Strict precautions could save lives as the disease spreads

COVID-19 has been changing daily life in the United States as SARS-CoV-2, the virus spreading the disease, has swept across the country, forcing activities to be cancelled and schools and businesses to close. The U.S. declared a national emergency in mid-March, and Americans have been adjusting to strict guidelines and mandates to stay home, wear face masks when they do go out, and stay 6 feet away from other people. Now experts are debating when and how the country can begin to safely reopen.

In early March, the World Health Organization (WHO) declared COVID-19 a pandemic—a disease outbreak occurring over a wide geographic area and affecting an exceptionally high proportion of the population. According to the WHO, there are more than 4.3 million confirmed cases of people with COVID-19  and over 295,000 people have died from the disease—a death toll that has far surpassed that of the severe acute respiratory syndrome (SARS) epidemic that occurred in 2002 and 2003. (While some news sources report different numbers, the WHO provides official counts of confirmed cases once a day.)

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The U.S. currently has the highest number of cases of any country in the world. While some pockets of the U.S., including New York, are now reporting a decrease in new cases, the overall numbers continue to rise. The Centers for Disease Control and Prevention (CDC) currently provides a rough picture of the outbreak in the U.S. here, currently putting the total confirmed and probable cases at more than 1.3 million, and estimating more than 83,000 deaths. If there any discrepancies, data provided by state public health departments should be considered the most up to date, according to the agency. 

SARS-CoV-2 is a virus that scientists haven’t seen before. Like other viruses, it is believed to have started in animals and spread to humans. Animal-to-person spread was suspected after the initial outbreak in December among people who had a link to a large seafood and live animal market in Wuhan, China. 

Scientists and public health officials are working as quickly as possible to find answers to key questions about how the disease is transmitted and why some cases are more severe than others, while they investigate treatments and a potential vaccine.

Below is a list of five things you should know about the coronavirus outbreak.

1. What we know about COVID-19 is changing rapidly

What we do know about coronaviruses is that they cause respiratory tract illnesses that range from the common cold to such potentially deadly illnesses as SARS, which killed almost 800 people. COVID-19 is the first pandemic known to be caused by the emergence of a new coronavirus—novel influenza viruses caused four pandemics in the last century (which is why the response to the new disease is being adapted from existing guidance developed in anticipation of an influenza pandemic). 

According to the CDC, reported COVID-19 illnesses have ranged from mild (with no reported symptoms in some cases) to severe, including illness resulting in death. People ages 65 and older, those living in a nursing home or long-term care facility, and people of all ages with underlying health conditions seem to be at higher risk of developing serious illness. But doctors are still working to develop a complete clinical picture of COVID-19, as evidenced by a CDC report noting that 20% of those who have been hospitalized for the disease in the U.S. are younger adults (between 20 and 44 years old).

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“I think there are two main questions,” says Richard Martinello, MD, a Yale Medicine infectious diseases specialist and medical director of infection prevention at Yale New Haven Health. “First, we need to know how this virus is transmitted between people so we can be more precise in our efforts to stop its spread. Data is needed not only to better understand when those who become ill shed the virus, but also which body fluids contain the virus and how those may contaminate surfaces and even the air surrounding them,” says Dr. Martinello. “Second, there needs to be a better understanding of the pathogenesis of the infection and resulting inflammatory response, so that knowledge can drive the development of therapeutic and preventive medications.

More information is becoming available. A letter to the editor published in The New England Journal of Medicine in mid-March showed the virus that causes COVID-19 may be stable for several hours in aerosols (in this case, droplets from an infected person dispersed in air or gas) and for several hours to days on surfaces. Scientists who participated in the analysis found SARS-CoV-2 was detectable in aerosols for up to three hours, copper up to four hours, cardboard up to 24 hours, and plastic and stainless steel up to two to three days. While there is much to learn, scientists involved in the analysis observed that emerging evidence suggests people who are infected might be spreading the virus without recognizing, or prior to recognizing, symptoms, according to the National Institutes of Health (NIH).

