By ROB LAMBERTS, MD
Updated – 3/11/2020
Things are developing regarding the spreading epidemic/pandemic and so here is an update to let you know the state of things, what we are doing, and what you should do.
There have now been more than 120,000 cases worldwide, with over 1000 in the US. Italy (as an example of what could happen here) is in crisis, with more than 10,000 documented cases and ER’s and hospitals flooded with very sick patients. Schools across the US (including Atlanta) have closed to decrease the spread of the virus. The pattern of illness remains the same:
- People present with a flu-like illness (fever, body aches, cough) with focus of infection more on the lungs.
- Children are largely spared from the severe disease, with the majority of deaths being in the elderly or otherwise high-risk individuals.
The problem we face here is twofold:
- We don’t have a good test available to diagnose COVID-19 in a clinically useful way (rapid and simple)
- Even if we did, there is no clear treatment for COVID-19, other than supportive care.
How We Are handling patients with Flu-like Symptoms
- We are trying to identify patients who may have coronavirus and treat them outside of our clinic. While we want to help people who are sick, we don’t want to expose high-risk people to the virus. So…
- We ask that if you have a fever or flu-like symptoms, that you do not come into the office. Instead we ask you to contact us via phone, email, or via Spruce. Be patient, as we are likely very busy with other sick people!
- Please tell us about your symptoms and we’ll guide you in what to do next. This may include triage and evaluation in our parking lot. Remember that we cannot diagnose you, and we cannot give you any treatment if you do have the virus. Yes, that makes things very difficult for all of us, but it is the situation we face.
- Also understand that we may have high-risk people at the office with other problems. Infected individuals in our office may spread the infection to others, so please understand, and don’t demand special treatment.
- If possible, do not come to the office if you are a high-risk person:
- – Over age 70
- – Diabetic (poorly controlled)
- – Significant lung problems (COPD, moderate/severe asthma)
- – Other immune-compromising problems or medications.
Important Note: Do not go to the Emergency Room for routine symptoms. ER’s are full of vulnerable people and (reminding again) testing is not available, and there are no definitive treatments for the infection.
The reason to go to the ER is if you:
Have shortness of breath
Are unable to hold liquids down and may be getting dehydrated.
The key to saving lives in our society is to take steps before infection to decrease the spread of the disease. This will not only allow new treatments and preventive measures to be developed, but also to decrease the burden on hospitals and government responses to the pandemic. How?
Wash your hands – often. This is better than hand sanitizer and needs to be the rule.
- Avoid large groups. This is difficult, but it will probably be taken out of our hands soon. Concerts, sporting events (yes…I suspect the Masters will be included), and other groups of people will be cancelled or curtailed in the near future. While this seems extreme, there is evidence that doing this (from past epidemics) saves lives and decreases disease.
- Be willing to help the vulnerable people in your life. Be aware that there may be people for whom you are the best help they can get. Don’t expose them to risk, but let them know you are willing to help (be that by shopping for them, checking on them over the phone, and doing what you can for them).
- What about school? That’s a difficult subject, but it’s likely that schools will start closing soon. This is not for the safety of the children (although some who have immune problems are definitely at risk), but instead for the sake of the vulnerable family members and other contacts in society that could catch the virus from children. You should consider keeping your kids from school if:
1. They have been diagnosed with significant immune problems or lung disease
2. There is someone in your home with significant immune problems or lung disease
3. There is someone in your home who is over age 70.
Again, it’s likely this decision will be taken from us soon.
Even though this stuff is quite scary, there is a big difference between fear and panic. Fear leads to caution and thoughtfulness. Fear makes us avoid bad decisions because we see their consequences. Panic, on the other hand, is self-centered and destructive. It is an “everyone for themselves” mentality that hoards and doesn’t share. It focuses on itself rather than others. As medical caretakers we are not able to panic, and we are at much higher risk than the general public. Don’t let this situation drive you to self-centeredness; let it drive you to generosity, to kindness, and to willingness to work together.
Please note the lack of political commentary in this. We are facing a human crisis, not a political one. Yes, some of the problems are created by political posturing, and some of the solutions will have to be political. But lining up on either political side of a public health issue will do nothing to help it. Please work with others on this, even if they disagree with your political views.
Coronaviruses are a common type of virus that infects people and animals. They usually cause mild illness in people, with typical upper respiratory symptoms. As is the case with other viruses (influenza being the most important example), a virus strain that infects animals can mutate and transmit to humans, creating a more severe illness. Usually this doesn’t cause big problems, as these animal to human transmissions are not able to have person to person transmission. On rare occasions, an animal to human transmitted virus becomes contagious to other people. This is what is thought to have happened with the COVID-19 (the current coronavirus that is causing all of the problems).
