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Rodney Richie: Battling COVID-19 successfully means first learning the fundamentals
CONTAGION REALITIES

Rodney Richie: Battling COVID-19 successfully means first learning the fundamentals

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Given exaggerations, misstatements and outright falsehoods confounding Americans facing the pandemic unfolding before us in Waco and beyond, it’s not only relevant but critical to underline some fundamentals about this novel coronavirus, its ability to spread and efforts to combat it, including crucial missteps along the way. We’re likely to be confronted with this crisis for months. Factual information increases our chances of surviving it and one another.

  • The etiology of the pandemic is a virus named SARS-CoV-2 and the disease it causes is COVID-19. This virus is similar to prior single-stranded RNA coronaviruses that caused the SARS (Severe Adult Respiratory Syndrome) epidemic in 2002 and the MERS (Middle East Respiratory Syndrome) epidemic in 2012. Both viruses originally circulate in bats that then infect animals (civet cats for SARS, camels for MERS) that then transmit the disease to humans. The original SARS and now the SARS-CoV-2 originated in “wet” markets in China where animals are killed on demand for immediate human consumption.
  • There is no proven treatment for infection with this virus. Use of steroids and NSAIDS (this includes Advil — ibuprofen) is not advised for treatment of fever or other symptoms of COVID-19. Tylenol (acetaminophen) is recommended for fever and aches and pains. Lopinavir/ritonavir is being investigated based on SARS and MERS clinical trials. Remdesivir, available through compassionate use, has also been tried and was given to the first U.S. patient identified. There has been some discussion in the news media mostly about hydroxychloroquine as a possible drug useful in this viral disease. None of these medicines has been validated as being useful thus far. A vaccine will likely not be available for another 9-12 months.
  • SARS-CoV-2 is transmitted by the millions in droplets sneezed or coughed into the air. The range of transmission is estimated to be 4 feet; hence the current recommendation for social spacing of at least 6 feet. The virus thankfully does not remain airborne as occurs in measles or chickenpox, where one person could infect an entire room of people.
  • The SARS-CoV-2 virus will remain viable on surfaces — up to 24 hours on cardboard and 2-3 days on plastic and stainless steel. It survives less than 24 hours on cloth. Washing of hands with soap and water is the preferred way to rid oneself of the virus picked up from surfaces. Hand sanitizers are to be used if hand-washing is not practical. There is a strong recommendation not to touch your face — mouth, nose and eyes — with your hands in this environment. As humans have been observed to touch their faces with their hands more than 20 times an hour, this is a major problem.
  • The masks bought in stores and available in packets do not prevent transmission of the SARS-CoV-2 virus from entering your nose or mouth. However, they do ameliorate transmission of the virus in droplets from infected people when they cough, and their use is recommended till those individuals can self-isolate. They also may be of some benefit in reminding us of not touching our faces with our hands and thus providing some barrier to transmission of the virus, but these in no way obviate the need for frequent hand-washing. There are masks — called N95 masks — that are used by hospital personnel when working with infected people. They are very uncomfortable to wear and are never recommended for general use. Also, to be effective they need to be specially fitted by hospital personnel.
  • The infectivity of SARS-CoV-2 is expressed as R0 2-2.5, which suggests that a single person with COVID-19 may infect another 2-2.5 persons. By way of comparison, influenza has an R0 of about 1.2. Early epidemiologic response to COVID-19 was containment, where workers tried to trace and contact all known contacts of a person infected with SARS-CoV-2 and isolate this population. However, once the infection is widespread, then the approach is mitigation, with an effort to have all infected and exposed persons placed in isolation.
  • From the time the virus enters the body till symptoms occur is called the incubation period and is on average 4-5 days but may be as brief as 2 days and as long as 9 days. Persons are infectious before they develop symptoms and this greatly contributes to the infectivity of the disease. For 97.5% of infected persons, symptoms appear by 11.5 days. Estimated median incubation time to fever was 5.7 days in China. There are also symptomatic persons who have been found to be “super-infectors” who invariably have significant symptoms. Because some people may have the SARS-CoV-2 contact but never develop infection, the Centers for Disease Control & Prevention has recommended a 14-day self-confinement, reasoning there should be no chance of infecting others after 14 days.
  • Symptoms are mostly upper respiratory with cough, sneezing and a sore throat but may also cause shortness of breath. There are no significant gastrointestinal symptoms with this viral infection, and the current public run on purchasing toilet tissue is curious. The good news is that at least 80% of people infected are well after several days to a week. Children and teens tolerate this infection with minimal symptoms with deaths exceedingly rare. About 10% to 15% of mild-to-moderate patients progress to severe, and of those, 15% to 20% progress to critical — overall 6% of COVID-19 patients progress to critical. The mortality most commonly involves males over the age of 60 — especially in older adults with immunodeficiency, heart disease, chronic obstructive pulmonary disease and diabetes, with the risk of death doubling for every decade over age 60. The actual mortality of COVID-19 is being debated, given the mathematical model used. Estimates run from 2.5% all the way up to 20% of persons infected.
  • From a public health perspective, it is best if most infected persons ride out the disease at home and in self-isolation, but if really sick then their being seen in a hospital ER is probably the next best step. The ultimate mortality of COVID-19 has varied from 2-8% from country to country.
  • Drive-thru diagnosis centers are being set up for people who have symptoms to be diagnosed as either having or not having COVID-19. This will be of value to public health officials as to the presence and spread or diminution of the disease and may also serve to enforce the recommendation for self-isolation. Using such drive-thru installations will also highlight the very real concern that if an infected person is seen in a medical clinic, numerous medical clinic personnel as well as other patients may be infected or at a minimum required to go into a 14-day self-quarantine.
  • For those who might be interested: The COVID-19 testing kits contain reagents that convert the single-strand RNA into DNA (reverse transcriptase) and reagents that then hugely multiply the number of DNA present (Polymerase Chain Reaction — PCR). The kits are therefore labeled RT-DNA, and current recommendation for persons testing positive is to be retested with a different kit testing for a different gene on the virus. Testing in the United States was initially done through kits provided by the CDC which contained a malfunctioning reagent. That’s why the United States is the least-tested country in the world to date. Testing in the United States is still too limited — because of the dearth of testing kits — for most persons being tested twice as recommended above.
  • Finally, to those who believe we’re making way too much of all this with school closures, cancellation of events, etc. — public health experts tell us these measures should ideally have begun a month ago to most efficiently “blunt the curve” of infection.

Rodney C. Richie, MD, FACP, FCCP, is medical director of Palliative Care Service, Ascension Providence.

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