The following is a summary of the current status of the coronavirus pandemic (as of 11/24/20 PM): The information is drawn from the CDC, WHO, NYS DOH, databases used by travel health practitioners, news outlets, and other reputable sources. I discuss this same information with patients, travelers, and now, friends and relatives. I am not an expert in the new coronavirus (or infectious disease). I am an experienced Internist and a travel medicine practitioner relaying information from many sources in what I hope to be an understandable way. Thank you for reading.
-At this time, international travel needs to be carefully considered. Countries are often either prohibiting travelers from the US from entering or are requiring a COVID-19 test within a week of arrival. Please check updated information regarding entrance requirements through your destination country’s official website. Dr. Klapowitz will also obtain your specific destination information immediately prior to your consultation and review it with you during your visit.
-For people age 50 and over and those with chronic medical problems, travel should be avoided unless absolutely necessary. Please see the information below for COVID-19 risks at different ages and with chronic medical issues.
-Unpredictable border-closings, potentially inaccurate data about COVID-19 case numbers from many countries, and severe limitations of medical resources outside the US if you should become ill are some of the current issues involved with international travel. These and other travel complexities will also be reviewed during your consultation.
GENERAL COVID-19 INFORMATION:
- NAME OF VIRUS AND ILLNESS: The World Health Organization has named the new coronavirus SARS-CoV-2 (“severe acute respiratory syndrome coronavirus 2”). The disease SARS-CoV-2 causes is called “coronavirus disease 2019” (COVID-19).
- SYMPTOMS: SARS-CoV-2 appears to cause fever and cough in nearly all cases of symptomatic COVID-19, and shortness of breath if severe. Decreased sense of smell, and a corresponding decrease sense of taste, has been reported to be associated with COVID-19 as well in a significant percentage of patients. Other symptoms such as diarrhea, sore throat, headache, are less common, but can be see in COVID-19. Chest x-ray usually shows pneumonia in both lungs (“bilateral pneumonia”). PLEASE NOTE: “Pneumonia” refers to lung tissue inflammation caused by bacteria, viruses, and other medical issues. Vaccines that we have in the US to protect against pneumococcal pneumonia (Pneumovax, Prevnar 13), a bacterial infection, DO NOT provide protection against COVID-19. In fact, there is no evidence that any vaccine we currently possess (“flu,” measles, etc.) provides any protection whatsoever against coronavirus. These vaccines provide important protection against other diseases, some of which can even develop alongside COVID-19.
- TESTING FOR ACTIVE DISEASE: Currently, the most accurate tests for identifying if someone is actively infected with coronavirus are the nasal and oral swab PCR (polymerase chain reaction) tests and “molecular” tests. The nucleic acids present in the samples are extracted, replicated, and then examined for regions of genetic material found in SARS-CoV-2. PCR tests use cycles of heat to expose genetic material so that it can be replicated. Molecular tests do not require heat. Tests can take from under an hour to a few days to perform. They can have up to a 25% false negative results (in up to 1/4 of the tests performed, the result says you do not have covid-19 but, in reality, you do). Rapid tests that look for antigens instead of using PCR/molecular technology are considered significantly less accurate currently and carry an even higher risk of false negatives and possibility of false positives (the result says you have COVID-19, but, in actuality, you do not). Tests for active disease are now offered at many walk-in clinics, some doctor’s offices, and drive-thru sites. At home self-test kits have recently received EUA (Emergency Use Authorization) but are not widely available and may be less accurate than other tests.
- TESTING FOR ANTIBODIES: If you or your doctor believe you have had COVID-19 and you have recovered and are no longer considered contagious, testing of antibodies (IgM and IgG) is ramping up. These tests usually involve a patient having their blood drawn and sent to a laboratory, with results taking up to a few days to return. We send bloodwork to a lab that uses Abbot technology at Travel Medicine Consultations in NYC. Many rapid antibody tests involving blood, nasal swabs, or sputum performed on-site (also called “point -of-service” tests) are already being manufactured and distributed, without proper analysis or FDA oversight. These tests are likely much less accurate and are not recommended by the World Health Organization currently. Some have already been shown to have a high false negative or, worse, false positive rate (erroneously identifying a person as having antibodies when they actually do not). All antibody tests should be performed at least 3-4 weeks after COVID-19 symptoms or exposure…less time elapsed than that results in a much higher false negative rate. A positive antibody test may mean you have short-term immunity, but we do not know that for certain, yet.
