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The SARS-CoV-2 story continues to rapidly evolve. We’re publishing an update mid-month to help people understand what’s going on and how to keep themselves healthy and prevent the spread of the virus.

What we know today

An analysis from China of 1,994 patients shows that the main symptoms of COVID-19—the name given to the disease caused by the SARS-CoV-2 coronavirus—and the frequency with which we they occur in patients in parentheses are: fever (88.5%), cough (68.6%), muscle aches or fatigue (35.8%), sputum production (28.2%), shortness of breath (21.9%). Minor symptoms include: headache or dizziness (12.1%), diarrhea (4.8%), nausea, and vomiting (3.9%). COVID-19 is predominantly a lower respiratory tract infection as it targets receptors in the lungs, not in the throat or sinuses. Yet upper respiratory tract symptoms like sinus congestion, a runny or stuffy nose, and sore throat have been reported. There’s also evidence that the virus replicates at a high rate in the upper respiratory tract initially and that even in mild cases, after resolution of symptoms, viral shedding continues for about five days in the mouth. Importantly, in that same study, seroconversion (development of antibodies to the virus) occurred between six to twelve days after the onset of symptoms, meaning these patients probably developed immunity to the virus. There’s been discussion that some patients have recovered from COVID-19 and then been reinfected, but as of this writing, this is unconfirmed. In general, infection with other coronaviruses confers immunity (though how long is uncertain).

We still don’t know the true case fatality rate (CFR), but we do know that it varies by age (it’s worse the older you are, particularly if you’re over 60, and much worse if you’re over 80). The most current data we have on CFR (and realize this will likely change) is a CFR of 8 and 15 percent among those aged 70 to 79 years and 80 years or older, respectively. The rates also will vary depending on the level of access to necessary medical treatment, like ICUs and ventilators. A higher risk of death is also associated with a BMI over 25 (that is, being overweight), hypertension, diabetes, cardiovascular disease, and cerebrovascular disease—but an important caveat is that, with the exception of being overweight, all those other diseases are also associated with older age, meaning the primary risk factor may be older age itself.

Asymptomatic carrier transmission is occurring, meaning people can be infected without symptoms and transmit the virus to people who then become symptomatic. This is contributing to the high infection rates.

Importantly, in one retrospective study in China, the median duration of viral shedding after symptoms had resolved in patients who were hospitalized and survived was 20 days. The longest observed duration of viral shedding in hospitalized survivors was 37 days. (This is in contrast to patients with minor symptoms who were never hospitalized whose viral shedding after recovery was found to be shorter, as mentioned above.)

The importance of environmental disinfection was illustrated in a study from Singapore, in which viral RNA was detected on nearly all surfaces tested in the isolation room of a patient with symptomatic mild COVID-19 prior to routine cleaning. Viral RNA was not detected on similar surfaces in the rooms of two other symptomatic patients following routine cleaning. Importantly, viral RNA detection does not necessarily indicate the presence of infectious virus.

What to do?

One of the big worries is that the U.S. healthcare system is about to become overwhelmed as too many critical cases are poised to occur in too short a period of time. The hospital system in the U.S. operates at near capacity on a regular basis, meaning there’s little extra capacity to care for a significant influx of critically ill patients. Our goal, therefore, is to “flatten the curve,” meaning slow the rate of new cases as best we can. It’s unclear if current measures in the U.S. will be enough to prevent the U.S. healthcare system from being overwhelmed as is happening in Italy, but we can all do our part by practicing social distancing. It’s when people come in contact with others that transmission occurs, so it’s incumbent upon all of us, whether we feel sick or not, to limit our physical interactions with others as much as is reasonable and possible for the time being. Consider that every single person and every surface with which you come in contact is contaminated. In practical terms, this means:

1. Disinfect home and work surfaces regularly (computer keyboards, mice, chair armrests, keys, light switches, countertops, table tops, faucets, door handles, toilet handles, cell phones, and cell phone cases) with germicidal disinfectant that kills viruses. For a list of disinfectants with activity against SARS-CoV-2, go here.
2. Carry a disinfectant wipe in your hand when you’re out and use it when touching anything. This will remind you not to touch your face as well as enable you to open doors without touching door handles (and temporarily disinfect them for the next person). Out in the world, the most likely way of catching SARS-CoV-2 is by touching a contaminated surface and then touching your mouth or nose, not by randomly being coughed or sneezed on by an infected person.
3. If you must travel, disinfect and wipe down everything you come in contact with and try to stay at least 6 feet away from other passengers (which may be difficult, we acknowledge).
4. If you choose to eat out, wipe your table, silverware, plate edges, and drinking glass with disinfectant and don’t share food.
5. Zinc gluconate lozenges are known to reduce the length and intensity of symptoms from run-of-the-mill upper respiratory tract infections, some of which are caused by coronaviruses other than SARS-CoV-2. Because zinc lozenges are safe, it’s reasonable to use them if you develop any symptoms of illness, including body aches, even before respiratory symptoms begin. There is no evidence that taking zinc before becoming infected will do anything to reduce the risk of infection, so we don’t recommend it. To learn how to use zinc lozenges correctly, go here.

WHAT NOT TO DO?