But Yale Medicine Infectious Diseases specialist Jaimie Meyer, MD, MS, notes, “A lot of times people will make basic science observations in the research lab, but it takes time for us to figure out how clinically relevant it is. So, we don’t know yet know what this study means for transmissibility. Until we understand more about the granular details of how SARS-CoV-2 passes from person to person, public health dictates that people maintain social distancing, wash hands, and frequently disinfect high-touch surfaces.”

2. Strict measures are critical for slowing the disease

While we still don’t know how the situation will progress around COVID-19, studies of influenza have shown that pandemics begin with an “investigation” phase, followed by “recognition,” “initiation,” and “acceleration” phases, according to the CDC, and that is followed by deceleration, during which there is a decrease in illnesses. Finally, there is a “preparation” phase, where the pandemic has subsided, and public health officials monitor virus activity and prepare for possible additional waves of infection. Different parts of the country can be in different phases of the pandemic, and the length of each phase can vary depending, in part, on the public health response.

The U.S. is currently in an acceleration phase, when the peak of illnesses occurs, and efforts are aimed at “flattening the curve.” If you map the number of COVID-19 cases over time, the expectation is that it will peak at some point—on a graph this peak would mirror a surge in patients (which could overwhelm hospitals and health care providers). Flattening the curve would mean there would be fewer patients during that period, and hospitals would be better able to manage the demands of patients who are sick with COVID-19 and other illnesses.

White House Guidelines for Opening Up America Again, a phased approach to help state and local officials reopen their economies, provides advice on continuing handwashing, wearing face masks, and taking other precautions even when that happens. Some state leaders have taken steps toward reopening. Connecticut, which plans to start a phased reopening on May 20, is currently keeping safety measures in place at least until that date. This includes requiring nonessential workers to work from home, prohibiting gatherings of more than five people, limiting restaurants to take-out service only, and directing people to wear face coverings in public when a six-foot distance is unavoidable, including in the workplace.

Meanwhile, top health officials have stressed the need for critical testing capacity and the implementation of methods for tracing contacts of people who are infected to protect people and prevent a resurgence of cases when the economy does reopen.

3. Infection prevention is key

There are many things you can do to protect yourself and the people you interact with. As with a cold, a flu vaccine won’t protect people from developing COVID-19.  “The best thing you can do at this point is take care of yourself the way you would to prevent yourself from getting the flu,” says Yale Medicine infectious diseases specialist Joseph Vinetz, MD. “You know you can get the flu when people sneeze and cough on you, or when you touch a doorknob. Washing hands—especially before eating and touching your face, and after going to the bathroom—and avoiding other people who have flu-like symptoms are the best strategies at this point.”

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The CDC also recommends the following preventive actions:

  • Wash hands with soap and water for at least 20 seconds. Dry them thoroughly with an air dryer or clean towel. If soap isn’t available, use a hand sanitizer with at least 60% alcohol.
  • Stay home if you’re sick.
  • Avoid touching nose, eyes, and mouth. Use a tissue to cover a cough or sneeze, then dispose of it in the trash.
  • Use a household wipe or spray to disinfect doorknobs, light switches, desks, keyboards, sinks, toilets, cell phones, and other objects and surfaces that are frequently touched.
  • Create a household plan of action in case someone in your house gets sick with COVID-19. You should talk with people who need to be included in your plan, plan ways to care for those who might be at greater risk for serious complications, get to know your neighbors, and make sure you and your family have a plan for caring for a sick person. This includes planning a way to separate a family member who gets sick from those who are healthy, if the need arises.

Some cities and states in the U.S. are requiring residents to wear masks in certain public places, like grocery stories and pharmacies. The CDC recommends that everyone voluntarily wear cloth face masks in public settings where other social distancing measures are difficult to maintain, especially in areas where there is significant community-based transmission. A cloth mask is not meant to protect the wearer from infection, but to slow the spread of the virus (if people who have the virus and do not know it wear masks, they may be less likely to transmit it to others). The CDC advises making face coverings at home from simple materials, and reserving surgical masks and N95 respirators for health care workers and other medical first responders.

