April 25^th, 2020

 

This email is about being safe during COVID-19, but the most important thing is to listen to your government and the guidelines. So this e-mail is not direct medical advice, but rather a synopsis of where things are now as far as I see them.

 

As a health practitioner who is currently looking after COVID-19 patients in the ICU, I spend my days immersed in the science of this infection, how to treat it, and the epidemiological statistics around its spread.  I often forget that some people don’t spend their entirety of their days with this science, and I have found that many people are trying to figure out details about this infection from news reports, social media, and word of mouth.  This variety of sources presents such a range of information it can be hard to sort out the truth from myth, inuendo, and rumour.  So I’ve thrown together this email to reflect some of the things I know about COVID-19 which might be of help.

 

First off, COVID-19 is a viral infection caused by SARS-CoV2 virus, which is a highly contagious virus that can be deadly in some people. It appears to be less deadly than Influenza, but more contagious than influenza.

 

COVID-19 is spread mainly by droplets, essentially the same as the common cold. Tiny particles of virus-laden mucus or saliva come from a person’s mouth or nose, and float through the air and land on surfaces. These particles are saliva or snot which contain millions of live virus particles.  They are about 5-10 microns is size, and travel out about a metre from the infected person’s mouth or nose. At this point they sink down and rain onto nearby surfaces. The virus/mucus particles stay in the air for up to three hours (much less in wind or well ventilated rooms), and are infectious on surfaces for various periods of time, based on the surface material. Eg. up to 72 hours on plastics, 48 hours on stainless steel, and 24 hours on cardboard. Touching an infected surface and then touching another clean surface can transfer the virus. The virus is very susceptible to regular household cleaners though, thank God, and cleaning the surface which just about any brand of home cleaner/disinfectant kills it.  And of course if just left alone, the virus particles stop becoming infective over time.  Even UV light (eg from the sun) will kill the virus on surfaces.  

 

Although people think that you mainly get COVID-19 from being coughed or sneezed on by an infected person, that is not likely the major way we get it. The vast majority of cases likely result from people getting the virus on their hands from touching surfaces with the virus on them, then touching their mouth, nose, or eyes. The virus then enters our bodies from either the mouth nose or eyes, or from getting it on your cheeks or face then wiping it into your mouth nose or eyes with hands, cloth, or pillows.  You can still get COVID-19 from being close to a person who is sick and coughing, but that is far from your biggest risk.  It's virus on your hands then touching your face that is the biggest risk to your life! And studies have shown the average person touches their face 16 times an hour and isn't even aware of it!

 

So the general strategy we are employing to prevent COVID-19 is to stay 2 metres apart so an infected person doesn’t spray droplets on you or you rarely cause you to inhale their droplets.  But more importantly we wash our hands to kill the virus we have picked up from surfaces we have touched. And we don’t touch our face so we don’t put virus from our hands into our system through mouth, nose, or eyes. Sometimes we ask people to wear masks to protects others from our secretions, but the mask doesn’t actually protect us as we will most likely get COVID-19 from our fingers not from the air. You may even touch your face more while wearing a mask as you constantly adjust it, so it is really to protect others from you. At work in the hospital we actually also wear goggles all the time to keep us from accidentally touching our eyes.

 

So that is how you get COVID-19 – touching virus-laden surfaces (door handles, gas pumps, money, shopping carts, ATM machines, debit card machines, store products someone else has handled, chip bags, counter tops, paper bags, shaking hands, railings on stairs, etc) and then touching your mouth, nose, or eyes inadvertently before you have had a chance to clean your hands. But what about what happens once you get it.

 

So first off, once you have put the virus into your mouth nose or eyes it takes a number of days to get sick, as the virus needs to multiply in the cells of the linings of your airways, mouth, nose, sinuses etc.  This usually takes between 2 and 9 days to happen, with an average of about five.  During that time you appear to have increasing infectivity to others, initially low, then higher as the virus multiplies in your system and some of the virus particles are shed from your body.  Interestingly you are likely most contagious in the 16 hours before you start to have symptoms to about two days after the symptoms start and are mild but getting worse.  This means YOU ARE MOST CONTAGIOUS WHEN YOU ARE STILL FEELING OK AND MAY BE OUT AND ABOUT AND SPREADING IT EVERYWHERE.  The average person who gets COVID-19 spreads it to two other people, and it is postulated this most likely occurs during the time just before they get symptoms.

