The concept that strict social distancing will decrease our individual risk of contracting COVID-19 serves as a powerful incentive to adhere to guidelines and recommendations (fortunately). The actual reduction in risk of eventually contracting the virus through social distancing is likely much more modest than we hope. This virus is highly contagious, and we are all still at high risk of eventually getting it. Paradoxically, social distancing will make the pandemic last longer than the usual social free for all.
The real goal of social distancing is to stagger the infections over a longer time period with the goal of decreasing the case fatality rate (CFR) rather than the total number of cases. In other words, by practicing social distancing, the goal is to decrease the risk of death from infection rather than the total number of cases (although it may do both to some extent).
I discussed case fatality rate in my previous blog. Essentially, it is the rate of death among patients confirmed to have the infection. Many factors impact case fatality rate (virulence of the pathogen, ascertainment bias/testing enough people to include mild cases, effective drugs to reduce the severity of the illness, access to resources needed to manage the most severe cases, etc). Since we cannot reduce the virulence of the virus and we currently have no effective drugs to decrease the severity, the only variable we can control is access to resources. In the case of COVID-19, that means ICU beds, ventilators, and ECMO (cardiopulmonary bypass).
Northern Italy’s failure to enact strict social distancing measures caused a surge in infections early in their epidemic. The results have been catastrophic. Doctors are in the terrible position of rationing ICU beds and ventilators to the youngest, healthiest patients that have the most life years ahead of them and will most likely recover more quickly to make the ICU bed/vent available to someone else. This surge has led to a CFR of 7%, twice the CFR in the Hubei Province of China where draconian isolation measures were enforced by the state. In contrast, S. Korea has a CFR <1%. While you have to be careful comparing CFR in different populations because of difference in ascertainment bias (the wide availability of tests in S. Korea likely reduced its CFR by including milder cases in the analysis), the large gap in CFR between N. Italy and S. Korea is still likely related to the difference in effective social distancing implemented early in the pandemic. Spreading out the infections over a longer period of time prevents the ICU beds/vents/ecmo from becoming saturated. So if you or your loved one needs a ventilator to support oxygenation/gas exchange while your body fights the infection, it will be available. Sadly, despite appropriate social distancing measures now in place in N. Italy, the CFR remains high. The horse is out of the barn. Social distancing works best when applied early and strictly. Everyday, our government reissues more strict isolation measures. Start aggressive social distancing now and stay ahead of the curve and the reactive rather than proactive guidelines issued by our government.
We have all been trying to absorb a deluge of information and instructions on COVID-19. In addition to my usual news sources, I get email blasts from hospitals, the CDC, medical science publications, and my practice leadership. I have attempted to distill this data into a practical guide for best practices.
We are facing a pandemic unlike any we’ve seen in our lifetime. Our understanding of the virus is changing rapidly and there are often conflicting data. The information herein represents my best attempt to present the most recent and best quality information in a clear and succinct fashion.
Droplet: Droplets are transmitted through the air when someone coughs, sneezes or talks. Droplets will not usually travel more then 6 ft and do not linger in the air. There are reports of droplets travelling up to 15 ft in an enclosed, moving space typical of public transportation (a city bus in Wuhan).
Contact: Self inoculation of mouth, nose, or eyes after touching a contaminated surface
Incubation period: 2-14 days following exposure with most symptoms arising 4-5 days after exposure.
Spectrum of Severity:
Mild: No lung involvement up to Mild Pneumonia-Not requiring hospitalization-81%
Severe: Respiratory failure requiring oxygen and hospitalization-14%
Patients with mild disease can deteriorate to critical very quickly, even after days of stability.
