- Well. I’m afraid this blog post didn’t age quite as well as I would have hoped.
I wrote this back in late January and back when I wrote it, there hadn’t been any real major community transmission outside of China. Since then, quite obviously, things have escalated. Now, truth be told, I’m afraid this blog post reads a little too flippantly, knowing what we know now. The temptation is to simply change it, but I wrote it so I should own it. I decided to put in updates with new information and these are all in italics. The original text of the blog post still appears, as it was originally written, in normal font.
In 2011, there was a movie released called “Contagion.” It starred Matt Damon and Gwyneth Paltrow and had (in my opinion) a particularly wonderful performance by Jude Law. The movie came out when I was in residency and I had the opportunity to ask several of the Infectious Disease doctors at the hospital I worked at if they’d seen it. Many of them had, and actually enjoyed it. The thing that may have been the most accurately depicted aspect of the movie was its tagline: “Nothing Spreads Like Fear.”
Now, statistically, things like the COVID-19 outbreak of 2020 and the Ebola outbreak of 2015 incredibly unlikely to affect anybody reading this (there have been more Americans married to Kim Kardashian than have died of the Ebola Virus) (no, really, that’s an actual mathematical fact). I get why people are captivated by virus outbreaks. I understand and completely appreciate the dread fascination with virus outbreaks because I am, myself, rather entranced by them as well. I certainly understand people wanting more information. So, let’s talk about coronavirus.
- This is the first thing I wish I wouldn’t have originally written. The sentence “Now, statistically, things like the COVID-19 coronavirus outbreak of 2020…are incredibly unlikely to affect anybody reading this,” (the point, actually, still stands about Ebola). What I should have written was the following:
Statistically things like COVID-19 outbreak of 2020 are unlikely to affect your health permanently. We’ve all, obviously, been affected at this point. High School State Basketball tournaments are cancelling and senior years are being marred. Spring break trips are being ruined. Kids are all home from school and parents everywhere are scrambling to take care of them. People’s lives are absolutely being affected…and yes, people are dying. At the time I made this update, in the US there are 41 recorded deaths and as you’ve read, Italy and Iran are really sadly being hit very hard.
It is still, statistically unlikely that you reading this will have your personal health permanently affected. But there are lots of other things to consider and now everybody is affected.
What is coronavirus?
Let’s get this out of the way right now—you’ve probably had a coronavirus before, and if you’re reading this you almost certainly lived to tell the tale. Coronavirus is estimated to cause between 5-10% of all respiratory infections, and between 15-30% of common colds. In other words, with as many colds as you’ve likely had in your life, it’s very probable that at one point or another you’ve had a coronavirus.
It is worth noting that coronavirus has been rather challenging to study; it’s very difficult to get coronavirus to grow and replicate in tissue culture. Until recently, it was hard to even test for, but fortunately we’ve come up with specific tests now that can search for individual types of coronavirus by looking for the virus’ DNA profile (well, actually RNA profile, but whatever).
Here’s the thing, though: There are many different strains of coronaviruses out there and they all have distinct profiles that our tests look for. If you go into an Urgent Care, they can run something called a viral filmarray, a really cool test that will look for all sorts of viruses that might be infecting your respiratory tract (which, by the way, can include anything from your nose all the way down to the end point of your lungs called your alveoli).
The filmarray panel includes, among other things, a test that looks for coronavirus 229E, HKU1, NL63, and OC43, which are just four of the possible versions of coronavirus that can give you a respiratory tract infection. It’s important to note that none of these are COVID-19—they’re just different kinds of coronaviruses that cause respiratory tract infections.
The coronavirus, which has been formally named COVID-19, not surprisingly, is different. For reasons we’re not sure about, COVID-19 has greater potential to cause pneumonia and other significant complications which can include, yes, death. Is this likely? Absolutely not. Is it still scary? Of course it is. Anytime there’s the idea of a virus floating around that seemingly indiscriminately kills some people but not others, it’s very scary.
- So, there’s lots of ways that can happen. Not surprisingly, I can’t do this briefly, but that because of a combination of me never being able to write anything with brevity and this needing to be explained completely.