- IMMUNITY? We do not yet know if having antibodies = immunity to (protection against) COVID-19. It appears that people who have mild symptoms of the disease or have an infection without symptoms (asymptomatic) may form fewer antibodies and/or for antibodies that do not last as long as people who have recovered from more severe symptoms. Data so far suggests that a majority of symptomatic COVID patients may have immunity that lasts at least 6 months. Because we do not yet know to what degree antibodies = protection from reinfection, a positive antibody blood test should not currently affect precautions you take to defend against the virus (social distancing, masks, hand washing, etc.). There have been a few documented cases, worldwide, of recovered COVID patients becoming infected a second time.
- IF YOU TEST NEGATIVE FOR ACTIVE DISEASE: Please discuss this with your doctor. It is possible that the result is a “false negative” (see above under “TYPES OF TESTING”), even with nasal or oral swab PCR (the most accurate testing). Rapid test kits can give false negative and false positive results (see above). Currently, we are telling patients that, if their symptoms were consistent with COVID-19 and their PCR or molecular test was negative, it is still possible they actually were positive.
- PREVENTION: Hand washing is considered an effective measure in preventing the spread of this and other viral diseases. Hand Washing, CDC . “Social distancing” (staying 6 feet from others) also appears to be effective at decreasing transmission of the virus, as is restricting gatherings and closing places where groups of people congregate (schools, restaurants, etc.). Wearing a mask if you are ill and have symptoms decreases the rate of coronavirus transmission. Wearing masks when you have no symptoms also appears to decrease transmission in the community and has been definitively proven to decrease transmission in clinical settings. (See CDC’s Cloth Face Mask Recommendation.) In NYC, facemasks are now mandatory in situations and locations where social distancing is not possible. Face shields may provide some protection if you cannot wear a mask for medical reasons, but they are not considered an adequate face-mask substitute by the CDC. Healthcare workers reduce their risk of exposure by wearing masks, gloves, gowns, and goggles in combination while caring for coronavirus patients. Individuals caring for family with symptoms at home should also wear masks during close contact.
- CONTAGION: People without symptoms are considered contagious. How much “asymptomatic” people are adding to the spread of the virus is under debate. (See “CASES WITHOUT SYMPTOMS” below) One infected person is estimated to infect 2 to 3 other people, on average, during the course of his or her illness (“R0” = 2-3). This number goes down when strict social distancing, masks, and other precautions are practiced. In New York, for example, the number dipped below 1.0 after strict “lockdown” was in place for several weeks. Measles, by comparison, is one of the most contagious diseases on earth and has an R0 value of 12-18. Anything above a value of 1.0 can potentially result in an increase in case numbers. COVID-19 is significantly more contagious than the “flu.” This is supported both by worldwide data case data and by our clinical experience locally.
- ISOLATION GUIDELINES:
- The average length of time between exposure to coronavirus and development of symptoms is 5 days.
- People who may have been exposed to the coronavirus are asked to isolate themselves for two weeks to make certain they do not develop symptoms of COVID-19 and do not put others at risk. If they then develop symptoms during isolation, see: “people with COVID-19 symptoms.”
- People with COVID-19 symptoms (with or without a positive test) go into isolation for ten days after the start of symptoms. At the end of isolation, an individual must also have been without fever (without Tylenol, Motrin, Advil, etc.) and with decreased symptoms (cough, etc.) for one day in order to safely end isolation. The CDC recommends a person should not return to work for 10 days after symptoms start and there are no symptoms for three days in a row. For the NYS DOH guidelines on quarantine and isolation, see: Quarantine Guidelines.
- People with no symptoms but who have a positive test (nasal or oral swab) must stay in isolation for 10 days.
- Specific exceptions to the above rules exist for hospitalized patients, severely immunocompromised patients, patients discharged from hospitals to nursing homes, and healthcare workers.
