COVID-19

With so much information about COVID-19 floating around, I wanted to organize the facts from the fiction. My hope is that my background and expertise can help to provide some clarity and dissipate some of the anxiety caused by the chaos and unknown. This post will be written from the perspective of someone living in Los Angeles (LA) County, California, United States of America (US).

MY BACKGROUND
I was a pre-medical student in my undergraduate studies and I graduated with a double major in biology and chemistry. I attended medical school for a year before deciding it wasn’t for me. Consequently, I pursued a Bachelor’s degree in nursing and worked as a registered nurse (RN) on the definitive observation unit (DOU) for ~1.5 years before working on the medical-surgical/telemetry/orthopedics floor for 1 year. Once I graduated in 2019 with my Master’s degree in nursing, I started working as a primary care family nurse practitioner.

WHAT IS COVID-19?

DEFINITIONS
There is a lot of terminology out there, and being able to properly define what certain terms mean helps our understanding of what is being communicated.

DISEASE or VIRUS?
A disease is a medical condition associated with specific signs and symptoms not caused by immediate external injury1. A virus is an infectious microscopic agent that may lead to disease and cannot replicate outside a living organism2.

Let’s use COVID-19 as an example3:

Disease… COVID-19 (COrona VIrus Disease 2019)
Virus… SARS-CoV-2 (Severe Acute Respiratory Syndrome COrona Virus 2)

By definition, if a person is infected by the SARS-CoV-2 virus but shows no symptoms, it is inaccurate to say that the person has the disease, COVID-19. The correct phrase would be to say the person has been infected with SARS-CoV-2. This concept works the same for a person who is infected with the Human Immunodeficiency Virus (HIV), but shows no symptoms. The person cannot say they have the disease, Acquired Immune Deficiency Syndrome (AIDS), until symptoms manifest. Nevertheless, HIV and AIDS are often synonymous in the minds of the majority. Of course, regardless of whether there are any symptoms after infection of SARS-CoV-2, it’s just easier to say, “I have COVID-19” (even if it’s incorrect, it conveys the idea).

PANDEMIC or EPIDEMIC?
On March 11, the World Health Organization (WHO) declared COVID-19 a pandemic4. A pandemic is an outbreak of disease that is widespread and affects multiple countries, whereas an epidemic is an outbreak of disease limited to smaller areas5. There is no specific number that determines when an epidemic becomes a pandemic. For example, in 2002-2004, the virus SARS-CoV-1, which causes the disease SARS, affected 26 countries worldwide but it was not a large-enough event to be labeled a pandemic6,53.

Other notable pandemics include:

  1. Flu Pandemic… There have been 6-9 recorded flu pandemics in history depending on which source you look at7. Also known as influenza, the flu is known to peak seasonally in the winter months of December through February, and pandemics of the flu are known to occur every 10-30 years8. With a high mutation rate, the virus that causes the flu changes so that the flu virus you caught last year may not be the same flu virus floating around the next year. This is why the Centers for Disease Control and Prevention (CDC) recommends everyone over the age of 6 months to get a flu vaccination on a yearly basis9. Every year, WHO collaborates with scientists and researchers around the world to put together a flu vaccine that covers the strains expected to occur most commonly that year10.
    • I won’t be going into the reasons why you should or shouldn’t vaccinate your kid. It’s not an appropriate rabbit hole to venture into for the purposes of this post. Just know that I stand on the side of vaccinating your kids and getting the yearly flu shot. There is no evidence that shows vaccines cause autism. If you’re interested in knowing more, you can read about how Andrew Wakefield et al.’s falsified reports were debunked for yourself here.
  2. Smallpox… While there has only been 1 recorded pandemic of smallpox, it is the pandemic most notably known for successfully eradicating the disease. Credit goes to Edward Jenner who created the vaccine in 179611. The last case of smallpox occurred in 197712.
  3. Cholera… There have been 7 recorded cholera pandemics in history, the last one occurred in 1961-197513. Since then, there have been multiple epidemic outbreaks, but thankfully none that were large enough to be declared another pandemic.
  4. Black Plague… Also known as the Black Death or Bubonic Plague. There have been 3 recorded Black Plague pandemics in history with several epidemic outbreaks since 185914.  It took scientists 3 years from culturing the causal bacteria (1894) to developing a vaccine (1897), and even then the effectiveness of the vaccine was controversial until the advancement of technology could confirm it 84 years later (1981)15. The first Black Plague pandemic is most notably known to have been the most fatal, having wiped out 30-60% of Europe’s population16. Once you contracted the disease, the death rate for the bubonic plague was known to be 50%17 . If the virus infected your lungs and became the pneumonic plague, chances of death rose to 90-95%14. Worse yet, if the virus reached your blood, the infection became the septicaemic plague which had 100% death rate. With the advent of antibiotics, the death rate still hovers around 1-15% for the bubonic plague and 40% for the septicaemic plague17.