What is a Coronavirus?
There are several factors that make COVID-19 so concerning:
– It is quite contagious from person to person.
– It has a 14 day incubation period where it can be contagious before symptoms appear.
– A significant percentage of infected people have little to no symptoms, yet they can still spread the infection to others.
– For those who do get the illness, there is a much higher percentage who have serious, even fatal complications.
The virus has spread rapidly from China, despite the quarantines and other aggressive measures to control spread of the virus. Most public health officials feel that it is very likely we will face a pandemic (serious infection that affects a high percentage of the world population) in the near future. How soon? It’s too early to tell. But we do feel it is time to prepare (see below).
The COVID-19 Infection
Infection is spread through usual means for respiratory viruses: mainly through hand contact or contact with airborne droplets from an infected person. The incubation period is up to 14 days, but symptoms typically show up from 4 to 7 days after exposure.
As stated before, a significant percentage of those infected are completely asymptomatic, and a majority (over 80%) have mild illness (mild cough, fever, upper respiratory symptoms). The more serious illness is generally in the lungs: lung damage, pneumonia, shortness of breath. This is much more common in the typical ‘vulnerable’ populations: the elderly, diabetics (especially those with poor control), and people with significant lung disease. It is not expected (at the time this is being written) that there will be a significant number of healthy individuals getting the serious life-threatening disease. Of note, infants and young children have not had an increased death or disease rate in the areas of high rates of infection.
At the present time, the COVID-19 infection has a 2% death rate associated, which is more than 20 times that of influenza. There is not a rapid test to diagnose the infection at the present time, so most diagnoses will be made by sending samples to national labs or just presuming the diagnosis where and when the infection rate is high.
What is Being Done
As of now, there is no definitive treatment for the infection, other than supportive measures to help the person while their body deals with the infection. There are some medications under investigation for this, but none of the medications we typically prescribe have been found to be effective in treating the infection. Specifically, antibiotics and antiviral medications (like Tamiflu) have not been helpful in treating this. Vaccines are being developed, but even at the rapid pace these are being done, the most optimistic time frame for a vaccine is 12 to 18 months from now.
The main effort presently is focused on slowing the spread of the virus by isolating infected individuals and quarantining communities when appropriate. The hope is that this will slow the spread while treatments, public health measures, and vaccines are developed. The more time we have, the more prepared we will be to handle the problem.
How You Can Prepare
The first and most important thing is to not panic. The vast majority of our patients are not at risk of getting serious infection, even in the midst of an epidemic. There is no reason to avoid school, work, or travel to places not effected by the virus (go to https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html to find specific travel restrictions/recommendations). Since we don’t know how fast this disease will spread, there is not yet cause to cancel plans for travel or other gatherings.
But we must be realistic: people will panic still, and that may itself cause significant problems. Stocking up on non-perishable food in case of a quarantine (which would last 2 weeks) is reasonable to do in the upcoming weeks/months. Furthermore, there are some practical things you should consider:
* If you have vulnerable family members, come up with a plan to care for them, and have alternate plans should the primary caretaker get sick.
* If you are a single parent, figure out ways to cope with illness to you or to one of your children.
* Workplaces should consider how to handle employee absences.
It should be noted that it is not advantageous for healthy people to wear masks, unless they are working directly with infected or high-risk individuals. Infected people may decrease the spread of respiratory droplets by wearing a mask. Overall, good hand-washing and common sense measures to decrease viral spread are always more effective than extreme measures. Is it reasonable to cut back on shaking people’s hands? Maybe, but mainly to just build good habits in case there is a local epidemic.
What our office is Planning
We have considered what measures we will take if/when the epidemic hits our area. Until that happens, nothing (aside from publishing educational material like this) will be different. If we are in a local epidemic, we will do the following:
* Cancel non-essential visits to leave room for the influx of coronavirus related care.
* Convert essential care visits to video or phone visits whenever possible.
* Be available to reach out to infected individuals as best we can.
* Continue to educate you and coordinate with other providers in our area.
This is a serious situation, but it is not the apocalypse. Most of us have not gone through a pandemic before, so this will create a lot of uncertainty and even panic in our communities. It is vital that we all think ahead, but not panic about what could happen. Reach out to your neighbors, talk to your coworkers, and make plans with your family on what you can do to prepare sin a way that is thoughtful and meaningful. Avoid spreading information that is not from very reliable sources, and don’t use this crisis to point fingers or increase political divisiveness. This is a time where unity needs to be of highest priority.
The best case is that this is an over-reaction and the pandemic will fizzle out. The worst case is that we will be caught unprepared, and that lack of preparation will cause harm to those who need help.
Rob Lamberts practices primary care medicine in Augusta Georgia. He blogs at More-distractible.org.