 

Before I go on, I wanted to explain when people say symptoms of COVID-19, what exactly do they mean. Well there have been a number of studies done, especially looking at some decent sized groups of patients, and here are the initial symptoms with the percentage of people that get them:

     -     88 % - loss of smell or taste or both

     -     68.6 % - dry cough

     -     35.8 % - muscle aches or significant fatigue. Often the muscles that usually bother you from time to time, like back or neck. Like your usual muscle aches just more constant and worse

     -     28.2 % - coughing up phlegm

     -     21.9 % - shortness of breath. Getting winded walking or going up stairs

     -     12.1 % - dizziness

     -     4.8 % - diarrhea or loose stools

     -     3.9 % - nausea and / or vomiting

     -     BUT REMEMBER, SOME PEOPLE DON’T HAVE ANY SYMPTOMS, ESPECIALLY SOME YOUNG PEOPLE, AND ARE WALKING AROUND SHEDDING VIRUS WITHOUT KNOWING

 

Now what about when you get infected, what does a case of it look like. Although the science isn’t clear on this, there appears to be four different types of severity of COVID-19 cases as follows (this is just a best guess based on the science):

 

1) No symptoms to Mild Symptoms: The first five days (on average) you have no symptoms with increasing level of infectivity. Then after about five days, and until a total of about 14 days, you are infective to others with very mild symptoms. Sniffles, frog in your throat, etc. What is important here is that you are CONTAGIOUS FOR ABOUT 14 DAYS WITHOUT ANY REAL SYMPTOMS.  This could represent about 30% of all cases.  More common in younger people.

 

2). Mild to Moderate Symptoms: The first five days (on average) you have no symptoms with increasing level of infectivity. For the next five days you have symptoms like listed above and generally feel pretty poorly. Then you generally get better. However you are contagious for about 3 weeks, but you are CONTAGIOUS FOR THE FIRST 5 DAYS WITHOUT SYMPTOMS.  This could represent about 55% of all cases.

 

3) Severe Symptoms: The first five days (on average) you have no symptoms with increasing level of infectivity. You then have a 4-day period of increasing severity of those symptoms above. It’s bad with horrible fevers and sweats, feeling of doom, increasing trouble breathing, and then by about day 9 since the original date of infection you end up needing to go into the hospital. Generally you are in the hospital for about two weeks then can go home, but you are contagious for about 25 days total from when you first got infected, but you are CONTAGIOUS FOR THE FIRST 5 DAYS WITHOUT SYMPTOMS.  This could represent about 10% of all cases, more common in older people.

 

4) Critical Illness: The first five days (on average) you have no symptoms with increasing level of infectivity. Then over about three days you develop severe shortness of breath and require urgent hospital admission and quickly after hospital you are moved to the ICU and put on life support. You will be on life support 3 weeks to two months and will either come off life support or die during your ICU stay. Importantly, you are CONTAGIOUS FOR THE FIRST 5 DAYS WITHOUT SYMPTOMS.  This could represent about 5% of cases, much more common in older people.

 

The tough part of all this is the fact that what severity category you are in between 1,2,3,or 4 is very much based on age. The older you are, the greater the chance you are in a severe category. It break out like this: 

- For people age 10-19 who are healthy there is a 0.2 % death rate

- For people age 20-29 who are healthy there is a 0.2 % death rate

- For people age 30-39 who are healthy there is a 0.2 % death rate

- For people age 40-49 who are healthy there is a 0.4 % death rate

- For people age 50-59 who are healthy there is a 1.3 % death rate

- For people age 60-69 who are healthy there is a 3.6 % death rate

- For people age 70-79 who are healthy there is a 8 % death rate

- For people over 80 who are healthy there is about a 15-22 % death rate

 

But if you aren’t perfectly healthy, it gets worse.

- For people who have had a previous heart attack or stroke etc , there is an average of 11 % death rate, which gets worse with age

- For those people with diabetes there is an average 7.3 % death rate, but it gets worse with age

- For those lung disease like emphysema or asthma there is an average 6.3 % death rate, worse with age

- For those with high blood pressure needing treatment there is an average 6 % death rate, worse with age

- For those who are battling cancer, there is an average 5.6 % death rate, worse with age

 

So people in their mid 70’s and beyond with a few significant chronic medical problems could easily have a 33 % chance of dying of they got the disease, and would quickly become a severe case when infected while the 29-year-old from whom they contracted the disease could have such a mild case they didn’t know they had it (and a very remote chance of dying).

