by Julia Getzelman MD
As you are aware, the situation around the SARS-CoV-2 or COVID-19 crisis is continuing to rapidly evolve. Since my original article about COVID-19 dated February 29th scientists, medical professionals, and even mathematicians have been studying the situation. Communities are beginning to take decisive action, including canceling large group events and “social distancing” is becoming a major focus to avoid transmission of the virus.
We have seen new data confirming our initial conclusion that children under age 10 are at low risk of severe illness themselves; however, this finding doesn’t mean that children are not becoming infected, and this raises a serious risk related to transmission to clusters of our family and friends who themselves are at increased risk of severe illness (including the elderly and individuals with severe underlying health conditions). Consequently, a theme of this article is: What steps can we take to “flatten the curve” and slow the spread of COVID-19?
We are in the second phase of the outbreak: community-spread transmission. For most people, the immediate risk of being exposed to the virus remains low. If we can slow the number of new cases each day, we buy valuable time to avoid overwhelming our healthcare systems and assure that those needing treatment will be able to obtain care. The illustration below was created by Dr. Siouxsie Wiles, an Associate Professor at The University of Auckland, who partnered with illustrator, Toby Morris, to create this powerful infographic:
In the earliest days of this crisis, officials throughout the world thought containment was possible. Unfortunately, containment appears no longer to be possible in the United States. News stories have been published about the executive branch of our government squandering opportunities to slow the spread of COVID-19 while disseminating “misstatements” and muzzling CDC officials from candidly discussing the situation. I continue to encourage you to critically think about what you hear from certain segments in our society (including on TV and social media). Listen to medical experts such as Dr. Anthony Fauci, the Director of the National Institute of Allergy and Infectious Diseases (NIAID), and look to organizations such as the World Health Organization (WHO), who base their opinions and advice on facts and science.
In our previous article, we addressed what the virus is, how many people have it, how it spreads, the symptoms, mortality rate, testing, treatment, travel, and how to protect your family. In this article, I answer frequently asked questions, discuss how you can flatten the curve, and why you should become aware of local clusters of infection. I also offer suggestions for talking with your children about COVID-19 because, at GetzWell, we know how deeply emotional health is connected with physical health.
How many people have COVID-19 today?
The number of people with COVID-19 is changing every day, and the numbers in the United States are increasing. This map has the most up-to-date numbers. The CDC has stopped reporting accurate numbers, opting instead to put that burden on individual states, so trust the numbers reported by a given state more than a number provided by the CDC or federal government. Additionally, the CDC has said it would stop publishing negative results for the coronavirus, “an extraordinary step that essentially keeps Americans from knowing how many people have been tested overall.” This step is outrageous. I encourage you to voice your concern to your Senate and House representatives either by emailing or calling.
Has the understanding about COVID-19 transmission changed since the last article?
Our understanding remains basically the same, although there is now more focus on reducing clusters of cases. The virus is spread mainly from one person to another, most likely through droplets of saliva or mucus carried in the air for up to six feet or so when an infected person coughs or sneezes. Viral particles may be breathed in, land on surfaces that people touch, or be transferred when shaking hands or sharing a drink with someone who has the virus. It’s also possible for people to transmit the virus though they are not exhibiting symptoms.
Accordingly, it’s vitally important to wash your hands thoroughly and avoid touching your face—especially eyes, nose, and mouth—unless your hands are clean. If your hands are not visibly dirty or greasy, using hand sanitizer that’s at least 60% alcohol can also help to keep your hands clean and help stop the spread of germs. Social distancing is also important. This means that when you do go out, do your best to stay 6 feet away from others. One example would be avoiding shopping during peak hours.
A new focus for flattening the curve is to reduce clusters of cases by early testing of potentially exposed individuals, then providing treatment of confirmed cases and interruption of further transmission through quarantines, social distancing, staying away from crowded public places and diligent hand washing and hygiene in the home and at the office. An increasing number of schools and universities have canceled classes and I expect that this trend will accelerate.
Different mortality rates are being reported for this disease. What’s the correct figure?
The rate still appears to be between about 0.6% – 3.4% depending, among other things, on the region of the world, available medical care, and patients’ age and general health before infection. The mortality rate calculation depends on specific figures, including the reported number of cases and the delay between when a person is identified as infected and what happens to them eventually. Any errors in or understating of any of the numbers that form the basis of the calculation will affect the accuracy of the mortality rate. In South Korea, which has been extremely aggressive in testing large numbers of individuals to identify carriers, the mortality rate is less than 1%.
Based on data from China so far, it appears that children who are 9 years old and younger have a 0% mortality rate. Data from China confirms that there is a relatively low infection rate in individuals 18 years old and under (2.4% of all reported cases). Children also seem to experience more mild symptoms than older adults. While this is great news for our kids and their health, it also means that parents and caregivers need to be extra vigilant so kids don’t pass the virus on to the most vulnerable. Before you take your children to visit their grandparents or your friends, consider the risk of transmission even if your kids have no symptoms. Help kids to thoroughly wash their hands frequently and keep them home if they exhibit any signs or symptoms of a cold. These precautions will help to contain the illness (whether it’s COVID-19 or the common cold—the symptoms can be very similar), thereby protecting the health of other people in the community who are far more vulnerable, including elderly people and individuals who are immunocompromised.
What about testing and treatment for COVID-19?
The CDC is beginning to make more tests available to approved centers. Private companies like LabCorp and Quest Diagnostics will begin testing (for a fee) later this week or next. The Stanford Health Care Clinical Virology Laboratory has also developed and launched a diagnostic test for COVID-19. But, as this article reports, the CDC’s response, especially with regard to testing, has been unacceptably slow and insufficient so far. Treatment recommendations remain the same as we reported in our previous article.