I’ve seen a lot of people (ie. news, social media, even memes) compare COVID-19 with the Black Plague. Maybe it’s for dramatic effect. Maybe it’s to draw attention. Maybe it’s click-bait. Regardless… it’s. not. helping. There are general similarities amongst going through any pandemic period, not just the Black Plague (eg. death, fear, unknown, search and study for the cause and cure, etc.). But the notion that going through the current COVID-19 pandemic is like going through the Black Plague pandemic is ridiculous. There are a number of reasons I can give for why they’re not the same (eg. knowledge, technology, dissemination of information, hygiene), but let me focus on the biggest one: fatality.

As of April 17, COVID-19 has a death rate of 5.12% with 34,641 deaths and 678,144 cases in the US18. Even in Italy, one of the hardest hit countries, the death rate is 13.12%19. Worldwide, there have been a reported 145,551 deaths from COVID-19 out of 2,182,823 reported cases, making the worldwide death rate 6.67%20. These percentages include 3778 unreported deaths that the New York mayor decided to include out of his personal belief that it is “probably” the case21. And these percentages don’t include the number of asymptomatic cases that have never been reported. (Take these numbers with a grain of salt, there’s a whole lot of nonsensical amounts of misinformation out there.) In other words, there is a current at worst 93.33% chance of not dying from COVID-19. I will take that percentage over the survival rate of 50-100% at the time of the Black Plague pandemic any day.

I am not undermining the severity of the COVID-19 pandemic. I am merely making the case that people who lived through the Black Plague went through a lot more death, fear, and unknown than we are living through today, and it is unproductive to think that we are going through the same insanity they went through in the medieval days – we aren’t. Back then, they dealt with a lot of unknown with too little information, whereas today, we are dealing with a lot of unknown with too much misinformation and disinformation.

SARS-CoV-2
SIGNS & SYMPTOMS
According to the CDC, symptoms of COVID-19 commonly include fever, cough, and shortness of breath22. Fever is a temperature over 100.4°F. The cough has been described as a dry cough, which means you have no phlegm, mucus, or sputum. Shortness of breath is a form of dyspnea, which can feel like extra breathing effort, chest tightness, or like you’re not getting enough air. However, all three of these highlighted symptoms are vague and general in the medical world. In other words, a multitude of possible illnesses are known to cause all three symptoms. They’re so general, that even if you are experiencing all three, it does not necessarily mean you have COVID-19. In order to distinguish which among the possible diagnoses is the actual diagnosis, further testing needs to be done. Currently, Abbott has developed a 5-to-13-minute rapid-testing kit to determine whether symptoms are due to SARS-CoV-2. The Food & Drug Administration has not approved it, but has authorized its use in approved laboratories and patient care settings for emergency use23.

Aside from these three symptoms, complications have been observed such as acute respiratory distress syndrome (ARDS), septic shock, heart and kidney injury, liver dysfunction, multi-organ failure, and death24. As with most diseases, there is a positive association between a person’s age and the chance of death from an illness. Meaning, as a person’s age increases so does the percentage of death from the disease. This rings true for COVID-19 as well25. While the idea that COVID-19 can lead to death for a person younger than 18 sounds frightening, this pattern for death and disease is actually more common than people think. The media has been bringing more attention and awareness to this pattern, so people often conclude that this aspect is unique to COVID-19… it isn’t. In the words of Dr. Mikhail “Mike” Varshavski, “Be alert, not anxious.”26

CURRENT TREATMENTS & RESEARCH STUDIES
There currently is no “cure” for COVID-19; current medicine does not have a means to killing a virus directly27. Medications like oseltamivir (Tamiflu) and acyclovir (Zovirax) stop the virus from multiplying and spreading, but it’s the human body that destroys the virus itself28,29. Therefore, researchers and scientists are currently studying SARS-CoV-2 in order to figure out how it works so that they can develop a drug that can specifically combat it. Some COVID-19 patients have been treated with hydroxychloroquine (Plaquenil) and azithromycin (Zithromax), from which some patients have benefited. However, how these medications work against COVID-19 is unclear, since Plaquenil and Zithromax are normally used to treat parasitic infections and autoimmune diseases (eg. malaria, lupus) and bacterial infections (eg. cold, ear infections) respectively30,31.

There’s a lot we do not know about SARS-CoV-2. Despite the familiarity we have with its viral cousins in the coronavirus family, it is still going to take some time for scientists and researchers to truly understand how SARS-CoV-2 works. In the meantime, we will need to wait calmly and patiently for these studies to produce solid results. It would be wise to look critically at any new information that is released. There is a lot of experimentation and trial-and-error when it comes to scientific testing. Valid (accurate) and reliable (consistent) results come from repeated testing and the reproduction of the same results with the same method of testing32. Once a laboratory releases its results, it goes through what is called the “Peer Review” process where other scientists and researchers scrutinize the data to determine its accuracy and suitability for publishing33. Thus, any released information on COVID-19 is highly subject to change and adjustment as scientists and researchers continue honing in on finding accurate and consistent results.

