COVID-19

It may seem odd that the first ISAKOS Blog post is from an epidemiologist and about an infectious disease, but that is the state of the world today.

I have been somewhat slow in composing this post during the coronavirus pandemic largely because early on there is still so much we do not know about the disease. That’s still true, but I now believe it’s past time to get this information out.

While ISAKOS is a medical/surgical society, in my interactions on twitter (@orthoepi for those who would be so kind as to follow me) I have been struck by how many orthopedic surgeons are grateful for information about how to adjust to life in the age of coronavirus. As such, if you find this blog post useful, please share it far and wide with friends, family, and colleagues. There is so much we can do to reduce the effects of this pandemic and get back to what can only be described at this point as the new normal, which I hope we can address in a future post.

For background, I have been a clinical epidemiologist at the Hospital for Special Surgery in NY for nearly 18 years focusing primarily on sports medicine and arthroplasty outcomes. While I have never studied epidemic disease professionally, I am well versed in the technical terms and understand how epidemics ebb and flow.

First off, let’s set the stage with an overview of some highlights. 

NOVEL CORONAVIRUS: This virus is deadly serious – for now. We have no immunity to it and it’s killing at a higher rate than the flu. There is no vaccine. There is no proven cure. The best thing to do is not get infected and if you do get infected, do your best not infect others. The good news is that as this virus mutates it may become less dangerous (over 18-24 months) and as more and more people are infected, it will not spread as easily. We will get past this. It is not the apocalypse.

SPREAD: The virus is most often spread through close contact with an infected person. This is primarily being spread through families, close friends, or coworkers. But it can also easily spread during events were big groups of people get together such as festivals, sporting events, night clubs, or bars and restaurants. It appears most commonly spread through the air if you’re close to an infected person, though it is also spread through shaking hands with an infected person or touching a contaminated surface. Healthcare workers who have lasting sustained contact with infected patients without adequate personal protective equipment are certainly at risk. One of my first friends to become infected is a private practice allergist who had a number of his regular patients seeking help in his clinic. He had no idea what he was up against.

RISK: Everyone is at risk of COVID19 and serious complications. Children appear to have more mild disease, but some still have extremely serious symptoms. It mainly appears to effect people with other comorbidities. Obesity is a risk factor. Males are at higher risk than females. Older people are at higher risk of hospitalization and death, although even people in their 20s and 30s can end up in intensive care units and some have even died. It appears to be causing heart attacks,  strokes, and thromboembolic events in younger people with no other risk factors

PREVENTION: Simple measures like social distancing and sanitation are most effective. I recommend reading the latest JISAKOS editorial by Niek van Dijk on COVID19 which provides an excellent historic perspective on hand washing policy. https://jisakos.bmj.com/content/early/2020/05/05/jisakos-2020-000472 . Stay away from people who could be sick (which during an epidemic is almost everyone) and wash your hands anytime you touch something that you don’t know where it’s been (which is most of the things we touch outside our homes). Alcohol solutions above 62% and diluted bleach are also effective for killing the virus on surfaces. And it goes beyond saying that you should not drink bleach and alcohols produced for sanitization.

INFECTION: How do you know you’re infected? In some cases you don’t. Some people never develop any symptoms. Early in the disease you may have a fever, fatigue, diarrhea, dry cough, sore throat or some combination. Many lose their ability to smell or taste, which seems to be a telltale sign that it’s not a regular flu. Up to 90% of patients have a fever. Most people should start to feel better in 5-7 days after first developing symptoms, though some will crash again and develop shortness of breath or other serious complications. If the shortness of breath becomes unmanageable, this is the point where you should seek medical attention. Otherwise, you should be able to self-manage and let the healthcare system take care of those who are in worse condition.

RECOVERY: Once you’re feeling better, get back to work. However, understand that you may still carry the virus for as many as 2 weeks so follow those precautions so that you don’t infect others. 95% of people who have been infected will be virus free within one week after they recover, but if you are part of that 5% who still carry the virus, it is better to be cautious (remember, 5% is 1 in 20 – not a rare situation at all). Also, volunteer to help others. Donate blood if a hospital in your community is testing antibody therapies. The world needs you.

That’s it. Feel free to stop reading here if you think you’ve got this.

Please stay safe and healthy. We are stronger together (at a safe distance).

Now …

If you’d like more specific recommendations, by all means, please keep reading.

THE SPECIFICS OF PREVENTION & MANAGEMENT

For more specifics on this, I’ve put together the following “tips” for those who may be confused by all of the information you may be hearing or reading. This information comes from medical professionals, my reading of research coming out of infected areas, and my understanding of how infectious diseases spread.

