We are following the evolving situation very closely and I would like to make the following points for our patients and staff so that we have a better understanding of this disease process and to avoid also unnecessary measures or anxiety.
Symptoms:
Greater than 95% of patients have a fever
Sore throat and dry cough: A productive cough is less likely to be COVID-19.
Myalgias, and in less than 10% of patients, nausea and vomiting, diarrhea.
Shortness of breath: This is extremely important. It occurs in patients in the later stages, and carries a very poor prognosis. It means that there is early ARDS. The main pathology is atelectasis and alveolar plugging, resulting in severe hypoxemia and respiratory failure. However many patients who are not subjectively dyspneic, have revealed CT scan appearances of atelectasis, bilateral infiltrates, interstitial changes, and these patients need to be monitored extremely closely in a hospital setting.
Majority of the patient’s, greater than 90%, may have mild symptoms at best, some fever, myalgias, sore throat, cough, and atypical viral course. Just like influenza, or respiratory syncytial virus, and other forms of viral disease, the course is rather benign. For young, healthy individuals, the distressing aspect is the social isolation and economic impact and inconvenience more than the actual illness itself that is a problem
A major distinguishing point between a regular upper respiratory infection and COVID-19, is a runny nose, productive cough, because these are more suggestive of a regular upper respiratory infection. It is also flu season still, so when a patient presents to the office with these symptoms, you will need to become educated to try to clinically distinguish the 2 syndromes. Shortness of breath is a major problem with COVID-19. The examination of the lungs will reveal crackles, consistent with a interstitial pneumonia, and a CT scan is the most helpful test together with a chest x-ray.
CONTACT: With somebody who has definitive COVID-19, means bodily contact, coming within 6 feet of each other, spending more than an hour with that person, means that you are now a person of interest. If someone comes in contact with the definitive case, they need to be quarantined for 14 days, looking for symptoms of COVID-19. They should be sent home and told to stay home, monitor symptoms, report ANY SHORTNESS of breath. This is where telemedicine is going to be helpful. Here at CVI, we are working on a telemedicine program. Coming into contact with somebody who thinks they have COVID-19, is not contact.
POSSIBLE exposure: Traveling from a COVID-19 area, recent international travel, requires a voluntary home quarantine for up to 14 days.
VIRAL SHEDDING: Means infectivity, starts 2 days prior to symptoms and continue so long as you have the symptoms, usually 14 days
Overall mortality: 6%, but highest in patients who are over the age of 60 and who have underlying cardiovascular disease, COPD, diabetes, renal failure and poor immunity. It takes a very benign course in the younger populations.
TESTS: The nasal swab is going to become more available as of this week, but, I am told that only 1000 samples can be processed by Quest and Labcor on a daily basis so we will try to get some swabs into our office. Whom will we swab? Patients at high risk from EXPOSURE, WITH symptoms. It is currently recommended that asymptomatic patients should not be swabbed. However special circumstances, for example President Trump, had it done to reassure the population even though he was asymptomatic.
In China, of all the patients who were swabbed for suspected COVID-19 and upper respiratory infections, only 4% were positive for COVID-19.
This tells you that most patients with upper respiratory infections have NON-COVID-19 illness. This is very reassuring.
Then, of all patients were positive, a small minority develop serious disease, 6% mortality, but majority of the patient’s recover as they would from any other viral disease. The testing is going to become more available, and in particular, a drive through program in the parking lots of Walmart, target, CVS, will become available for some patients. As I have said, in asymptomatic patient with possible exposure, we will refer them to 1 of these places to get the test done.
The test result may take 24-48 hours to return. More rapid point of care testing swabs are in development but they going to take many months.
VACCINATION: This is a long way away, but in the meantime, it is my opinion that the majority of the population of the United States is going to develop herd immunity via exposure. The current containment is not going to be effective to contain and eradicate the virus. The current measures of social isolation is simply going to spread out the cases over a longer period of time, so as not to overwhelm the health care system with sick patients. Without the current measures, the rapid exposure to COVID-19 and resultant severe pulmonary disease will overwhelm the current healthcare system. We do not have the capacity to double the ICU beds at this time. Once herd immunity is in place, there will be serological tests in the future which we do not have currently, which will confirm past exposure and immunity. (Although a questiontill over the longevity of immunity and risk of reinfection).
PREVENTION: It is mostly spread through coughing, sneezing, close contacts such as touching, shaking hands, touching an object or surface with the virus on it and then transmitting HTR nose or mouth or eyes.
Wash your hands often for 20 seconds with soap and water. You can use an alcohol based hand sanitizer is warm. This is important after every contact. Do not touch eyes nose or mouth. Do not come in contact with sick people. If you are sick, cover up the cough or sneeze with a tissue, and then throw it away. Clean and disinfect frequently touched objects and surfaces such as computer keyboard, tabletops, pens, handrails and other surfaces that are touched by others. Keep your hands to self. Keep a 6 feet distance from others. Avoid traveling. Avoid gatherings such as concerts parades festivals sporting events.
NUTRITIONAL: A strong immune system is a strong defense. A week or immune system accounts for the mortality in elderly patients, and patients with underlying predisposing factors example diabetes, heart failure, liver disease, renal failure. To boost your immunity, I have always recommended a low sugar, non-processed, low carbohydrate, no omega 6 processed oil consumption diet. Vitamin C, vitamin D, zinc, magnesium, fish oil are important supplements. Garlic, sprouted broccoli, spinach, cruciferous vegetables, yogurt, turmeric, almonds, ginger, Kale, papaya, citrus fruits, green tea, Kefir, are all excellent foods to boost immunity. Lastly, time restricted feeding and intermittent fasting have been shown to improve immune function in many studies. Do not snack. Daily exercise at home is essential. 7 hours sleep a day is essential. Consumption of water as the best beverage cannot be over emphasized. Dehydration allows viruses to penetrate the cell membrane more easily. Discontinuation of antiestrogens, and testosterone supplementation, may be an important issue, and more information on this is coming out. Need to speak to your provider about this.
PSYCHOLOGICAL well-being: It is time to be sensible and not overreact emotionally. This is NOT a deadly virus for the majority, and the mortality of 6% is predominantly composed of people over the age of 60 with underlying health problems. The lesson to learn here is that even if you over 60, if you have invested in healthcare, taking care of what you eat and drink and how you live physically and emotionally, you can be a healthy octogenarian with a good immune system. This disease is deadly for those who have a poor immune system.
The virus is definitely going to go through the population. The death rates are going to be in the elderly and weak patients. The current social isolation is recommended so as not to overwhelm the health care system, but is unlikely to stop the virus from spreading.
Economy: Without a work force, the economy is certainly going to suffer. Therefore, we need to appreciate our jobs, work hard for job security, adjust to the requirements, and be frugal. The economy will improve again, with newer visions, and self-sufficiency. I estimate at least a 6 month time for recovery.
