Summary of CDC and WHO Recommendations

Provided by an MD colleague and Edited by Dr. Herskowitz

Keeping ourselves and those we love safe is important to all of us. Anything that I say here can of course change and quickly, and I am not an infectious disease expert. There are a lot of important unanswered questions about the virus, many of which will be answered over the coming days. Here is the CDC web page. The Who sent a joint mission to China to investigate the epidemic at place where it is most advanced (but also in relative control now) and reported their results here.

Because this is long, a summary of the main points are below. Read the rest in the links for details.

The Covid-19 epidemic is extremely serious, growing exponentially, and is almost certainly going to get worse before it gets better. The primary tool for minimizing epidemics like this is “social distancing”. So, those responsible for planning in-person get-togethers would be advised to consider postponing them for now, or find ways to hold them remotely. For essential gatherings, learn and take precautions to safeguard those attending, including frequent hand washing, cleaning often touched surfaces, and staying 6’ apart. If you are providing care for someone with a sore throat, cough, and fever of 101.5 or higher, take precautions to avoid getting this yourself. Note that each location in the country has somewhat different risks today, and may make different decisions right now. The infectious disease experts agree that this is going to get worse and all of these precautions and more will most likely be needed in all locations in the near future. There are good reasons for acting NOW as described in the social distancing article linked above.

So lets start with what we are talking about:

  • Covid-19 is more contagious than seasonal flu. It appeared in a small number of people in China Dec 29, now 2+ months later, it is in more than 100 countries and 100K cases). It’s doubling time for known cases outside China has been about 5 days. That will change over time. Note that with 11 doubling times (55 days), 500 cases would grow to more than a million cases. In another 50 days, it would grow to a billion cases. In general, humans fail to grasp exponential growth, but tend to linearize it (what has been called “the exponential growth bias”).
  • Covid-19 is more deadly than seasonal flu. The reason there are fewer cases and deaths than seasonal flu right now is that it is very early in its spread. The death rate goes up with age, rare in kids, 4% in those over 60, 8% in those over 70.
  • Covid-19 has been diagnosed in or near all three domains. Health experts no longer believe that it can be contained because the virus is quite contagious, has a 3-14 day incubation, and people are contagious before they are symptomatic.
  • Symptoms are typically a sore throat, cough, fever progressing to pneumonia which can cause death. A small number of people do have “cold” symptoms first (runny nose, sneezes, etc.) but is usually accompanied by a dry cough.
  • There is no “cure” or treatment other than supportive care. A mild case may last days to weeks but does not require oxygen or ventilatory assistance (a respirator). More serious cases require oxygen and even ventilatory assistance in a hospital. A vaccine is being researched, but if found it will take about a year best case.

Transmission

Covid-19 is transmitted by droplets from mucous membranes to someone within 6′. However, the most common source of infection is not airborne. The droplets land and remain infectious on surfaces for hours to days. So the most common source is touching an infected surface, then touching your face. Studies show that people touch their faces unconsciously 90+ times a day, so once it gets on your hand, you will transfer to your face and mucous membranes unconsciously. Note for gym goers, sweat does not contain virus (but your face against a mat with virus on it can infect you).

The Threat of Exhausting Health Care Resources

The biggest threat from Covid-19 is not just death from the pneumonia but that it is highly contagious and will overwhelm healthcare resources. If nothing is done to slow its spread, then the rapidly increasing number of patients in any area will exceed the number of hospital beds and ventilators (and health care workers well enough to help, with masks and hand sanitizer, etc.). Then people will die because they cannot get the care that they need.
So, the primary goal of current recommendations from the CDC and the County health departments of all three of our domains is to slow the spread with “social distancing” so that there are sufficient resources to treat those who get sick. An excellent article explains how social distancing works and why it must happen NOW. There are a lot of apparently healthy people walking around in all of our communities who are spreading the disease. Since it is highly contagious, this means exponential growth in the number of cases before very many cases appear. Everyone needs to disrupt their typical lives to stop the spread of the virus before it “explodes” into view with so many cases that many of them will die for lack of ventilators and other treatment resources. If we all act to successfully slow down the disease, health care provides will be available to provide better care to the sick and buy time for doctors to work out better treatments and ultimately the development of a vaccine.

People at Greater Risk

People over 60, people with asthma, diabetes or other serious diseases, people with a lowered immune system due to cancer treatment. The death rate in these groups is 8 – 10% or higher, compared to .5 – 1.5% in healthy middle age.

