In this special edition episode, Victor F. Tapson, M.D., from Cedars-Sinai discusses the coronavirus (COVID-19) and how it might impact pulmonary hypertension patients.
Hi, I’m Vic Tapson. I’m in pulmonary critical care at Cedar Sinai Medical Center. Wanted to talk for a few minutes today about this coronavirus (COVID-19) and how it might relate to pulmonary arterial hypertension (PAH) and how we should be reacting and some thoughts about this.
I think maybe the most important point to make first is while we’re taking this seriously, we don’t want to panic. One comment I want to make right up front is if you’re a patient with PAH, most patients with PAH are no more susceptible to this than anyone else is, but let me give a bit of background here. I don’t want to talk a lot of detail, because you can find a lot of this online. For those of you that don’t know, it appears that just like some of the earlier viral epidemics, like SARS and MERS you may have heard of, we clearly know the coronavirus, this novel strain called COVID-19, it’s clearly transmissible between people.
Right now, 100,000 cases around the world, and this is early March. It’s been identified now in a hundred countries. Most of the deaths so far been in China, more than 3,500 deaths so far in China. More than 400 cases identified in the U.S. so far right now. Keep in mind, we haven’t done a lot of testing, so there may be more. 19 deaths in the U.S. Most of these have been in this Washington state cluster in a nursing home. We’re seeing some cases in California now. New York State has now declared a state of emergency. But again, I want to keep reemphasizing, this is not the deadly type virus that some of these early viruses, like SARS and MERS, which had more than 10% mortality rate. Our mortality rate right now we’re thinking is in the very low range of one or 2%, something like that. It does seem to affect certain people more than others, the elderly and immunosuppressed maybe more common.
It’s around the world now. Italy has had more deaths than any other country except China now. The government in Italy’s closed all the schools. We’re certainly not there yet in the U.S., but there’s some schools that have been closed so far. I’ve missed three national meetings in the last couple of weeks because of caution with this virus. The impact, if we’re careful, I think because it is going to be pretty minimal in patients that have pulmonary arterial hypertension.
Let’s talk a minute about symptoms and then how might relate to PAH. Right now, the incubation period of this virus, it may be a few days up to 14 days. Most infected people seem to show symptoms in about five or six days. In the original Chinese cohort from late January, most common symptoms were fever, fatigue and dry cough. That still seems to be the case. A percentage of patients, maybe around a third, may have muscle pain, difficulty breathing. Then a smaller percentage, sort of atypical symptoms, like diarrhea, nausea, things like that. But again, if you have PAH, if you get the flu or a bug like this COVID-19, those are the symptoms you’ll probably have, fever, fatigue, dry cough. Then maybe, we don’t know for sure, but a percentage of patients may get worse. Over 80% of patients will have very mild disease, may have minimal symptoms, if any. They may think they have maybe like a common cold, sore throat, runny nose, fever and you may get better from it. So majority people are going to do fine from this. We’re more concerned with older patients and immunosuppressed patients, like I mentioned.
What I should maybe comment about now would be recovery. Again, many people that have gotten this disease, if it’s mild, may be over completely in two weeks. If it’s more severe, it may take three weeks or more to recover. There’s going to be some variability. This virus, it multiplies in the respiratory tract, so things like coughing, sneezing, may help spread this. Also, talk about shaking hands. Even people doing fist bumps now, elbow bumps now, because we don’t want to pass this virus. We want to be cautious with hand washing. We don’t know right now how long this virus might last on inanimate objects. People are very careful to wipe down your tray if you’re flying someplace. There’s certain specific things we can talk about even in terms of travel.
Let’s talk a little bit about what you might do if you are exposed, depending on where you are. One of the reasons I’m a little concerned about doing any unnecessary travel is even if I get this coronavirus, I might do OK. Now, I don’t have pulmonary hypertension, but just like most PH patients, I’ll probably do fine. I’m a little worried about getting quarantined. I don’t want to get quarantined someplace for two weeks, so I’m going to be cautious travel-wise for that reason, as well. Necessary travel is one thing, but travel that really isn’t necessary probably wise to back off from.
A few things to keep in mind, again, whether you have PAH or whether you don’t. If you’re going to be around other people, a lot of other people, consider wearing a mask, cover your mouth and nose with tissue to cough or sneeze, discard it in a trashcan, immediately wash your hands with soap and water for at least roughly 20 seconds. Use a hand sanitizer if you can, but soap and water are really preferred. Another important thing, again, for anybody, PAH or not, avoid touching your eyes, nose and mouth. If you don’t think you do it, then test yourself, because we all do it a lot more than we think. We all touch our faces just randomly and without realizing it subconsciously. You’ve got to try to practice not doing that. It may prevent infection. Best not to share dishes, drinking glasses, eating utensils, things like that. Wash things like that after you use them. Use a household cleaner to wipe countertops. Again, this stuff applies whether you have PAH or not.
Another important key point I should make too is you should get vaccinated for flu if you haven’t. That won’t help with COVID-19, it won’t help with the coronavirus per se, but if you get the flu and you can be tested for COVID-19, you might be designated as a possible case, you might get quarantined. You can imagine how they can just confuse things. We’ve got people coming to emergency department with flu because they didn’t get vaccinated. We’re not going to know right away whether they have COVID-19 or the flu or what they have, and that’s going to create problems. So, I’d keep that in mind.