 

The next thing I want to talk about is how much COVID-19 is out there. The numbers do not look terrible right now, but a recent study from Stanford University in California suggests there could be much larger group of people who are asymptomatic in the community and therefore not being counted because they don’t know they have it.  This might be especially true of the young.  The actual number could be quite a bit higher.  As well, since everyone who is contagious at the beginning phase of their illness, and up to one third of people (maybe) don’t get any symptoms, there could be a whole slew of people out there walking around with no symptoms and shedding virus.  It is postulated that you could easily come in contact with corona virus out and around town without ever seeing a person who is sick. That is why the government wants you to stay at home. How many of those people at the grocery store or at the drug store are asymptomatic but contagious and shedding virus all over the store surfaces and products for sale. There is no way to know.

 

So far in Ontario today we have over 14,000 positive cases with over 800 people who have died. Of those 800 deaths, 94% have been over the age of 60. Now many of those have been people whose overall health level is low such as someone in a nursing home with multiple health issues.  However I have already looked after people at death’s door from the virus who were very healthy and active before, the only strike against them is that they were over 70.  This is really a virus that preys proportionally on the older members of our population and being a healthy 70 or 80-year-old doesn’t necessarily afford you a ton of protection. And yes young people do get this virus, and some do die, but much less commonly so the risk is smaller.

 

Influenza, the other common respiratory virus we see in ICUs proportionally kills the very young AND the very old (the upper and lower extremes of life span).  So babies and toddlers are at risk as well as the geriatric adults.  But COVID-19 proportionally only kills older people, NOT the younger ones, so even babies and younger children have a much lower risk that those over 60. I hesitate to talk about this, but in fact, this propensity to strike older people was noticed by a segment of our youth in public school and high school who are frustrated with older people not taking global warming seriously when it's them that will inherit the planet in 40 years. So in a very dark and insensitive way these young people have started calling COVID-19 "The Boomer Remover" for its propensity to take from us the older generation. I know several elementary school teachers who have heard their students referring to it as that. If the grade 7 and 8's already know the risks for the older population, so should you.  Although the term "The Boomer Remover" is insensitive and callous, if it scares you enough that you stay at home because you are an older member of our population, then as a dark reminder of your risk this awful and inappropriate term may also save your life! 

 

So how could you catch COVID-19 if you go out shopping, for example.  Well here are some hypothetical scenarios to illustrate how it can be passed on.

 

Example #1: You go grocery shopping and want to buy the milk.  As you always do you choose your cartons from deeper in the cooler, you know, those ones with the longer time until they expire.  You move the carton at the front aside and grab the one at the back.  It just so happens that an hour earlier someone also did that same thing, but they were infected with the COVID-19 virus but didn't know it because their symptoms were not going to start for another day ... the time when they are most infective. Grabbing that front container of milk to move it transferred COVID-19 virus from the carton to your hand. As you keep shopping you get an itch in your eye, the kind that makes your eye twitch and without even thinking you wipe your eye. You now have COVID-19. Even if you were wearing gloves you now have COVID-19 if you touched your eye with the gloves. Even if you were wearing a mask, you now have COVID-19. You transferred it from the milk carton to your fingers, then from your fingers to your eye.

 

Example #2: A young person is hungry and goes to the fast-food drive through to get some fries. They pay with cash, and get change back. What they didn't know is that three customers ahead of them in the line was someone who has COVID-19 but is two days away from becoming symptomatic and is shedding virus but doesn't know. The change the young person got back was coins that this infected person had used to pay and are teaming with virus.  This young person now has COVID-19 virus on their hands from handling the coins. They drive away putting COVID-19 virus on their steering wheel. Being careful, they pull into the parking lot and clean their hands with hand sanitizer so they can eat the fries as they drive home. However after cleaning their hands they touch the steering wheel again and recontaminate their hands.  As they drive home and put fries in their mouth they become infected with COVID-19. It was transferred from the coins to their hands, to the steering wheel, then after they sanitized their hands back to their hands from the steering wheel, then from their recontaminated hands to their mouth.  The next week this young person does groceries for their grandmother who lives alone. The young person has a very mild sore throat and itchy eyes, but essentially no symptoms. She welcomes her grandkid into the home, hugs them and thanks them for getting the groceries. Two weeks later the grandmother is in the ICU with COVID-19 and dies two weeks later.  Her grandchild had only a mild case contracted while he was out and about around town, and wasn’t even aware of the illness.  The grandmother didn’t stand much of a chance because she was over 80, and had a number of chronic health problems.

 

So these are hypothetical scenarios, but shows how this could easily happen. A recent study suggests that nearly half of all cases of COVID-19 are caused by infection from people not showing any symptoms. So staying away from sick people does not protect you.  This is because it is spread by asymptomatic people, and lives on surfaces, so it is very likely that you could get COVID-19 without ever seeing a sick person. If you are older, stay away from people period!  