What To Do

  • Because the route of infection is primarily hand to face, wash your hand frequently. The virus has a fatty envelope so it is much more vulnerable than typical cold viruses. Hand sanitizer that is at least 60% alcohol or a 20 second hand wash with soap and warm water will get rid of the virus from your hands. Do this whenever you have been touching surfaces that others are also touching.
  • No hugging, no handshakes. In Asia they do a sole of shoe to sole of shoe bump. Google it, it’s fun.
  • Stop touching your face. This is easier to say than to do because most of us have no idea that we do it constantly. It is very hard to stop a non-conscious behavior. (There is a funny youtube video of someone reading the health recommendations from paper and wetting their finger to turn the page as they say to stop touching your face.) Use a tissue if you need to touch your face.
  • Clean and disinfect frequently touched surfaces (70% alcohol, bleach, lysol, etc.). At my house, we are sanitizing all door/gate knobs, light switches, sink handles, toilet sets, every day. These are touched by a lot of people so most likely to be contaminated.
  • Just like with blood play, assume that every surface in any “public” place is contaminated. Use a towel when you touch them.
  • If you get a sore throat, cough, and fever of 101.5, then call your doctor or local medical facility. You need to be tested for Covid19. Do not go to a doctor’s office. Do not go to a hospital unless you are very sick and having difficulty breathing. Self-quarantine in your household (caretakers need to use precautions, you need to wear a mask, drink lots of fluids, rest.). If you test positive, call your doctor but remain at home unless your breathing becomes difficult, in which case you will need to go to a hospital.

What NOT To Do

  • Avoid air travel when possible. Air travel is particularly risky, both airports and on the plane.
  • Limit where you go. People at risk (due to age or chronic health conditions like asthma, diabetes, cancer, etc.) should limit outings and avoid all gatherings unless it is essential.
  • Avoid getting together with groups. A gathering of a number of people significantly raises the risk of infection because asymptomatic people can infect others. (I am going to cite SF Public Health here because SF has the most cases for the longest so they are further down the road in terms of responding. The Health Departments in other domains will likely get here soon, as the disease spreads.)

The SF Public Health Department Recommendations

  • Nonessential gatherings should be cancelled (the City has cancelled all big gatherings on city-owned properties)
  • Avoid people who are sick.
  • Telecommute if possible.
  • Avoid public transit, and air travel.
  • Avoid health care settings if possible.
  • Wash your hands frequently.

The SF Pubic Health Department Recommendations For Workplaces

  • Suspend nonessential travel.
  • Minimize employee working within arms length.
  • Eliminate in-person meetings and conferences.
  • Urge employees to stay home when they are sick and do not require a Doctors note.
  • Telecommute whenever possible.
  • When employees are needed in person, aggressively sterilize the work place and use other precautions for their protection.
  • Clean surfaces wherever possible, at least daily.
  • Have tissues and hand sanitizer readily available.

Other Things To Consider

  • Lots of groups have cancelled their meetings for a few weeks. These are good places to start but the likelihood is that this isn’t going to be over in two weeks or in two months. It will get worse before it gets better.
  • Where possible, consider using Zoom for meetings (Zoom is a video conference application that works on desktops, laptops, and phones)
    Zoom (and Skype and others) have extended what you can do with the free version as a public service.
  • If someone in your household gets sick or someone you know and want to help out gets sick, you need to take precautions.
    • They need to wear a mask.
    • You can wear a mask to, but you need to learn how to wear them, it must be sealed to work.
    • You need to wear gloves while caring for them.
    • Dont share a bathroom with them if that’s possible.
    • Use Clorox or lysol disinfectant on trays, or other surfaces around them.
  • Health experts caution against buying/using masks if you are healthy. Unless you have the right mask and know how to fit it properly, it isn’t going to protect you against inhaling droplets. (Its only possible benefit is keeping you from touching your face.). And the supply of masks is critically low so hospitals and health care professionals cannot get them. The result is they get sick, which limits health care resources and results in higher death rates. If you are sick, then you do need to wear a mask, and be taught which kind and how by a health care professional.

About Ahvie Herskowitz, MD

Dr. Herskowitz’s extensive training includes a medical degree from The Albert Einstein College of Medicine, residencies in Anatomic Pathology and Internal Medicine, and Fellowship training in Cardiology at The Johns Hopkins Medical Center. During his 12 years at Johns Hopkins, he became Associate Professor of Medicine and Immunology and Molecular Microbiology and led a research team in the study of molecular and immunological mechanisms of inflammation, autoimmunity, ischemia, heart transplantation rejection and congestive heart failure.

Dr. Herskowitz’s latest academic appointment was as Clinical Professor of Medicine at UC San Francisco. To learn more about Dr. Herskowitz, you can read it bio here.

      

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