WHAT TO DO NOW

I would say this to those who live in areas that are not yet affected or have relatively few cases identified.

COVID19 IS ALREADY IN YOUR COMMUNITY. This is not to alarm you, but to let you know that the number of undiagnosed cases in communities without widespread testing may be as high as 100x as what is being reported. If your town has 5 confirmed cases, you can assume that number is possibly closer to 500. This holds true until widespread testing begins. The area where I live most of the year, Fukuoka, Japan, had 656 reported cases as of May 14th. While I do not think there are 65,600 cases here due to Japanese cultural norms, I would not at all be surprised to learn there are 6,000 to 12,000 cases, because there simply isn’t enough testing being done.  Health authorities in many countries report that only 1-7 % (average 3%) of their population has currently been infected. For herd immunity, the point at which most people exposed to the virus are not at risk of getting sick, we need approximately 60% of the population infected or vaccinated according to  WHO guidelines.

SOCIALLY DISTANCE. Coronavirus is primarily spread through contact with an infected person. The easiest way to social distance is to assume you are infectious and keep at least 1 to 2 meters away from anyone else as much as possible. Work from home if your job allows it. Don’t see friends or family any more than necessary. If you choose to continue to socialize, keep your social circle small and avoid crowded places. Use video chat or the telephone to keep up with those important to you.

DEVELOP GOOD SANITARY HABITS. Before the virus is widespread in your community is the time to start new, better habits around keeping clean. Don’t touch your face. Many of us touch our face hundreds of times a day without realizing it. Start realizing it. Wash your hands like a Take your shoes off at the front door (or in the garage if you have one). Change your clothes as soon as you get home. Don’t re-wear clothes you’ve worn outside. Avoid touching more surfaces than necessary when in public. These habits may seem like overkill now, but they’re easier to adapt when you’re not in the center of a crisis than when you are.

BUILD UP YOUR IMMUNE SYSTEM. Get enough sleep. Don’t drink too much alcohol. Don’t smoke or vape. Eat fresh, nutrient rich foods. Stress is hard on the immune system and as we face this disease, all kinds of stress is likely to occur. So it’s vital that we all get some downtime – read a book, watch a movie, enjoy a hobby. This applies triply if you develop COVID19. Do your best to stay hydrated, fed, and well rested. Your immune system will need the energy.

DON’T PANIC SHOP. Buy what you need, but don’t hoard necessities that others need as well. In case you get stuck indoors during the peak of the epidemic and you need to stock up food, then choose foods that can be stored for weeks or months like pasta, rice, beans, canned vegetables, canned fish, etc. Try to limit grocery shopping to no more than once or twice a week.

WEAR A MASK IN CROWDED PUBLIC PLACES. If you are sick it lessens your chance of spreading the virus. It also prevents you from so easily inhaling someone else’s cough or sneeze droplets, which is more likely in a crowd. Also, please note that “do not touch your face” also applies to “do not touch your mask” – if the mask has kept virus from contacting with your nose or mouth the virus may still be on your mask so touching it may contaminate your hands. Some masks can be reused if gently washed with soap and warm water. You don’t need to treat them as disposable.

Note: if you’re in a high risk area it may be best to dispose of them after a single use, but since we don’t know just how long this is going to last, even a good supply of masks may dwindle quickly. I’m currently switching back and forth between 2 masks which I wash and hang to dry as soon as I return home.

IF YOU LIVE IN A PLACE WITH WIDESPREAD INFECTION

ASSUME EVERYONE YOU MEET IS INFECTED. Do not take anyone’s seeming lack of symptoms to be a sign of safety. Just because you know someone personally doesn’t mean they don’t carry the virus. Many cases of infection appear to have been from someone who was infected, but 1-2 days before they showed symptoms, so most people are infectious before they know it.

ASSUME EVERY PUBLIC SURFACE IS INFECTED. The virus can survive in indoor air for about 3 hours (ventilation may clear it away more quickly) and on hard surfaces for up to 3 days. Wear rubber gloves when you are going someplace where you may need to touch public surfaces. If using disposable rubber gloves, dispose of them upon returning home. Use recommended medical glove removal technique (check YouTube).

DELIVERIES. In this environment, it’s better to order delivery and be exposed to one person than to venture out and be exposed to many. However, this is not good for the delivery person (other than the paycheck). If you order delivery, ask the delivery person to leave the packages at the door. Tip them well if tipping is customary in your community. They’re risking their health and life to get supplies to you. If you go out for shopping instead, stay 1-2 meters from anyone, wear a mask, and wear rubber gloves.

