconomic fall out that seems to be really impacting us.  This has just begun.  We have all watched those near post-apocalyptic movies where humanity narrowly escapes pathogenic doom.  Never did Hollywood go into Stock Market crashes.  Our economy is likely to take a bigger hit than direct disease numbers.  People are already not traveling, going out to eat, to the movies, to the mall, engaging in parties and events.  Schools of all levels are being released 2-3 months early this year as a quarantine technique.  This will prevent working parents from doing so, many people will be unable to pay their bills at some point or another. 

4.       At the front lines of this economic bruising are medical centers.  Hospitals are becoming overwhelmed with patients, many of whom need to be there.  Resources are running low or out, including hospital beds and life sustaining equipment.  There are not enough ICU beds and ventilators to go around.  Staff is exhausted and getting sick themselves.  There is not enough stuff to manage this deluge. 

So, everyone is getting into the 2020 groove of “social distancing”.  It’s a great practice, and does seem to mathematically compute to be effective in “flattening the curve” of infectivity.  In the US we seem to be doing it early, which is good, because we are not testing.  I live and work in West Virginia, the last statistical hold out for the virus.  This is nonsense of course.  We are simply not testing people.  And we (the US, not just WV) are still using the now clearly outdated screening question of being “outside the US or in contact with someone who has in the last 2 weeks?”.  I do not think our national numbers are accurate. I truly have no idea why this is happening.  The only apparent conclusion I can come to is that the people in charge of this process are idiots, even perhaps evil.  Its not the first time in history that people have had to act beyond the capacity of their elected officials.  Won’t be the last either.  Let this be a lesson in independent thinking and action.

I want to end this little update with a note on a couple of things NOT to do. 

Firstly, the statistical likelihood as of now, you, Reader, dying from this is low.  Which means if you catch COVID-19, you’ll get sick, probably, but be OK.  Please do NOT come to a medical facility unless you really need to.  Remember, we are barely testing people at this point, so if that’s your reason to go “get checked out” then is a poor one.  Believe me, I would love to be swabbing everyone to get a real sense of this thing. But, currently, that’s not in accordance with reality. Come to a hospital if:

1.       You are having trouble breathing.  Either you are getting very short winded moving around, or having to breath faster than normal when resting. 

2.       You are sick and cannot care for yourself.  This means not being able to do things like keeping yourself hydrated, fed and able to get to your bathroom.

3.       You are sick and have a preexisting condition, like asthma, COPD, heart disease, cancer, taking immune suppressants, lack a spleen, have liver disease etc…

If you come into clinic/the ER with cold symptoms and an unimpressive fever, remember, in all reality you won’t be tested.  You’ll be sent home. In the meantime, you’ve exposed everyone to a potential hazard.

I hope no one has to explain that drinking alcohol, smoking, doing drugs and even eating junk food, drinking sugary beverages, allowing yourself to get dehydrated and sleep deprived are the fastest ways to pull an otherwise healthy immune system down.  I truly hope that is not news to anyone.

One more point: you cannot do without excellent hygiene.  With all the talk on washing hands, not picking your nose and wearing a mask if you really feel you need to (if you are not otherwise sick, if you are it’s a MUST) I was asked a question recently that had not occurred to me. Should we wear gloves?  My answer is a resounding NO!  Here’s why: 1. the average person does not know how to properly use them.  Look, I am not out to lord over anyone and call them ignorant.  But trust me on this one, if you have not been wearing exam gloves for awhile and have not practiced taking them off after they’ve been covered in feces or blood, then you will screw it up.  Go get yourself a few pairs and rub some ketchup on them and practice.  Its harder than you think.  2. If people start wearing gloves, you know what’s going to happen?  PEOPLE WILL STOP WASHING THEIR HANDS.  Oh yes, the false sense of a germ barrier will smear this virus around faster than anything else I can think of.  People will think: “I wear gloves, I’m protected”, but then they touch this, that and the other thing while out, stop using wipes, washing hands every chance they get etc.  Ask yourself: is the average citizen going to change out an expensive set of latex-free exam gloves every time they open a door or pick up and put something down in a supermarket?  And what good does this do if they can’t get the gloves off properly anyway?  Do you know what I do in clinic after I take off a set of dirty gloves?  I WASH MY HANDS.  If the glove wearing trend starts we will now have a subset of people walking around with two fists full of filth and the whole community effort of personal hygiene effort goes out the window.  Please, for all that is holy, sacred and scientific, PLEASE DON’T WEAR GLOVES IN PUBLIC. …..And don’t you know the following day after being asked this very question, I am walking through a Publix and what do I see?  An elderly couple pushing their carts around…. In gloved hands.  I’d have done a face-palm, but we aren’t doing that right now….

