COVID-19 is a potentially lethal respiratory infection caused by a novel coronavirus known as SARS-CoV-2 (aka 2019-nCoV), which is in the same family of coronaviruses with SARS. To be clear, COVID-19 is the disease, and SARS-CoV-2 is the virus. By comparison, SARS was responsible for infection of 8098 people between 2002-2003, and 774 deaths. MERS was also caused by a coronavirus, which from 2012 to November 2019 has been found in 2494 cases, and attributed to 858 deaths. COVID-19 unfortunately has much higher numbers as I will review below.
While it is true that most people will survive COVID-19, and that many have a mild infection, this is not true for all groups of people.
According to the Centers for Disease Control and Prevention (CDC), people at higher risk of getting very sick from this illness include older adults, people who have serious chronic medical conditions such as heart disease, diabetes, and lung disease. (1)
The severity of illness, and the incidence of death from COVID-19 increase with age. This is not to say that younger people are not infected. It seems likely that younger people, and those without chronic illnesses are better able to tolerate the infection.
Hence, the population of people who read MPDN should please pay special attention to this article. I want to limit your risk, and to correct some of the thinking that has been shared with me in recent days.
This is not “just a virus,” and if you are infected, unless you take isolation measures, you stand a high probability of spreading the disease, probably to someone you care about, and to plenty of people you don’t know.
Where did COVID-19 come from?
Coronaviruses were known to medicine for decades prior to SARS and MERS and were typically associated with mild respiratory infections such as the common cold, similar to rhinovirus. However, viruses can mutate, or have changes in their genetic code, that make them more infectious, and perhaps more deadly.
SARS-CoV-2 is a mutated strain that has only been known since the end of 2019, when it caused a deadly form of pneumonia in Wuhan, China. This was around the time of the Chinese Lunar New Year, the largest annual mass travel event worldwide. (2) December 31, 2019 Chinese officials reported the deadly infection to the World Health Organization (WHO). By that point, there were numerous cases in China, many having traveled home from Wuhan after the holiday.
January 2020, the first case of COVID-19 was reported in the United States: a 35-year-old man who had visited Wuhan to see family during the recent celebrations. He had returned home to the Seattle, Washington area on the 15th of the month. (3) Four days later he presented to an urgent care clinic in Snohomish County, Washington (just north of Seattle) with a complaint that since his day of arrival home he had a cough and fever. He informed health workers of a CDC alert he’d seen regarding a virus in Wuhan, and was admitted to the hospital with pneumonia. Testing confirmed SARS-CoV-2.
As was typical, there were many flights from Wuhan to the United States, and surely, this man was not the only case to travel from Wuhan to the U.S. and other countries. Meanwhile, by February 11, 2020 COVID-19 had spread all over China, with more than 72,000 cases. (4) The U.S. government was slow to respond, and the chief executive declared the situation under control. It was not. By March 11, 2020 SARS-CoV-2 had spread not just in the U.S., but around the globe, and was declared a pandemic by WHO.
As of March 17, 2020 the State of Washington Department of Health reported 1012 confirmed cases with only 2% under age 20, 7% under age 30, the remaining 91% of cases over 30. Percentages of those infected increase by small margins with age. (5) Among those 1012 cases there had been 52 deaths. In part the numbers were misleading. There was a delay in getting test kits, and only a limited number of test kits available. Therefore, only the most ill patients, or those that met very specific criteria had been tested in the hardest hit state in the nation.
The problem is that almost certainly there were and are, many more asymptomatic or only mildly symptomatic carriers capable of spreading the infection to others. The incubation period (time from exposure until symptomatic) ranges from 2-14 days. Complicating matters, Americans travel. The virus travels with them, and we have had cases in every state.
The State of Maine has a total of 42 confirmed and presumptive positive cases as of today, March 18, 2020. However, this is after starting limited testing less than a week ago. Most of the positive cases have come from Cumberland County, though seven counties are affected so far. There is a strong likelihood however, that as with other locations, many more people are infected and capable of transmitting the disease.
Per the CDC there are today 7,038 cases of COVID-19 in the U.S., and there have been 97 deaths. The worldwide number is staggering. This brings us to important conclusions: we need to take this seriously and do all we can to limit the spread of the virus. It is time for social distancing, and we need to flatten the curve.
Social distancing
This means staying home unless it is absolutely necessary to go out. It also means if you are around other people, stay out of the droplet range (six feet), even if they appear to be well. This is an airborne disease, meaning it can be spread in the air around you by breathing, coughing, and sneezing. It can also be spread by droplets on surfaces such as doorknobs, rails, shopping carts, counter tops, and hands. Don’t shake hands with others, and don’t touch your face unless your hands and your face are clean. In particular, don’t touch your eyes, nose or mouth with unclean fingers.