UNPACKING DELIVERED OR PURCHASED ITEMS. Keep in mind that the delivery person is probably not the only person who has handled the items you had delivered (or the items you picked up on the store shelves). Unpack them outdoors or in your entryway. Once you’ve opened the outer package (preferably with gloves), sanitize your hands before removing the interior items. Dispose of the outer packaging immediately.

ITEMS YOU BRING INTO YOUR HOME. Wash any items you can with soap and water. Things that can’t be washed should either be wiped down with alcohol or left in an unused part of your living space for 3-4 days.  After finishing this cleaning process, wash your hands thoroughly.

IF YOU GET SICK

Despite taking precautions, some of us may still develop COVID19. Here’s what to do if you get sick.

STAY HOME and in a separate room than those you live with who are not yet sick. You being sick does not guarantee they will catch it so be careful for their sake. If someone in your home has already recovered from the virus, they’ll need to be the one who takes care of you. They’ll need to be doubly careful not to infect others who have not yet gotten sick by following the precautions above. If someone lives with you, clean up everything you touch in shared spaces with soap and water or alcohol.

DON’T SEEK MEDICAL ATTENTION unless your symptoms become serious. Emergency departments are being overwhelmed with too many people seeking care. Most “mild” cases start to recover in about 5 days after onset of the symptoms, so hold out at least that long if you can. I wrote “mild” because apparently even mild cases are often miserable with fever, sore throat, cough, body aches, and tiredness. Shortness of breath is a common symptom with more serious cases of COVID19, but even some of them can be self-managed. Lying on your stomach can help relieve this symptom and emergency room physicians have even avoided putting people on a respirator by having them lie on their stomach.

IF YOUR SYMPTOMS GET WORSE. If your symptoms worsen or do not start to get better within about 7 days, call your physician (or a helpline that’s probably been set up in your community). They will instruct you what to do. It is at about this time that a diagnostic test may be necessary since you may need medical attention to recover. They should also let you know which warning signs represent an emergency for which you should go to the hospital. Some physicians are suggesting that if you develop shortness of breath, that’s when you should go to the hospital.

IF YOUR HOUSEHOLD FAMILY MEMBER GETS SICK

Many of us may end up caring for loved ones who get sick. Just because they’ve gotten sick doesn’t mean you will. If you follow the above suggestions and those below, you have the best chance of avoiding infection.

SEPARATE LIVING AREAS & BATHROOMS. Ideally the sick person should have their own bedroom and bathroom. If there is only one bedroom, the sick person should be isolated there and others should sleep in the main living area. If there is only one bathroom it will need to be thoroughly cleaned every time the sick person uses it. Soap and water or alcohol will do the trick. If they’re too fatigued to do it, someone else will have to do it for them.

TAG TEAM IF YOU CAN. If more than one healthy person lives in the house, you should work together – one to collect and clean possibly contaminated clothing, dishes, etc. and the other to open and close doors, get soap, etc. If there is only one other person in the house, you should be extra careful in sanitizing anything you touch after cleaning up for your sick family member.

AVOID HIGH RISK FAMILY MEMBERS. If an elder or someone with other medical problems lives in the same home, their caregiver should not also care for the person with COVID19. If there is only one caregiver available, the high risk family member should be isolated or moved to another residence if possible.

IF YOU’VE RECOVERED

CONSIDER DONATING PLASMA. A number of hospitals around the world are testing the ability of the antibodies in survivors’ blood to help those currently sick with the virus to fight it off more effectively. This could save lives.

GET BACK TO WORK. Society is going to need the economy to keep moving forward. Goods and services will still need to be made and delivered. Those who recover are an invaluable part of that. However, understand that you may still be carrying the virus so keep using those precautions to make sure you don’t get others sick.

CONSIDER VOLUNTEERING. There are so many things that need to be done and in many cases those who would be doing them are either at risk of getting sick or are too sick to do them. Find what help is needed in your local community, and volunteer to help.

FINAL THOUGHTS

COVID19 is a legitimate pandemic and a threat to our health and welfare. However, it is not an invincible disease. It’s just a virus just like any other and can be killed very easily with soap and water or high alcohol solutions. We just need to get into good habits of social distancing and sanitation. With just those two main things, we can beat this together to prevent further illness and death.

Please stay safe and healthy. We are stronger together (at a safe distance).

-Stephen L. Lyman, PhD JAPAN, Communications Committee Chair

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