I want to be a little more specific about PH now. If you’re older, elderly, and I won’t give a cutoff age, you’re a little more susceptible to viruses and to getting more severe disease. If you have any abnormality of your immune status, if you’re on prednisone, steroids, things like that, you may be a little more susceptible to this disease and getting a worst case I should say. Let’s suppose you’re a patient with idiopathic PAH, like many of you out there, or scleroderma. If you’re not on steroids, you’re not on immunosuppressive drugs, let’s say if you’re younger, you’re stable, there’s no particular worry you’re going to have a severe problem if you get this disease. If you’re one of the rare people, just like patients without PH, you could get severe disease, but 80% plus patients are going to be just fine. Just do the same things we talked about. Wash your hands, don’t touch your face, et cetera, et cetera.
Let’s suppose you’ve got scleroderma or maybe you have lupus, suppose you are on immunosuppressive drugs. Again, you want to be very careful not to get any kind of a viral illness or bacterial illness if you can help it. We’re more concerned about patients that are immunosuppressed or older, so that applies again, PAH or not. Let’s suppose you’re a patient that has PH from CTEPH, from chronic pulmonary embolism or maybe from congenital heart disease. Again, you’re no more likely to catch this coronavirus than anyone else. If you get it, if your disease is very stable, you’re unlikely to get any more ill than anyone else would. You may be one of those rare people that gets sicker, but it’s more likely if you’re older.
What if you’ve got PH from IPF or pulmonary fibrosis or COPD? Again, many patients that have these diseases are older. If you’re older, you’re going to be more susceptible, and if you have abnormal lungs from severe PH and/or pulmonary fibrosis or COPD, again, you might not tolerate a severe infection as well as someone that doesn’t have lung disease. If you’re a PAH patient who has severe disease, maybe you were just started on IV treatment. You’ve got more severe disease, again, your lungs aren’t going to tolerate the insult from a virus as well as someone who has normal lungs, but again, 80% plus, most patients who aren’t older and don’t have any kind of immunosuppression going on are likely going to do fine and not get severe disease.
A situation where we want to be additionally cautious would be suppose you’ve got PH and you had a transplant. If you had a transplant, then you are on immunosuppressive drugs. These immunosuppressive drugs can make you more susceptible to infections and you might get a more severe case. Again, you want to be particularly cautious about being around a lot of people at the same time, [not] being closer than six feet to someone if you can help it. You don’t want to fly any place that’s unnecessary if you can help it. But you really want to use particular cautions in that situation.
In summary, in pulmonary hypertension, if you aren’t immunosuppressed for any particular reason, if you did get a severe case, you’re more likely to tolerate it better, but you’re less likely to get a severe case of this coronavirus. Again, I can’t emphasize enough the importance of hand washing, not touching your face, not being any place in crowded conditions where there’s a lot of people around, especially people who have traveled. These are some of the important things that you should keep in mind.
We don’t know what’s going to happen here. I think we’re watching very closely. I’ve got a couple meetings coming up. I’ve got one in New York in a couple of weeks, I’ve got to decide whether I can go or not. In some situations, these decisions are being made for us because the meetings are being canceled. Some medical centers, I’ve heard of several now, are limiting travel. Certain medical centers are saying you cannot travel, if you’re on staff you cannot travel internationally. Some are even saying you can’t travel domestically. We need to make sure that physicians and healthcare professionals don’t get sick and get quarantined.
These dynamics may change over the upcoming weeks. There’s no vaccine, as most of you know, right now. The CDC, they’re scrambling. Researchers are working on this. We don’t have a vaccine right now, but again, get a flu vaccine if you haven’t had it. Make sure you’ve had the flu vaccine, because that might prevent confusion and prevent you from getting sick also.
These are some of the key points. Right now, we’re in a dynamic phase with this disease. If you’re older and you’re immunosuppressed, you’re a little more susceptible, but everyone should be cautious, using hand washing, being careful not to do unnecessary handshaking and sharing utensils, things like that. If you do get symptoms, you should report it. Many people will have mild symptoms, and if they can’t be tested yet, should still try to stay home and be quarantined, self-quarantined if you have to. Stay away from others, especially those that are more susceptible to this illness.
Most people that contract the coronavirus, this COVID-19, will not require hospitalization or medications of any kind. Most patients, PAH or not having PAH, are not going to require such medical care and will recover on their own. Some will require hospitalization and more intensive care. Most patients with PAH, if they get coronavirus, are going to do fine. They’ll probably be in that 80% plus that don’t get severe disease. If you do get a more a severe syndrome, the vast majority of people will survive this, unlike some of the earlier epidemics, like SARS and the Middle Eastern Respiration Syndrome, MERS. Again, I think the bottom line should be let’s take this seriously, let’s be careful. Keep up to date on what’s going on, on the news and the online, with this coronavirus, but let’s not panic. There’s no reason for panic, let’s just stay educated.
What I would say about patients who think they might’ve gotten this virus, they may have some cold symptoms, a cough, a fever. Sure, you need to contact medical personnel, but I wouldn’t just show up at an urgent care clinic. I would call ahead. If you’ve got a family doctor, let your doctor know and say, “Here’s the scoop. I think I’m getting something. I don’t know if it’s coronavirus, but I’m getting sick. Based on my symptoms, what do you think I should do?”
If someone’s having a high fever, is having difficulty breathing, they’re going to need to present for help, but they should be guided. Naturally, anytime someone is suddenly very, very sick, you call 911, but if you get to that point, I think that’s going to be pretty rare with a situation. You want to let any EMS personnel know that you’ve been having these kinds of symptoms so they can take proper caution. You always want to let the medical personnel at the clinic know upfront you’re coming, let ED know upfront you’re coming. It’s better for them to be able to give you some advice about how to handle it. I think in many, many cases patients can be monitored and can stay at home, but we started to want to ignore patients who are having more severe symptoms.
Well, folks, keep tuned in everybody on what’s going on with coronavirus and maybe we’ll talk again soon. Thank you.
My name is Vic Tapson, and I’m aware that my patients are rare.
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