1. Don’t overestimate the seriousness of COVID-19. Use the precautions we mention above and carry on with your life.
2. Don’t underestimate the seriousness of COVID-19. Our behavior shouldn’t only be aimed at keeping ourselves and our loved ones safe, but also at contributing to flattening the curve of infection in society. Social distancing is especially important for younger people at low risk for serious infection who go out a lot and are therefore more likely to transmit the disease to people who are high risk.
3. Don’t touch other people, even family members. If a family member is ill, not only don’t touch them, don’t sleep in the same room with them. If they’re coughing, either stay more than 6 feet from them, or arrange to live separately.
4. Don’t touch your face (specifically, your mouth, nose, and eyes). This is the most important—and hardest to follow—advice we have to give.
5. Don’t kiss your children, your grandchildren, or your spouse.
6. Limit or refrain from visiting seniors in retirement or nursing homes and hospitals if at all possible.
7. Don’t congregate in large groups in close proximity. Small gatherings in homes among asymptomatic people likely won’t convey the same risk, but if you choose to gather, which we can’t in good conscience recommend, don’t touch anyone, wipe down all surfaces, and avoid touching your face. Remind everyone around you to do the same.
8. Don’t show up at drive-by testing facilities or hospitals asking to be tested.
9. Don’t call your doctor without any symptoms to ask for a test.
10. Don’t read about SARS-CoV-2 on Twitter, Facebook, Reddit, or any other social media platform. There’s a lot of misinformation out there. Pick a reliable source, get the facts, and be appropriately prepared. Nothing seeds panic more than people bloviating about what they see online.
11. Don’t stock up on toilet paper, bottled water, or any other nonperishable item as if the world is coming to an end. It isn’t.

Given the absence of widely available SARS-CoV-2 testing, what should you do if you develop symptoms like muscle aches, fevers, a runny or stuffy nose, sore throat, cough, diarrhea, or vomiting? The unfortunate answer is to presume you are infected with SARS-CoV-2, self-quarantine immediately, and call your direct primary care physician. Your ImagineMD physician will triage you on the phone and provide you with direction. We hope widespread testing will be available soon, but in the meantime, because of the emerging data on viral shedding time, you should self-quarantine for at least 5 days after a mild upper respiratory tract illness (symptoms of sore throat, nasal congestion/drip, sinus congestion, ear pain) without a cough and for at least 10 days after a lower respiratory tract illness (by definition, cough present). You should self-quarantine a full month—sorry!—if you were definitively diagnosed with COVID-19 and hospitalized. If you have any of the above symptoms AND shortness of breath, call your ImagineMD physician immediately. He or she will then direct you to appropriate emergency medical services and alert the hospital about your imminent arrival.

WHO’S AT PARTICULAR RISK AND WHAT should you do?

The following types of people are at particular risk of dying from COVID-19:

1. Patients with compromised immune systems from diseases like common variable immunodeficiency disease, HIV, and chronic lymphocytic leukemia. This does NOT include patients with autoimmune diseases like lupus or rheumatoid arthritis, unless they’re also . . .
2. . . . taking immunocompromising medications like chemotherapy, prednisone, methotrexate, Imuran, or biologic agents.
3. Patients with severe emphysema or other lung disease whose lung function is severely limited.
4. The elderly (older than 60), and especially those over the age of 80.

If you fall into one of these categories, you should strictly self-isolate immediately. What this means may be different depending on your life circumstances, but is basically a stricter version of what we discussed above. If you don’t have to work, or can work from home, do so. Contact people physically as infrequently and as minimally as possible. Stay home as much as possible. When you have to go out, use the disinfectant wipe strategy mentioned above. Anyone who lives with you doesn’t need to self-isolate as strictly but must physically isolate from you in your home and must disinfect all surfaces mentioned above regularly. Avoid travel. Don’t eat out.

WHAT’S BEING DONE To figure out how to treat the virus?

The following medicines are being studied for their potential activity against SARS-CoV-2:

1. Remdesivir, which inhibits replication of SARS-CoV and MERS-CoV in tissue cultures and displays effectiveness in non-human animal models. Given that SARS-CoV-2 is similar to SARS-CoV, the virus that causes SARS, there’s hope that remdesivir will be effective against SARS-CoV-2. There are already anecdotal reports in hospitalized patients that it may be.
2. HIV drugs lopinavir/ritonavir, which were shown to be effective in patients with SARS-CoV.
3. Antihypertensive drugs that block angiotension receptors, like lisinopril, losartan, and others as ACE receptors are a known binding site in the body for SARS-CoV-2. Unfortunately, in one observational study, there was no observed difference in use of these medicines between survivors and non-survivors of COVID-19.
4. Chloroquine, an anti-malarial drug, has activity in the lab against SARS-CoV-2, and is being studied in people.

A key point here is that until we have definitive evidence that any of these drugs work, there’s no indication to use them in mild cases. In severe cases in which patients are hospitalized, there may be an argument for compassionate use of some of them. But until we do the studies, we just won’t know if they do more harm than good. (For example, there’s some reason to think that using steroids, which can limit the immune system’s response to infection and theoretically reduce the severity of lung disease, might help, but anecdotal reports suggest they may actually worsen the prognosis.)

Easy-to-obtain, widespread testing is not yet available and needs to be soon. Test kit production is ramping up now. Hopefully, drive-by testing without a doctor’s order for anyone with symptoms will soon be available.

As always, maintain a healthy respect for the risks of COVID-19 without becoming overly fearful or worse, panicking. We’re all in this together. We will get through it.

1. For previous posts related to COVID-19, see:
   1. Coronavirus February 2020—Part 1 What We Know So Far
   2. Coronavirus March 2020—Part 2 Measures to Protect Yourself
   3. Supporting Employee Health During the Coronavirus Pandemic

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