TRANSMISSION & TRANSFERENCE
Bacteria, viruses, and fungi are everywhere. Some of these pathogens cause disease, and some do not. Some cause disease in certain animals but are harmless to humans, and vice versa. So what determines whether a potentially disease-causing agent, like SARS-CoV-2, becomes harmful to humans? For that, we need to understand how these microscopic agents work.

INVASION & INFECTION35
In every human body, there are natural external mechanisms of defense to prevent unwanted substances from entering the body – skin, nose hair, pH such as stomach acid, etc. For substances that successfully enter the body, there are natural internal mechanisms of defense to destroy it such as white blood cells36. After successful invasion and survival, a pathogen must find a way to replicate otherwise it will die. For a virus, it needs to invade the cell by tricking the receptors on the cell’s surface to gain entry37. Simply put, receptors are like locks that require a matching key in order for what is outside to gain access to what is inside. If a virus is able to match its own receptors to the receptors on the human cell, then it is able to enter the cell, take control, and start replicating38. Once the virus has replicated enough, it will then release its clones to go and infect more cells39. If the virus successfully replicates enough, it has reached viral load and symptoms will begin to show40. This whole process takes about 2-14 days from SARS-CoV-2 entering the body to the showing of symptoms22,49.

The body is remarkable in that it is able to learn how to identify a foreign pathogen from a national cell and destroy it. This process, however, takes time. Without going too deep into immunology, the body basically develops an antibody that is a specific match to the invader’s surface receptors (called an antigen) and destroys it41. The immune system then develops memory cells that are able to expedite antibody production to quickly destroy the invader should it try to invade again42. Should the virus mutate the antigens on its surface, the body would need to go through the immunological process again of creating a new antibody to fight off the invader (eg. as seen in the variations of the flu).

HOW TO PROTECT YOURSELF
To understand how to best protect yourself from developing COVID-19, we take a look at the Chain of Infection43. For SARS-CoV-2, the virus needs an environment or host that it can survive in (reservoir). From there, the virus needs to be able to leave (portal of exit) and transfer itself elsewhere (mode of transmission) where it can get into its new host (portal of entry). This susceptible host can then become a new reservoir, and the cycle of transmission continues. In order avoid infection, it is necessary to stop the cycle at some point in the chain.

For SARS-CoV-2, scientists and researchers have determined that humans can act as both host and reservoir for the virus44. According to the CDC, a host/reservoir can be asymptomatic, meaning they show no signs of being infected45. Even if you’re not experiencing any symptoms, it is still possible to spread the virus to someone who can become symptomatic46. It is debated whether SARS-CoV-2’s mode of transmission is aerosol or droplet because the difference depends on its size and how long the virus is able to survive in the air47,48. Either way, similar precautions should be taken to protect yourself from contracting the virus, especially if you’re a person who is at risk (eg. elderly, immunocompromised, pregnant, etc.)49:

  1. Avoid Large Gatherings… Should a person be an asymptomatic carrier of SARS-CoV-2, it would be best to avoid close contact with them because the virus is still contagious46. Because the virus can travel through the air, the CDC recommends “social distancing” a term used to describe the avoidance of large crowds and also keeping a 6 feet distance from others50. There is no clear evidence that suggests that 6 feet is any better than 5 feet or 7 feet, but the point of the 6 feet rule is to stay a substantial distance away in order to avoid contact with viral droplets/aerosols shed off an infected individual47.
  2. Wear a Face Mask… When out in public, it would be safest to wear a face mask or some sort of facial covering (eg. scarf, bandana). The logic behind it is that: 1) it prevents droplets/aerosols from leaving the mask when speaking/coughing/sneezing, 2) it keeps other peoples’ droplets/aerosols from reaching your respiratory passages, and 3) it decreases how often you touch your face48,49,51,52. Research shows that the SARS-CoV-2 can survive in the air for 3 hours, cardboard for 24 hours, and on plastic and steel surfaces for 3 days53. In order for SARS-CoV-2 to infect you, it has to enter your body through respiratory passages such as your mouth, nose, and eyes54. So even if the droplet/aerosol lands on your skin or makes contact with your hands through a contaminated surface… don’t touch your face!
    • Previously, face masks were only recommended to individuals who exhibited symptoms (or if caring for someone with symptoms), but the CDC has since changed their recommendation while WHO still stands by it54,55. There’s been differing guidelines for the use of masks; all of them recommend symptomatic people to wear a face mask, but often differ when it comes to whether a healthy person should wear a face mask56. Either way, if you wear the mask, be sure to wear it correctly (it does nothing if it’s worn incorrectly)55!
    • Personally, I am of the opinion that if you go out and need to interact with others… wear the darn mask. I look to Taiwan’s response to the pandemic57,58. As of April 17, their death rate has been 1.52% (395 reported cases with 6 deaths)59. Their numbers are reflective of having taken wise precautions to the outbreak, which include wearing a face mask even if you’re healthy60,61. Whatever they’re doing, it’s working. Better safe than sorry, just do it.
  3. Wash Your Hands62… In contrast to the controversy of who should wear a face mask, all recommendations are in general agreement when it comes to washing your hands. However, hand washing isn’t as simple as putting your hands in water for 5 seconds and calling it a day. First, the water should be running as rinsing your hands in still water (eg. basin) will have contaminants floating in the water. The temperature of the running water can be hot or cold. Second, use soap. Soap has properties that trap viruses and other contaminants in a bubble-like structure called a micelle63,64. The running water then washes the micelles away. Using water with soap then is more effective than using water alone. Third, scrub your hands for at least 20 seconds. Make sure to cover all surfaces of your hands including under the fingernails. Friction from the rubbing plays an important role in removing viral contaminants so that the soap can trap it and the water can remove it. A nice video demonstration can be found here. Dry your hands with a clean towel, and be sure to turn off the water at the end with a towel or tissue so you don’t re-contaminate your hands.
    • The CDC also recommends the use of alcohol-based hand sanitizers that contain at least 60% alcohol65. The sanitizer kills the viruses that are on your hands, rendering it unable to infect you. Keep in mind that studies have found that not all alcohol-based hand sanitizers are as effective in killing SARS-CoV-266. If you use it, read the instructions as some may require as much as a quarter-sized amount and others will need to be used for up to 30 seconds in order to be effective, 64,66. Even if the alcohol-based hand sanitizer does manage to kill the virus, the viral carcasses remain on your hands. So be sure to wash your hands at some point, you should not be depending on hand sanitizer alone.

TIMELINE
Data mainly gathered from Wikipedia67 and WHO68.

  • December 31, 2019: first case of pneumonia of unidentified cause reported in Wuhan, China
  • January 10, 2020: pneumonia determined to be caused by new strain of coronavirus dubbed 2019-nCoV
  • January 13, 2020: first case of 2019-nCoV reported outside China in Thailand
  • January 26, 2020: CDC reports first case of 2019-nCoV reported in California in LA County
  • January 30, 2020: WHO declares 2019-nCoV a Public Health Emergency of International Concern
  • February 11, 2020: novel coronavirus named COVID-19 for COrona VIrus Disease2019
  • March 4, 2020: Governor Gavin Newsom declares California in a State of Emergency
  • March 11, 2020: WHO characterizes COVID-19 as a pandemic
  • March 12, 2020: California bans mass gatherings of over 250 people69, Mayor of LA Eric Garcetti calls for postponement of events with 50 or more people70
    • March 12, 2020: FCBC Walnut suspends all on-campus ministries until further notice
  • March 16, 2020: President Donald Trump promotes social distancing and to limit gatherings to no more than 10 people71
  • March 19, 2020: California instates state-wide mandatory “Stay-at-Home” and “Shelter-in-Place” order72
  • April 1, 2020: California Department of Education acknowledges likely closure of schools for remainder of school year73
  • April 7, 2020: LA Mayor Eric Garcetti institutes Worker Protection Order requiring face coverings for all workers and customers of essential businesses50

I know this entry is chock-full of information. Maybe it was too much, maybe it was too little. Either way, I hope you were able to learn something. I believe knowledge helps calm a lot of the anxieties that we may have towards COVID-19. I don’t believe in being blissfully ignorant, but given the level of misinformation floating around, I also don’t believe in blindly accepting new information the moment it is announced. Do your research. Take the whole picture into perspective. Use your brain! And don’t forget about common sense. Keep calm, and stay safe and healthy!

I may choose to update the details of this post as time goes on and as new knowledge comes to light. I’m not infallible, so if there’s anything that I’ve stated incorrectly please kindly let me know!

——————-

EDIT: There will be no post for COVID-19 (part two). Originally, I wanted to write a piece on COVID-19 misinformation. But, there’s simply too much. Just thinking on the topic can get me heated. So rather than make myself go through ~2 weeks of emotional frustration and disappointment, I’ve decided to not go down that rabbit hole. Please exercise critical thinking! Know that everyone will present information in a way that is supportive of their own views and serves to further their motives, whether it’s done blatantly or with subtlety. Ask questions, think things through. Don’t get complacent in accepting information with shady credibility or no sources. We’ll get through this together, and we’ll do it wisely and courageously.


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