 

To show you how much viruses can spread, let me tell you of an experiment done a number of years ago.  Researchers placed a device in a person's nostril that leaked a tiny bit of fluid periodically, simulating a very mild runny nose.  They then sent this person to a cocktail party.  What they didn't tell anyone is the fluid had a chemical that glowed under a black light.  At the end of the party they got out the black light.  Everyone was astounded how much glowing there was from the fake runny nose.  Doorknobs, sofas, the bowl of nuts, the coffee table, the wall, but also on the hands, upper body, and face of many of the guests.  This is exactly how COVID-19 can spread from an asymptomatic person.  Viruses get around.  Person to surface, to person.  And if it gets to your mouth, nose or eyes, you get sick!

 

I am frequently asked about wearing gloves or wearing a mask.  Is that a good idea when going out. 

 

Let me talk about gloves first.  At the hospital we are trained how to use gloves.  How to remove them by peeling them inside out so you don’t ever touch the outside to your uncontaminated skin.  We practice this.  And then right after we remove the gloves we discard the gloves inside out in the trash and wash our hands with soap and water thoroughly.  And gloves are only ever used when we are actually in a room with a patient with proven or suspected COVID-19.  When outside the room of these patients, or in the halls, or at the work stations, we never wear gloves.  Because gloves need care and training to use without contaminating yourself.  Unless you are directly dealing with a person with a suspected COVID-19, for us it is safer to use bare hands and wash our hands frequently.  So if you are wearing gloves while shopping how are safely removing them.  How are you preventing the potentially contaminated gloves from touching our uncontaminated skin, or car, or the interior of your house.  If you wear gloves to shop then pull them off to pay, you have just collected a store’s worth of virus on the outside of the gloves and transferred all this virus to your hand as you pull the glove off.  And some people reuse the gloves from store to store collecting more and more potential virus on them.  The COVID-19 virus doesn’t enter your body by soaking through the skin of your hand.  It enters from your mouth, nose, and eyes from your fingers, gloved or otherwise.  So it is far better to carry a bottle of hand sanitizer around the store and clean your hands periodically, and DO NOT TOUCH YOUR FACE while shopping.  I fear gloves are just another complicated item that presents a hundred ways for you to contaminate yourself with and gives people a false sense of security.

 

And what about masks.  Well I think wearing a mask is a kind gesture to the people around you to show that you care about not spreading virus onto the surfaces of the store if you happened to have COVID-19 but don’t know it yet.  In the hospital we put masks on all the COVID-19 patients when we have to take them to x-ray or to the OR, as it prevents them from spewing virus everywhere.  However, if you are wearing the mask to prevent yourself from getting COVID-19, that is a very unlikely scenario. Breathing in aerosolized mucus particles in the air from someone coughing with COVID-19 is a very unlikely scenario, especially because these droplets only travel a metre from the person, and because studies show a simple cloth or surgical mask likely won’t afford much protection in those scenarios.  You are essentially wearing the mask to prevent others from getting COVID-19 from you, not the other way around.  However, it comes with one caveat.  If wearing a mask makes you touch your face more, as you adjust it, or scratch the itches it causes, DON’T WEAR IT.  I have watched people wearing masks in stores, and one person I saw touch their face several times a minute to adjust the mask as it slipped, not cleaning their hands each time.  Under this scenario, you have a greater chance of getting COVID-19 because you are touching you face with your dirty hands more often.

 

And finally, remember that the virus rarely lasts longer than 4 days on surfaces as it dies out. So if you are worried about something that can't be cleaned, like a book, or papers, let them sit for four days or longer before handling. If by chance that the person that brought these items to you is infected, the virus will no longer be contagious on those items after four days.  So if you can’t wipe down the item with cleaner because it would ruin it, or has too many nooks and crannies, let it sit for four or more days, and clean your hands after handling it.

 

In conclusion, every member of our society needs to follow the government’s advice and protect yourself. But if you are an older member of our society, especially over the age of 60, you need to take extra special precautions. 

 

What for a young person might well be a mild illness with low chance of dying, for those over 60 is a real risk of dying. It’s just not worth it. Stay at home, you never know what surfaces in stores, bank machines, etc have virus on them. Try not to expose yourself to younger people when you don’t have to, as they have a greater chance of having COVID-19 and not being aware. Let your younger family members do your shopping, but let them drop off the goods on your step and leave before you out and pick them up. 

 

Please don’t expose yourself. A small risk of dying for a young person is a serious risk for those older members of our society. Be safe. Older members of our society best be much more strict and careful than what the government recommendations advise.  And as this COVID-19 pandemic peaks and winds down, it will get very easy to be complacent.

 

Sorry for the long winded email, just wanted you all to have a clear picture of what the issues are.