15 Questions About the Coronavirus, Answered by a Doctor
COVID-19 has now claimed the lives of more than 318,789 people worldwide, and cases continue to accumulate; the current estimate is that there have been more than 4 million to date. When we initially reported this story in February, the World Health Organization (WHO) had declared a global health emergency and people were preparing for disruptions to daily life.
Now it's a full-on pandemic, but months of living with the virus and its consequences haven't left us with fewer questions. Here, the most prevalent, answered by Keith Roach, M.D., an internist at Weill Cornell Medicine and NewYork-Presbyterian Hospital, answers those questions.
1) How can we put the coronavirus outbreak into context with other high-profile outbreaks in the last decade, like Zika or H1N1?
Zika isn’t a good comparison, because Zika is spread by mosquito bites, and COVID-19 is spread person-to-person, having first been introduced to humans through an animal (COVID-19 is very closely related to a bat coronavirus, but whether it went through another animal first is not known).
The infectivity of an infection is described by a number called the basic reproductive number, R0, (we say “R nought”). However, the R0 doesn’t tell you all there is to know about how alarming the infection will continue to be. The best guess for R0 for COVID-19 is between 2 and 2.5, making it more infectious than most seasonal flus.
2). How does the mortality rate compare to the flu?
This remains unknown in the US, because there remains poor information on overall number of novel coronavirus infections, and some uncertainty about how many actual COVID-19 deaths there are. As such, mortality estimates range from 0.7% to 5.7%. I suspect the actual number is towards (or below) the lower end of that number. Even so, the number is still very, very high: more Americans have died of COVID-19 than died in the Vietnam war.
As of May 1, there have been 1,070,000 cases and 62,000 deaths from COVID-19 in the US (3.21 million worldwide) compared with 30 million flu cases and about 50,000 flu deaths in an average year. Since COVID-19 is so new, nobody is likely to have partial immunity as some people do to the flu, which they’ve built up by previous infection or immunization to flu.
3) How long does the virus linger on porous/non-porous surfaces? What are the risks of the virus being transmitted on packaging and goods?
Coronaviruses have been shown to persist as long as 9 days on glass, metal, or plastic in the worst case, with a very large amount of virus inoculated. Packaged goods are very unlikely to have infectious particles due to long shipping times and reduced virus infectivity on paper.
There have not been cases transmitted from packaged goods, including takeout food, according to the CDC.
Although initial reports found virus persisting up to nine days, a recent report shows that with the exception of surgical masks (where infectious virus may still be recovered a week later), COVID-19 cannot be transmitted after more than 2 days on porous surfaces like paper or cloth, and no more than 4 days on non-porous surfaces like plastic or glass.
4) Should we continue to wear masks?
The CDC recommends using a cloth mask to protect other people from any virus-containing droplets that could be coming from your nose and mouth, even if you’re not showing any symptoms. Although most health care workers now have access to the personal protective equipment they need, CDC continues to recommend against using masks intended for healthcare workers, especially the N95 masks. The need for masks will continue as long as community transmission is likely, which I can’t predict.
5) Do you think the isolation efforts that the U.S. made were necessary to the coronavirus' containment?
Absolutely. In an infectious epidemic, the public health officials have only a few really effective tools. One is an effective vaccine, which there is not yet one for COVID-19. Another is medication, if there were effective antiviral medicines, which there aren’t any proven (trials are ongoing and one medicine, remdesivir, shows promise). The final, and oldest, is keeping people away from each other, especially quarantine and isolation. We saw a real flattening of the curve, especially in those areas that had the most restrictions on movement and interactions.
6) Where are we on the curve for number of new cases?
The rate of new cases in many areas of the US has been decreasing, due to the social distancing measures. Government officials are balancing the risks of relaxing the measures which have controlled the outbreak with the benefits of restarting the economy. Whether there will be a second wave of infection is not clear, and depends on the number of people that have been infected (which is not well known) and the degree of immunity (also not well known).
7) Is there anything I should be doing to prepare myself for a possible second wave?
The most important precaution is to not get sick: wash hands religiously (or maybe obsessively); keep away from people who are sick (literally 6 feet away will eliminate most risk); try not to touch your face; if you are sick, STAY HOME.
