The following is a summary of the current status of the coronavirus pandemic (as of 6/29/20 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.
- 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. 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 (polmerase chain reaction) tests. The nucleic acids present in the samples are extracted, amplified, and then examined for regions of genetic material found in SARS-CoV-2. These tests can take from two to a few days to perform. These tests 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 (the “15-minute test”) and do-it-yourself-tests (a patient collects and submits their own specimen) are considered significantly less accurate and carry an even higher risk of false negatives and possibility of false positive (the result says you have COVID-19, but you do not). Tests for active disease are now offered at many walk-in clinics, some doctor’s offices, and drive-thru sites.
- 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. Only a few tests, out of dozens that are now offered, have Emergency Use Authorizations (EUA’s) and only equipment used by major laboratories from Abbott, Roche, and Ortho Diagnostics have been tested and are considered highly accurate. These tests usually involve a patient having 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 at Travel Medicine Consultations in NYC. Many rapid 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 immune when they are not immune). Some studies have estimated some tests to have a greater than 10% false positive rate (more than one in 10 results show antibodies to SARS-CoV-2, but none are actually present)!
- 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. Because we do not yet know if 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.).
- 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 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 manditory in situations and locations where social distancing is not possible. 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). Measles, one of the most contagious diseases on earth, has an R0 value of 12-18. Anything above a value of 1 can cause outbreaks or epidemics. 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.
- People already diagnosed with the virus (with symptoms, with or without a positive test 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 without symptoms (cough, etc.) for three days. The CDC recommends a person does not return to work for 10 days after symptoms start and there are no symptoms for three days in a row. A patient may leave isolation earlier if they are without symptoms AND they have tested negative for active disease (nasal or throat swab) twice in at least 24 hours. For the NYS DOH guidelines on quarantine and isolation, see: Quarantine Guidelines.
- People with no symptoms but have a positive test (nasal or oral swab) must stay in isolation for either 10 days or until they have two negative tests at least 24 hours apart.
- VIRUS SURVIVAL OUTSIDE HOST: The virus may survive from hours to three days outside the host. A recent 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.
- “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: There are over 10,000,000 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.
- UNITED STATES CASES: There have been over 2,500,000 cases diagnosed in the US, and over 130,000 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.
- NEW YORK CITY: 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.
- DEATHS: There have been over 500,000 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).
- TREATMENT: Antivirals to treat infection caused by SARS-CoV-2 are now under investigation in dozens of studies, mainly in China. Remdesivir has preliminary been shown to help decrease the number of sick days in severely ill patients. Multiple other agents are under investigation. Hydroxycholorquine (Plaquenil) and Cholorquine (Aralen) have, overall, not been shown to be beneficial (and is likely harmful). Work on a vaccine by many companies across the globe, particularly China, are also ongoing. Preliminary, unpublished data from Moderna shows presence of virus-neutralizing antibodies in 8 of 8 individuals after experimental vaccine administrations. Use of antibody-containing plasma from recovered COVID-19 patients is now being studied in critically-ill COVID-19 patients and appears to be useful. 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.
- 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 may also turn out to be ineffective and harmful.
The following map from the Centers For Disease Control and Prevention website shows the worldwide distribution of reported cases of SARS-CoV-2 as of 6/12/20 (Content source: WHO Coronavirus disease 2019 (COVID-19) situation report)
At this time, both international travel and travel within the United States needs to be carefully considered.
For those age 50 and over, or those with chronic medical problems, travel, both local and international, should be avoided.
For under age 50 without chronic medical problems, travel still likely poses increased risk to individuals and risks further spreading COVID-19 to the rest of the population.
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 lift many restrictions on their populations. Unfortunately, this seems to have been associated with a rise in cases (beyond what can be explained by increased testing). Therefore, some countries and many US states have slowed or reversed their openings. NY, NJ, and Connecticut are requesting travelers from high-risk states self-quarantine for 2 week upon arrival.
…To Be Continued
For more information regarding coronavirus, go to CDC Coronavirus Information.