What are the signs, symptoms, disease progression and severity?
Symptoms of COVID-19 are non-specific and the disease presentation can range from no symptoms (asymptomatic) to severe pneumonia and death. As of 20 February 2020 and based on 55,924 laboratory confirmed cases in China, the WHO reported that typical signs and symptoms include: fever (87.9%), dry cough (67.7%), fatigue (38.1%), sputum production (33.4%), shortness of breath (18.6%), sore throat (13.9%), headache (13.6%), myalgia or arthralgia (14.8%), chills (11.4%), nausea or vomiting (5.0%), nasal congestion (4.8%) and diarrhea (3.7%).
People with COVID-19 generally develop signs and symptoms, including mild respiratory symptoms and fever, on an average of 5-6 days after infection (mean incubation period is 5-6 days, the range is 1-14 days). Encouragingly, an increasing number of patients have recovered including persons who had severe cases. Not surprisingly, early identification of cases and contacts allows for earlier treatment. It is clear that we need to massively increase testing in the United States.
Most people infected with COVID-19 virus have mild disease and recover. Approximately 80% of laboratory confirmed patients have had mild to moderate disease, which includes non-pneumonia and pneumonia cases, 13.8% have severe disease and 6.1% are critical (respiratory failure, septic shock, and/or multiple organ dysfunction/failure). Individuals at highest risk for severe disease and death include people aged over 60 years (with highest mortality among people over 80 years of age) and those with underlying conditions such as hypertension, diabetes, cardiovascular disease, chronic respiratory disease and cancer. A very small proportion of those aged under 19 years have developed severe (2.5%) or critical disease (0.2%).
Have travel recommendations changed?
Travel advisories are the same since our last Coronavirus article, and you can check the CDC website for updates as the situation unfolds.
What about cancellations of large gatherings? And what criteria should I use to evaluate whether my family or I should attend an event?
The California Department of Public Health recently issued guidance about “mass gatherings” and large community events (“Mass gatherings are events, including religious services, where large numbers of people are within an arm’s length of one another. They do not include typical office environments or stores.”) Many public events and conferences in San Francisco have already been canceled or postponed. Companies have been encouraging employees to work from home, if at all possible. The idea is to limit the opportunities for and likelihood of transmission of COVID-19. By reducing the number of people we have close contact with, the opportunity for infection goes down. Another way to reduce the spread of COVID-19 (or any virus) is by not shaking hands. Asking community leaders ahead of time what they are doing to keep people healthy at a gathering and requesting that they explicitly state that it’s a “wave-but-no-handshakes” event could be useful. Their answers may help you decide whether to attend an event.
How should I think about preparedness?
First, preparedness is not the same as “panic buying.” Panic is surely what has caused so many people to hoard toilet paper. Regardless of what you decide you need in your home to be prepared, be reasonable and don’t hoard. Overbuying can result in shortages and price gouging, which hurts all of us. What we really need to be doing right now is looking out not only for ourselves, but also for our communities. Check in with your friends and neighbors, especially those who face challenges that come with age or chronic illness. Ask how they’re doing and offer to help them.
Ideally, we’d all have well-stocked pantries in case we need to stay home for a couple of weeks. But if you have been to the store lately, you’ll have noticed that the shelves with canned goods are already astonishingly empty, the rice and beans are basically gone from many places, and so are the disinfecting cleaning supplies. So just be reasonable and do what you can that makes sense at this point. Maybe you already have supplies in your earthquake kit that would be useful if you need to stay home. Some experts have suggested that it can be helpful to have disposable nitrile gloves, as well as disinfectant wipes and sprays, zinc lozenges, hand sanitizer, tissues and similar items on hand. We continue to advise boosting your immune system at every opportunity.
Measures like reasonable preparedness, hand washing, and opting to wave or elbow-bump when greeting someone help keep us healthy as individuals. Even better, though, they can add up to a positive impact on health in our greater community. By taking these steps, we help protect the health and lives of people like grandparents, older aunts and uncles, friends and neighbors who have earned octogenarian status, as well as people who are immuno- compromised. As one physician in Toronto, an infectious disease expert, recently put it, “Let’s meet this challenge together in the best spirit of compassion for others, patience, and above all, an unfailing effort to seek truth, facts and knowledge as opposed to conjecture, speculation and catastrophizing. Facts not fear. Clean hands. Open hearts. Our children will thank us for it.”
How should I talk to my kids about COVID-19?
Talking with your children in an age-appropriate way about COVID-19 is important. Start by asking questions to see what your child already knows (or what they think they know), and go from there. Using your emotional intelligence, get curious about how they are feeling. If they are feeling anxious, worried, or apprehensive about safety, you’ll want to help them feel more secure.
Pay attention to how racial or ethnic bias may be affecting how you or your child views who contracts or transmits COVID-19. This disease knows no bounds. Be sure to question and disrupt any notions that could lead to discrimination against Asian people. Rely on empathy and active listening when you talk to your children, and do your best to keep your answers simple. Lean on solid family routines for hand washing and hygiene. Teach your kids new ways to greet friends, by waving, tapping elbows or feet, and invite them into a game where you each spot when the other touches their face. Reassure them that most people only experience mild symptoms, and even if they do get sick, GetzWell Pediatrics and hospitals are there to help them get better. Finally, remember to share things you are grateful for! Gratitude can be a powerful force, especially in times that feel uncertain.
Remember to contact us if you have any questions. If your child is experiencing respiratory symptoms, be sure to let us know when you call.