March 15, 2020

We have a “new” virus spreading around the world, the 2019 Novel Coronavirus (COVID-19).  Not totally novel, it’s a mutated version of a familiar entity, the Coronavirus,  one of the causes of the common cold. Especially if you’ve ever gotten a head cold in warm weather, there’s a good chance you’ve had  a Coronavirus. 

“Coronaviruses are a group of viruses that have a halo, or crown-like (corona) appearance when viewed under an electron microscope.” https://en.wikipedia.org/wiki/Coronavirus#/media/File:Coronaviruses_004_lores.jpg

This newly mutated Coronavirus is drawing attention,  because it makes you much sicker than a cold, more of a SARS or MERS picture.  Basically, a bad respiratory bug.  Today, I finally caught up on the CDC’s COCA (Clinician Outreach and Community Activity) call.  You can check it out for yourself:

https://emergency.cdc.gov/coca/calls/2020/callinfo_013120.asp

I spent some time afterward, digging a little deeper, got some statistics on viruses of past and present.  I also read a little about Wuhan China.  Here is what I have learned thus far.

The COVID-19 presents much like influenza, which is to say very variable.  Mostly, people develop high fever, headache, lower respiratory symptoms such as cough and shortness of breath.  But not everyone.  Like flu, some get no fever.  Some report an initial sore throat and a few presented early on with diarrhea.  The COVID-19 has an incubation period of 2-14 days, most often about 5 days.  That’s how long it takes to start showing symptoms from the time you get an adequate dose of the bug.  Currently, there is an observation that there can be a sudden decline around week 2 of illness.  So, it looks like flu, during flu season.  Pretty unhelpful.  Currently in the US, the CDC reports a total of 260 people in 36 states have been tested for the COVID-19, 11 have been positive and 82 are pending as of the date of the posting of this blog essay. 

The COVID-19 is associated with animal reservoirs, as are other coronaviruses, influenza viruses etc.  Coronavirus is found in Beluga whales to bats.  It is the horseshoe bat in China that the COVID-19 is currently thought most likely to have come from.  According to my husband there is a video circulating the internet of an Asian appearing woman eating a bat.  I cannot vouch for this as I have not sought it out.  I doubt the video is terribly informative and therefore unhelpful.  Additionally, my culture has taught me that eating bats is a disgusting no-no.  I’ll leave it to my imagination.

Clinicians are being educated to ask about recent travel or contact within 14 days with someone who has traveled outside the US.  Airports are screening  people passing through for fever.  If you present to a medical facility with an active cough you will be given a mask to wear.  It is a respiratory virus after all, and that is indeed how it is transmitted.  People should understand that any respiratory virus is very easy to catch.  If you have ever been in a store and watched someone cough in an aisle, it would be best to not go near the area.  Viral particles are very light and hang in the air for some time.  The time depends on wind, ambient humidity and of course just how much virus someone is shedding.  But it is very possible to catch a virus by walking into someone’s lingering sputum cloud minutes after it’s been ejected into the air.  Viral infectivity, in general, depends upon the individual somewhat.  Some people are “super-shedders”, they pour a lot of virus particles into the environment, while others are better at keeping it to themselves.  Additionally, people should understand that all viruses continue to shed beyond convalescence.  That’s to say you can still infect people days to even weeks after you feel all better.  Yes, I agree, that is frightening.  But knowledge is power.

How bad is the COVID-19?  Let’s look at some statistics.  According to the COCA call on January 31, 2020 the numbers were:

China – about 10,000 infected with 200 associated deaths

USA – 6 infected, 0 deaths

As of February 5, 2020, according to the same source the numbers now look like this:

China – 24,316 infected, 491 deaths   Much higher numbers have been reported, but new models and improved tests indicate that the higher numbers are incorrect.