While everyone should take precautions, measures may be critical for adults over 65 years old (the risk seems to gradually increase with age starting at age 40, according to the WHO), people who live in nursing homes, and people of all ages with chronic conditions (such as diabetes, heart disease, and lung disease). People in these categories especially should stock up on household items, groceries, medications, and other supplies in case they need to stay home for an extended period.  

4. Experts are working rapidly to find solutions

In the U.S., widely available testing will be important in understanding how the disease is transmitted and the true infection and mortality rates. There are two kinds of tests: viral tests help diagnose a current infection and antibody tests can tell if you’ve had a previous one (it is not yet known whether COVID-19 antibodies can protect from being infected again or how long protection might last). Health care providers and state and local health departments make determinations about who should be tested. There is an increasing number of tests available, although it may still be difficult to find a place to get tested. Until there is comprehensive testing for COVID-19, it’s difficult to know how many cases have not been identified. 

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One recent development is the first in-home test for the coronavirus. The nasal swab kit, approved by the Food and Drug Administration (FDA) in mid-April, will be made available to health care and emergency workers who may have been exposed or have symptoms of the virus before it is released to the public at a later date.

Meanwhile, scientists are studying the virus closely. “With the new virus in a culture dish, they are looking at the biology and working to make drugs to treat it,” says Dr. Vinetz. There is also a great deal of effort underway to assess drugs in development (and some medications currently available) to determine if they are beneficial for treating patients infected with COVID-19, adds Dr. Martinello.

While no pharmaceutical products have yet been shown to be safe and effective for COVID-19, a number of existing medicines have been suggested as potential investigational therapies. In early May, the FDA issued an emergency use authorization for the investigational antiviral drug remdesivir to treat suspected or laboratory-confirmed COVID-19 in adults and children hospitalized with severe disease. There is still limited information about the safety and effectiveness of remdesivir when used for COVID-19, but preliminary studies have shown that it can shorten the time to recovery in some patients. Remdesivir is an antiviral treatment that  was previously tested in humans with Ebola virus disease and has shown promise in animal models for treating SARS and Middle Eastern Respiratory Syndrome (MERS), a deadly virus that was first reported in Saudi Arabia in 2012.

5. If you feel ill, here’s what you should do

So far, information shows the severity of COVID-19 infection ranges from very mild (sometimes with no reported symptoms at all) to severe to the point of requiring hospitalization. The CDC recently expanded its list of possible symptoms of COVID-19 The symptoms can appear anywhere between 2 to 14 days after exposure, and may include: 

  • Fever
  • Cough
  • Shortness of breath and difficulty breathing 
  • Chills
  • Repeated shaking with chills
  • Muscle pain
  • Headache
  • Sore throat
  • New loss of taste or smell

You should call your medical provider for advice if you experience these symptoms, especially if you have been in close contact with a person known to have COVID-19 or live in an area with ongoing spread of the disease. The CDC has a Coronavirus Self-Checker that may help you determine whether you should seek help.

Most people will have a mild illness and can recover at home without medical care. Seek medical attention immediately if you are at home and experience emergency warning signs, including difficulty breathing, persistent pain or pressure in the chest, new confusion or ability to arouse, or bluish lips or face. This list is not inclusive, so consult your medical provider if you notice other concerning symptoms. 

Be aware of the information and resources that are available to you

Because knowledge about the new virus is evolving rapidly, you can expect information and recommendations to change frequently. Threats like COVID-19 can lead to the circulation of misinformation, so it’s important to trust information only from reputable health organizations and government sources such as the CDC and the WHO. “The public health infrastructure in the U.S. is a critical resource for leading the federal, state, and local response,” Dr. Martinello says.

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