Now that the COVID-19 outbreak is likely here to stay and will ultimately involve many more places than the 37 countries where cases have been reported, it is a good time to review some questions about the disease process and ways to prepare for the outbreak – coming to a city near you.  This is Part 3 of the COVID-19 posts.  Please refer to the other posts for more information of the virus and start of the epidemic and for epidemiology terms.  

As of Wednesday AM February 26, there were worldwide 81,194 cases worldwide, mostly in Hubei province,  1,595 cases in South Korea, 447 cases in Italy, and 57 (40 were from the Cruise ship) cases in the United States, to name a few.  Cases are being reported in Bahrain, Iran, Japan and will likely reach other countries soon.

On Being Asked Questions about COVID-19

Not many people are able to call themselves experts on COVID-19, because it is novel.  As a front-line doctor who serves as Hospital infectious diseases specialist and County Health Officer, I have taken upon myself to review the primary references and the epidemiology coverage.  My career as an infectious diseases specialist has allowed me to see and/or treat multiple viral diseases, even unusual ones like HHV-8 (Kaposi’s sarcoma), Dengue virus and Monkey pox virus, as well as EBV/CMV/HSV/VZV and HIV not to mention COVID-19’s “pretty cousin” that causes the common cold. It has truly been a fulfilling career filled with lifelong learning.

So, it is with this knowledge base that I was asked several of the following questions on KGW-8 for a COVID-19 question and answer blitzkrieg.  

What is unique about the virus?

For the most part, the virus is similar to influenza virus:  Cough, Fatigue, Myalgias, Influenza-like symptoms and Pneumonitis (see below).  The majority of people (80%) will have a mild disease;  about 18-20% will have severe disease and 2-3% will be critical.

The infection presents similarly to influenza.  There has been suggestion that the fact that it causes viral pneumonia (technically viral pneumonitis) is unique, but this is not true.  Influenza virus and Adenovirus are a few of the viruses that can present with potentially severe viral pneumonitis.  These infections can worsen over days, just as COVID-19 has been described to worsens and is likely not unique to COVID-19.  The fact that there is a higher mortality rate in COVID-19 than with influenza factors in the consequences of possibly a more vigorous pneumonitis – which leads to respiratory distress and other sequellae.

Should I buy a mask?  Which one?    NO, just healthcare workers

At present, there is no need to stock up on masks. Surgical masks and N-95, which are used in the hospital and specially fit-tested by hospital staff, are available at hardware stores for painting and other use. Fit-testing is a way to assess that the mask fits appropriately and will provide protection from infectious particles. It is performed by squeezing a bulb with e.g. saccharin and assessing if it can be tasted while wearing a mask. Having a beard or a nose ring may affect the seal.

The descriptions of N-95 mask were taken out of context. They are the better masks, with pores or fenestrations (or pores) that are 0.3 microns (300 nanometers in size) versus surgical masks which protect from droplets of 5 microns or greater. Studies on surgical masks show airflow is still present although reduced. The CDC currently recommends the N-95 for healthcare workers treating patients with COVID-19 infection.

At present, the CDC does not recommend anyone else not in that category get masks. Those with any viral infection should wear a mask to protect themselves from contaminating their hands, touching their face. The coronavirus is likely transmitted on small respiratory droplets rather than airborne on air currents, and is more similar to influenza than measles in that way. Measles has an R0 (“R-naught”) of 20, meaning that it is extremely contagious, because it can be transmitted by the airborne route. From what is gathered by predictions based on the COVID-19 outbreak, it has an estimated R0 of 3, above influenza (R0 1.3).

Respiratory droplets are spread in the air after someone talks, coughs or sneezes. The droplets generally fall by around 4-6 feet. Smaller particles can spread on air currents for hundreds of feet. COVID-19 does not appear to be transmitted this way. Therefore, it is unlikely that masks will ever be necessary for those that aren’t infected, since transmission is within a range of 6 feet. That doesn’t mean that the transmission characteristics will remain static.

Is there any reason to “stockpile” food?    Probably Not

We have seen with this outbreak that it doesn’t take a lot of uncertainly to destabilize our lives – look at the 2000+ point drop in the stock market. There may be a short fuse when the disease is identified in a US city, as it has shown to be in Italy, Iran and South Korea.  This means that there will be a rapid initial spike in cases, before we set containment measures.  The US is paving the way to have more readily available test kits for state health departments rather than only through the CDC. Researchers are working on vaccinations which may take the next several months to be tested, confirmed and prepared. At this time, there is no reason to have months of provisions. Most people’s refrigerator and pantry probably have enough for several days, if it were needed to extend a little further.  Images of empty shelves in Milan supermarkets do evoke the concerns that come up when a city faces mass panic and lock-down fears. My faith is that the infrastructure that is in place already with our seasonal influenza preparedness will likely be effective in reducing spread of this virus when it emerges in various cities in the US.  Maybe phone apps can be useful in pinpointing at-risk locations, where multiple people are presenting with flu-like illness, when COVID-19 does reach the US.  Other apps for food order and delivery may also become more vogue, as people wrestle with new challenges.  Though there may be a halt in multiple lines in the food industry, in the worst case scenario.  One to two weeks stocked food is likely going to be sufficient at the time of a spike  – probably amounting to the shopping for the week.  Water concerns are not expected.

Milan Supermarket:  Photographer not listed

How long do virus particles survive on surfaces?  Probably only several hours

Most likely, the particles desiccate (dry) as water evaporates from the droplets that they are on. Virus particles are notoriously incapable of surviving outside of their host for long periods. It is usually felt that only a few hours outside the host is needed for the virus particles to no longer be “viable”. Some research has called that into question, raising concern that when giving the right carrier droplets /mucus, the coronavirus may live for longer period than 2 hours, even for several days (9 days possibly). My judgement would be that for the most part this would be extremely unlikely – and I would lean toward only several hours outside the host.

Another variation of this question is whether a package delivered from China could harbor COVID-19 and be able to transmit the infection to an enthusiastic box-opener.  The answer is NO.

Can the virus be transmitted in feces?

Coronaviruses cause infection most similar to the influenza virus. Although certain viruses can be shed in stool, like Norovirus, Rotavirus and Sapovirus, it is likely that COVID-19 is not able to be transmitted by fecal-oral route. Initial concerns were related to testing for the presence of RNA in the stool – though the presence of genetic material is not uncommon and doesn’t mean there was live virus. The major route of transmission is likely saliva, mucus and other respiratory secretions.

What Can I do to Prepare for this?

COVID-19 has shown to have a mortality rate of 0.9 %, which is likely two-fold to four-fold higher than seasonal influenza, which usually has an attributable mortality rate of 0.1 -0.3 %.  When you see these mortality rates for the population, it is important to understand that mortality rates is not the same for various ages, and is likely higher than 0.9% for those with chronic diseases, obesity and older age and lower than 0.9% for those immunologically healthy (fit, younger).  For the most part, vascular health correlates to a robust immune system.  Conditions such as diabetes mellitus, coronary artery disease, hypertension likely care a higher risk of mortality from COVID-19 infection.

1.  Get plenty of sleep
2.  Limit processed foods and eat plenty of vegetables.  If you are a diabetic, optimize your nutrition to optimize your immune system.
3. Exercise daily
4. Wash Hands Regularly
5. Flu season = Fist bump season or Air hand-shake season.
6. Get vaccinated for the Flu if you haven’t already.
7. Think good thoughts; limiting stress has a positive correlation to immune health.