Symptoms: The best data to date comes from a study from Wuhan, China conducted early in Feb. Results are likely skewed by a CV19 population with more severe illness as milder cases were not being recognized or tested. As more data comes out regarding symptoms in mild cases, the frequency and severity of symptoms are likely to change:
Dry cough 59%
Body aches 35%
Shortness of breath-31%
Of note, Rhinorrhea (runny nose) was only present in 4%. So if you have cold symptoms with prominent rhinorrhea it is unlikely CV19
Age and prognosis: The case fatality rate (CFR)-rate of death among those confirmed to have the virus was updated by the WHO on March 5th. Keep in mind that the CFR may be impacted by ascertainment bias. Ascertainment bias occurs when mild cases are not tested. In the case of of the chinese study, ascertainment bias would result in an overestimate of the case fatality rate because the patients captured in the study tended to have more severe illness (mild cases were not recognized and therefore not included the the analysis). As testing becomes more widely available, the ascertainment bias may begin to correct and I predict CFR will go down. Keep in mind that age is only one factor that impacts prognosis and the numbers below do not account for other medical problems. As an example, An 80 year old marathon runner with no medical problems might behave more like a 60-69 year old, while a 50 year old that smokes 2 packs per day and has emphysema might behave like an 80+ year old. Happily, young children have not been dying from the illness and tend to have a mild course.
Overall CFR according WHO 3/5/20: 3.4%
CFR by Age:
Part 2: Protect yourself, your loved ones, and the community.
In this section, I will attempt to give more practical advice than what I am typically seeing in the media.
Wash for 15 seconds with antimicrobial soap. The HBD song is about 15s. Wash hands when you get home if you have been out.
Hand Sanitizer: No longer widely available. Hand sanitizer (or as my 6 year old daughter calls it, hanitizer) is very effective at killing CV19. Should contain 60% alcohol. Apply liberally and allow to airdry.
Put sanitizer in your car and in your pocket. You need it most when you are out and about and don’t have access to a sink.
Public spaces: How to not get infected when out in public spaces (reverse the following if you are left hand dominant).
Your left hand is for interfacing with potentially contaminated surfaces. This is your left hand’s chance to finally do something really important.
Tasks for your left hand: Open public doors, pay and sign at checkout, pick items from shelf, etc
Tasks for your right hand: touch phone, open your car door after shopping, scratch, reach into your purse or wallet.
Rationale: You are much more likely to accidentally touch your face, pick your nose, rub your eyes with your dominant hand (remember, you should not be doing those things but in reality it is hard to avoid it).
After I open my car with my right hand, I get into the car and don’t touch anything with my left hand. I use my right hand to pump hanitizer into my left hand. If I used a credit card (which I keep in my right pocket), I wipe it down as well.
Keep your feet at least 6 feet from others. Dont ride public transportation
Clean groceries and other items with a sanitizing towel
Do not shake hands. I continue to run into people that try to shake hands. Please politely educate people that are still shaking hands.
Don’t bump elbows (we are supposed to be coughing into our elbows)
Acceptable: air high fives, air hand shakes, shoe bump, exchange of knowing glances.
Stay at home as much as possible and avoid public places
Do not go to work unless you must
What my family and I are not doing:
Birthday parties, dinner parties, etc
Going to gyms
Leaving our house to enter public places in general, unless absolutely necessary
What we are doing:
Going to the grocery store weekly and trying not to make special trips.
Spending quality time together as a family
Working outside the home: If you work in a healthcare setting or work outside the home, take more extreme isolation measures to protect family members
I am an oncologist with a busy practice, I cannot simply stop or postpone working. I will be separating from the family in a different part of the house and will not be doing any in-person socializing until we have more information. I plan to do this in 2 week increments.
Business owners and managers:
Do everything you can to allow employees to work from home.
If core employees need to continue working, try to isolate at the work place by staying 6ft from each other.
In my practice, we are only keeping core staff in the clinic.
Most of us will be eating lunch in our cars, etc
If you are elderly or infirm, stay away from everyone. If you are everyone, stay away from the elderly and infirm.
As above, older patients have a much higher risk of death
In Northern Italy, ICU beds and ventilators are saturated. Doctors are in the terrible position of having to ration beds/vents to patients with the most life years ahead of them and those that are likely to spend the least amount of time on a ventilator. That means they are letting older patients die in order to save younger, healthier patients that need critical care services. https://www.theatlantic.com/ideas/archive/2020/03/who-gets-hospital-bed/607807/
Part 3: If you have been directly exposed to someone who has the virus.
Notify your doctor by phone. Do not make an appointment as you do not want to expose anyone without proper protection. In addition, most testing locations are not made public because they do not want to be overwhelmed by patients that have not been appropriately screened