Wash your hands often, especially after blowing your nose, coughing, or sneezing, or having been in a public place. Soap and water are always best, especially if your hands are visibly dirty. Hand washing should cover the entire hand and take at least 20 seconds.
To wash hands properly, wet your hands with clean, running water, apply soap, lather your hands by rubbing them together with the soap, covering the backs of the hands, between the fingers, and under the nails. Rinse off soap and dry with a clean towel or air dry. However, if soap and water are not available, a hand sanitizer with 60% alcohol or higher inactivate kill the virus.
The CDC also recommends stocking up on supplies such as groceries and medications, keeping away from sick people, limiting close contact, avoiding crowds “as much as possible,” especially in poorly ventilated spaces, but also cruise ships, and non-essential air travel.
If COVID-19 is in your community, and you are in a high-risk group, investigate ways to get food brought to your home via family, social, or commercial networks. You should still stay in touch by phone, emails, or texting with loved ones, because social isolation can be emotionally and psychologically very difficult.
If you have a caretaker, make sure they stay well, and have a plan for the possibility that they fall ill. Have a backup caretaker in mind such as a family member.
Flatten the curve
When an outbreak of an illness occurs in a community, numbers climb over time, as it is spread from person-to-person.
With a rapidly spreading and dangerous illness the threat is not just that many people will fall ill, but that the number of sick people may overwhelm hospitals and other health resources, as has happened in Italy and China.
In that case, a person who needs help might not get it, with disastrous consequences for the person who otherwise might have pulled through with therapy. I cannot put it any more plainly that to say in that case there will be more death and more disability. That is why we want to “flatten the curve.” This means slowing the rate of exposure or decreasing the number of cases that happen at once. If we flatten the curve, likely there will be fewer cases overall, and hospitals will not be overwhelmed, as was the case in Singapore and Taiwan. If the rate of infection is kept low enough, everyone gets a chance for treatment.
Imagine a hospital with 150 beds. If 300 people come in with a severe illness, half of them might not be helped. Under normal circumstances we would call around the state or to neighboring states for help. But, if hospitals are all experiencing a surge in cases at the same time, there will be no help.
Now, imagine everyone in the state practicing social distancing, washing their hands, using common sense and care to avoid spread. The disease spreads very slowly, and the hospital and health workers are not overwhelmed. Everyone gets a chance. We all fare better.
This is flu season, and hospitals are already dealing with a lot of infection and respiratory illness. Because of this, and because of COVID-19, elective procedures in hospitals and clinics around the state are being put on hold in order to free up hospital beds for a potential surge in patients. In fact, many doctors’ offices are not seeing anything but urgent patients, to limit risk for healthy patients.
If you think you have been exposed to COVID-19 by a known case and/or develop a fever and symptoms, such as cough or difficulty breathing, CDC recommends you call your healthcare provider for medical advice. However, you should be aware that doctors’ offices are receiving very high volumes of calls, and many offices cannot keep up with this. Please do not contribute to that burden unless you meet the above criteria. Many of the questions people are asking can be answered online at Maine CDC (6) or at the Federal CDC (7) websites.
Many people in the U.S. with mild symptoms are staying home and weathering the illness, but should be in isolation within the home. Such a person should have their own room, ideally their own bathroom, and wear a mask when around others-which should be limited, to limit the spread of droplets. Surfaces in the home they have touched should be cleaned.
In conclusion, I don’t mean to be alarmist. This is a serious situation which warrants concern. We have only to look to China and Italy to see how bad this can get. However, it does not have to be that way here. I suspect however that it will not be over in weeks, but will take months for this spread to stop. You can help by social distancing, and by flattening the curve. These are the right things to do.
REFERENCES
- https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html
- Phelan, et al. The Novel Coronavirus Originating in Wuhan, China. Challenges for Global Health Governance. JAMA 2020;323(8):709-710.
- Holshue, et. al. First Case of 2019 Novel Coronavirus in the United States. NEJM 2020;382 (10):929-936.
- Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. Vital surveillances: the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020. China CDC Weekly. http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51
- https://www.doh.wa.gov/emergencies/coronavirus
- https://www.maine.gov/dhhs/mecdc/infectious-disease/epi/airborne/documents/Public-COVID19-FAQ-16March2020.pdf
- https://www.cdc.gov/coronavirus/2019-ncov/index.html