- VIRUS SURVIVAL OUTSIDE HOST: The virus may survive from hours to three days outside the host. A study showed the following survival durations: Cardboard: up to 24 hours, plastic and stainless steel: up to 2-3 days, copper: up to 4 hours. (Study by the National Institute of Allergy and Infectious Diseases, the Centers of Disease Control and Prevention, UCLA and Princeton University. Letter in NEJM) Whether or not finding virus outside a person’s body on a surface means that virus can infect someone is still under investigation. As we have learned more about transmission, it appears that catching COVID-19 from a contaminated surface is much less likely than through airborne droplets.
- “APPROVED” CLEANING PRODUCT LIST: Cleaning with bleach solutions or other products approved by the EPA for coronavirus can be found at EPA SARS-Cov-2 Disinfectant List
- TOTAL CASES WORLDWIDE: There are over 60,000,000 cases (people who test positive for SARS-CoV-2) diagnosed worldwide. Most countries of the world are now affected. See Updated list of affected countries.
- DEATHS: There have been over 1,400,000 deaths due to coronavirus worldwide. The mortality rate is much lower in younger people and higher for 60 and over (as age goes up over 60, mortality increases rapidly). Please note: The ACTUAL death rate is likely significantly lower than it appears to be when looking at the total number of deaths divided by the total number of cases. This is due to the fact that many people without symptoms or mild symptoms have not been tested and are therefore not counted as “cases.” (Please see “UNITED STATES CASES” above).
- UNITED STATES CASES: There have been over 12,500,000 cases diagnosed in the US, and over 260,000 deaths. This death rate (deaths divided by cases) is likely a high estimate, due to the fact that most people with mild or no symptoms have not been tested in the US and therefore not being counted as “cases.” The same would hold true for severe cases and those requiring hospitalization, both in the US and worldwide. This all assumes that deaths and severe cases are not being substantially under-diagnosed or misdiagnosed compared with the rate of “missed” cases of mild or asymptomatic cases. As noted below, the severe disease and death rate is much higher for older people and those with chronic illness.
- UNITED STATES DEATH RATES (percentage of people infected who die due to COVID-19): Age under 18: 0.1%. Age 18-44 2.8%. Age 45-54 5.1%. Age 55-64 12.4%. Age 65-74: 21.6%. Age 75-84 27.1% Age >85=30.9%. These percentages include people with diseases that increase COVID-19 death rates.
- RISK FACTORS strongly associated with increased hospitalization and death due to COVID-19: Older age, significant heart disease, cancer, chronic kidney disease, emphysema, severe obesity, sickle cell anemia, receiving a solid organ transplant, type 2 diabetes, and active smoking. There is mixed or limited evidence that other medical issues (high blood pressure, asthma, and others) affect outcome of COVID-19 adversely.
- NEW YORK CITY DATA: For up to date information about the pandemic here in NYC, please go to NYC.gov COVID-19 data page.
- SEVERE CASES AND RISK FACTORS: Worldwide, around 2 cases in 10 have been classified as severe or critical disease. Most patients with severe disease are age 50 and over or have chronic medical issues (high blood pressure, diabetes, emphysema, etc.). It appears, from studying cases in China, that children are as likely as adults to acquire coronavirus infection. However, it appears that severe illness is less likely in people without chronic diseases under age 50 and, particularly, under age 30.
- CASES WITHOUT SYMPTOMS (ASYMPTOMATIC): It is thought that only relatively small percentage of people with SARS-CoV-2 infection are truly asymptomatic (most have mild to moderate symptoms). There is still uncertainty regarding the level of transmission that occurs from asymptomatic individuals. COVID-19 can be transmitted at least 1-2 days prior to the development of any symptoms.