USA – 11 infected, 0 deaths. Currently Arizona, California, Illinois, Massachusetts, and Washington state have reported these cases, but we are still awaiting results from other PUIs (person under investigation).

Many other countries on all other continents have a handful of proven cases now.  Only Africa, Central and South America and the Poles have no reported cases. 

Here is the main CDC page on COVID-19:  https://www.cdc.gov/coronavirus/2019-ncov/index.html

There is no treatment for this virus.  A BBC article cites testing of lopinavir and ritonavir, both antiviral agents used in SARS, but there has been nothing that has been announced as effective, and certainly nothing is approved at this time.  Treatment is supportive, with more specific interventions associated with addressing comorbidities (such has preexisting lung disease).

A tiny bit about the city of Wuhan.  Wuhan is the capital of Hubei Province,  a rich natural resource producer, known for rice production as well.  Interestingly, Wuhan itself boasts the largest college student population in the world.  Yes, the entire world.  Wuhan is touted to have 89 universities.  While I do not wish to convey anything subjective here, I cannot help but wonder about the world’s largest close-quarters population in the midst of this outbreak.  Perhaps there is some degree of cause and/or effect here.  Again, this is pure speculation.  I am too old to believe in coincidence, however, I think that is a word to cover for that which we do not otherwise see.

Enough about my personal ruminations.  Let’s look at a few simple numbers to get a feel for the magnitude of the COVID-19.  The 1918 influenza epidemic that killed my great-grandfather had a mortality rate of 10-20%, estimated loss of 3-6% of the entire world’s population.  That’s a big discrepancy, but we were still figuring out how to collect international data 100 years ago.  The truth usually lies between two given extremes, but we can go with 10% to be optimistic.  If we divide 491 (total number of Wuhan deaths) by 24,316 (total number of documented Wuhan cases) we get 2%.  If indeed the number of infected is higher then of course that percentage declines.  Not so bad when we compare it to the 1918 epidemic.  Looking at the US stats for last year’s influenza season (2018-2019) we documented about 35.5 million cases and about 34,200 deaths.  That gives us a mortality rate of 0.1%.  Suddenly, 2% is looking ominous.  Of course this is a bit of comparing apples versus oranges.  The US is far less densely populated than China in general.  The culture is different, health care access varies, etc.  Still, viruses mutate, it is how we got COVID-19.

How do we avoid infection?  Well, if you don’t have to get on an airplane right now, don’t.  And some countries aren’t letting you in.  Borders are being closed and cruise ships held in ports. (https://www.bbc.com/news/world-asia-china-51389490). But really, its about paying attention.  Not just giving a wide berth to coughing people (cover your face please), but washing your hands.  No really, wash them, a lot.  It pains me to watch people walk right out of a public bathroom, passing up the sinks.  It is unbelievable that in this day and age people out in public do not wash their hands at every opportunity they get.  Next time you are in a crowded place, watch people.  Watch us touch our faces, stick our fingers in our mouths, sneeze on ourselves, touch our cell phones, use the bathroom (leaving said bathroom with cell in hand)… and then grab a door handle.  I think public school health classes need some serious microbiology curriculum.  We are absolutely failing on this front.  This doctor is going to brag - I am the only physician I know that actually washes her stethoscope in water, with soap.  Yes, lots of practitioners wipe theirs down with bleach or peroxide wipes.  But we know very well things like Clostridium difficile spores are pretty recalcitrant to a lot of chemical cleaners.  Most germs are best washed down the drain.  The last piece of general advice is to not wear yourself down.  Nothing pulls your immune system down faster than being stressed, sleep deprived, smoking/chewing tobacco, drinking alcohol and eating sugar containing foods every day.  The latter just doesn’t get discussed enough.  Sugar makes you ill.  A subject for later discussion.  Bottom line is, we all know those whose misfortune it is to become sick, fare far better when they are well going into it. 

Be vigilant, Reader.  Vigilant toward not just your environment, but your own body and how it’s doing these days.  Because one thing is for certain, a serious viral pandemic will happen again.  It always has and always will, that’s the nature of life. An ounce of prevention is worth a pound of cure.  Especially when it is difficult to see exactly what it is, on the horizon.

I will update this post as I see the need to.  Basically, if things progress or radically change I will do the best job in I can in my tiny corner of the world to report it.

Be well, Reader, and stay alert.