8) Have the symptoms and signs of COVID-19 changed?
Fever, cough, and shortness of breath remain the most common symptoms. Chills, with or without shakes, muscle pains, headache, sore throat, and loss of taste or smell have been added by the CDC to the list. In my role in taking care of suspected COVID-19 patients, I will say that loss of taste and smell seems to be pretty reliable. A few people have presented with diarrhea, but that isn’t common. There have been reports of skin changes, especially in children.
9) When should I go to the Emergency Room?
The main warning symptoms of severe coronavirus infection include severe shortness of breath, confusion, grogginess or difficulty arousing, chest discomfort, and cyanosis (bluish discoloration, often seen best in the lips or face). If you have been diagnosed with COVID-19, then a handheld pulse oximeter is a very useful tool: the oxygen level in the blood is a powerful predictor of outcome. Low oxygen levels are common in coronavirus infection, but levels consistently below 92% are concerning, and less than 90% are a reason to get medical advice.
If you develop typical symptoms of COVID-19, you should call your doctor (this is why it’s important to have a relationship with a primary care doctor). However, if you develop the warning symptoms above, you need to go to the ER. We have lots of experience now deciding who needs the hospital, as well as in managing symptoms and supportive care.
If you’re having another type of emergency, it’s also important to go. It’s very important for me to note that I have had patients refuse to go to the ER for conditions that would have definitely brought them there before. I have had patients ignore chest discomfort, only to have a heart attack diagnosed days later. The overall death rate is higher than would be expected by reported COVID-19 deaths; some of this is unrecognized coronavirus, but I suspect some of the excess mortality is in people waiting too long to get critical illness evaluated.
10) When do I need to get tested?
The most important time to be tested is if you are very ill with an infection compatible with COVID-19. Testing milder disease is becoming more frequent as the ability to test people has become easier, but that depends on local conditions. However, there are certain times when we do test people with no symptoms. Examples include people with cancer who need to know whether it is safe to receive chemotherapy, and people with end-stage renal disease on hemodialysis, as dialysis units separate patients depending on their Covid-19 status.
11) When should I get a blood test to look for immunity?
It’s not clear that people who have antibodies are protected from future infection (and if they are, how long they will be). It’s also evident that the different blood tests available are highly varied, with some having poor sensitivity (many false negatives: the test says you have no antibodies but you do) and poor specificity (many false positives: the test says you have antibodies when you don’t). I understand the desire to get the test but they aren’t *quite* ready for prime time. They are most valuable for people who have had symptoms and who live in an area (such as NYC) that has had a lot of COVID-19 activity.
12. What's happening with a vaccine?
A great deal, but it is all still early. Even though some candidate vaccines are beginning testing, proving safety and effectiveness is time-consuming, and must be done properly. I will be surprised if a vaccine is available commercially before fall 2021. Vaccine safety is so important. Back in 1976, they rushed out a swine flu vaccine—and it was a bad vaccine. There are still patients who refuse flu vaccines because of episodes like that. Normally, a vaccine takes a minimum of 3 to 5 years to develop and test. While we all want a vaccine quickly, it is critical to be sure it is safe, and that always takes time.
13. Are people still infectious after recovering?
We are seeing people still being swab-positive for the virus even weeks after a clinical recovery. Very recent evidence suggests that people are very unlikely to be infectious 10 or more days after symptoms began, even in people who have virus found on testing.
14) I'm pregnant. Should I be taking any special precautions or preventative measures at home or at work?
No, pregnant women should take the same precautions as anyone else. Early reports show that pregnant women are not at increased risk. However, similar viruses can be more severe in pregnancy, so your doctor will take extra care of you in case you get sick.
15). What would your general advice be for how we should be feeling at this point?
I am deeply divided. I am proud of many of the things we have done, as a country, with social distancing and isolation, which has allowed the medical system to avoid being completely overwhelmed. I understand the desire to return to normal, and have seen the mental health issues associated with prolonged isolation and with high levels of financial stress. However, I am very disturbed that we may be trying to rush to stop these important measures. Policies must be guided by the best available evidence and by science.
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