- TREATMENT: Remdesivir (Veklury) was approved (EUA) October 22nd for COVID-19 for patients requiring hospitalization. There is weak and conflicting evidence that it is effective. Bamlanivimab was approved (EUA) November 9th for patients who are not hospitalized but at risk of severe COVID-19 complications. A combination of Remdesivir and Baricitinib received EUA November 19th for severely ill, hospitalized patients. Most recently, on November 21st, Regeneron’s combination of Casirimab and Imdevimab received approval for mild to moderate COVID-19 patients at risk for hospitalization and severe disease. None of the aforementioned drugs or monoclonal antibodies is yet associated with overwhelming evidence that they are effective at preventing disease progression or reversing severe disease at this time. The effectiveness of infusions of antibody-containing plasma from recovered COVID-19 patients is still under debate. A commonly used steroid, hydrocortisone, may improve outcomes for oxygen-requiring and intubated COVID-19 patients (U.K. NHS RECOVERY trial).
- REINFECTION? We do not know how long immunity to COVID-19 lasts after infection. The reinfection rate within the first few months is likely very low. Experience with Coronavirus infections in the past (MERS, SARS) suggest immunity may last from months to a few years, but much more study is necessary to predict immune response with any degree of certainty. Currently, it appears that COVID-19 infection triggers immunity that lasts at least 6 months in the majority of patients.
- INACCURATE MEDICATION PROHIBITIONS AND COVID-19 CURES: ACE inhibitors and ARB’s (both used for treatment of high blood pressure, prevention of kidney disease in diabetics, and heart failure) have not been proven to affect a person’s overall risk of severe illness due to COVID-19. NSAID’s (Ibuprofen, Advil, Naprosyn, etc) also have no proven negative effect on patients with the disease. Azithromycin (Zithromax) has not been proven to help infection. Hydroxychloroquine appears to be ineffective at treating COVID-19 and has harmful side effects.
- VACCINATION: Multiple countries are working on dozens of vaccinations. Companies that are seeking emergency use authorization from the FDA after finishing Phase 3 of their clinical trials are as follows: Moderna, Pfizer/Biontech, and AstraZeneca. When a vaccine is noted to be “90 percent effective,” a number that is approximately what has been quoted for all three companies, it means the following: Out of thousands of test subjects, about 200 people have developed COVID-19 over the last two months. Of those, 180 received a placebo (not the real vaccine) and 20 received the vaccine (these numbers are approximately the numbers from all three companies). What this will translate into when the vaccines are administered to millions of people remains to be seen, but the assumption is that these same percentages will continue. It should also be noted that the vaccines appear to prevent progression to severe disease, even if symptoms do develop. Finally, all vaccines have at least two months of strong safety data. Overall, the data appear to be very positive.
SELF-PROTECTION and SPREAD REDUCTION RECOMMENDATIONS:
- IF YOU HAVE RESPIRATORY ILLNESS SYMPTOMS: If you have a cough, fever, loss of smell/taste, or diarrhea, consider contacting your medical practitioner before traveling to a healthcare office (assuming you do not feel ill enough to require emergency care. In that case, call 911). If, after discussion with or visiting your healthcare provider, it is determined you may have coronavirus, the CDC recommendations are as follows (see link): Prevention of Spread of Coronavirus
- SOCIAL DISTANCING: The WHO and other public health organizations recommend keeping space between you and people you are near. The current recommendation in our area is 6 feet.
- PUBLIC GATHERINGS: The maximum allowable number of people in one location varies from state-to-state and region-to-region.
- FACEMASKS: Please see above “PREVENTION.”
- GATHERING SUPPLIES: Access to groceries, medication, and other essentials is variable currently and may change if another “wave” of coronavirus occurs. For this reason, please consider making certain you have enough supplies at home to last for a few weeks at all times. Avoid allowing supplies to dwindle, if possible. This includes food, vital medication, and medication to treat fever (Tylenol, ibuprofen (Motrin, Advil, etc.)…assuming there are no medical reasons you cannot take these medications…consult your doctor) you and your family members may need.
RETURNING TO “BUSINESS AS USUAL: States across the US and countries internationally have lifted many restrictions on their populations. Unfortunately, this seems to have been associated with a rise in cases. Therefore, some countries and many US states have slowed or reversed their openings. We are optimistic that the situation will improve if distribution of the vaccines goes forward in 2021.
…To Be Continued
For more information regarding coronavirus, go to CDC Coronavirus Information.