Your lungs have this thing called a mucociliary escalator. If you remember high school biology, you have cells with things called cilia and they line the tubes that go into your lungs. Cilia are little hairs on cells that can sweep things away, if needed. Air flows down into your lungs through a series of tubes which are lined by cilia and the cilia’s job is to sweep everything up and out, away from the functional unit of the lungs, which is the alveoli.
Now, if it helps, think of your lungs like an upside-down tree because the two things are damn near perfect reflections of each other.
Your trachea which is the first thing air flows into after your mouth is the tree trunk (it is not at all by accident the words “trachea” and “trunk” sound alike). The trachea splits into two bronchi (branches) and keeps splitting, about 27-30 times and the tubes get smaller and smaller. If you’ve ever heard of bronchioles, or broncholitis, that’s basically an inflammation of the twigs right before the leaves on our lung tree.
Just like a tree’s leaves, our alveoli is where gas exchange happens. Oxygen crosses the alveoli, into the capillaries, where it’s collected by red blood cells, and the red blood cells are taken back to the heart, and your heart pumps it to the rest of your body. And that’s basically how the system works.
If your alveoli can’t exchange the gas, the whole system collapses. Now instead of being flat like a leaf, alveoli are sort of spherical ends to the twigs on our respiratory tree.
One of the functions of the cilia is to keep sweeping moisture and mucus up and out so it doesn’t flood the alveoli. The problem with many viruses, COVID-19 included is that it’s ciliotoxic. The presence of the virus stops the cilia from beating, which stops the moisture from being moved out of the alveoli, which causes the alveoli to flood, which stops the gas exchange, and the whole system collapses. That infection of alveoli – that’s a pneumonia. Basically, a pneumonia is an infection of our leaves. Bronchiolitis is an infection of our twigs. Bronchitis is an infection (well, an inflammation) of our branches, so on and so forth. As an FYI, smoking, among other things, has the same ciliotoxic effect.
The other thing that can happen is a bacterial superinfection on top of the viral one. Because the mucociliary escalator doesn’t work, you’ve got a standing pool of water in your alveoli. Now you’ve got a great place for bacteria to grow. And that’s a big problem because bacteria, just by being there, cause all sorts of problems. They are toxic to the cells, they make toxic products, etc.
Influenza is a bit different in the sense that influenza when it is replicating actually destroys the cell that it’s being released from. So, in addition to the above process, influenza causes respiratory cell death when it leaves the cell to go find other cells to infect. Influenza also causes something called a cytokines cascade which doesn’t happen with every strain but did happen with H1N1. Basically it causes the immune system to go WAY too nuts, and your immune system, in an effort to kill virus, accidentally takes out your respiratory tissue. It’s essentially a friendly fire incident.
COVID-19 doesn’t seem to do that, because that’s a thing that generally happens in young people (hence the one of the reasons the 1918 pandemic was so hard on young people).
And so that’s how COVID-19 and other viruses cause fatal pneumonias in your lungs. COVID-19 seems to have a much more pronounced effect on older lungs and in people with underlying conditions like heart disease and pre-existing lung disease.
How does coronavirus spread?
Here’s what we know about the coronavirus family, which includes COVID-19:
- Coronavirus appears to spread through self-inoculation. What that means is if you get coronavirus on your hands and you wipe your nose, that’s how the virus gets into your body. Coronavirus also appears to be transmitted through large water droplets that you can get on your hands. As near as we can tell, if you don’t want to get any coronavirus (and why would you?), make sure you wash your hands.
- This information is still very relevant and hasn’t changed other than to add – don’t touch your face.
- Coronavirus is enveloped, meaning the virus has coating on the outside of it. As it happens, the envelope means that the virus doesn’t survive well outside of the body—they usually can’t last longer than 24 hours outside of the body and usually only last less than 12. This is a good thing in terms of containing an outbreak. It also means coronavirus can be killed by hand sanitizer and soaps, which isn’t the case with other types of viruses (most notoriously norovirus), so your biggest defense against coronavirus is washing your hands. The problem with viral envelopes is that they allow the virus to more easily evade your immune system. So, the enveloped virus has a disadvantage outside of a person, but once it gets in, the envelope gives it a dangerous edge. Enveloped viruses (which include influenza) tend to cause longer, more problematic infections for this reason and are more difficult to develop a vaccine for because of the envelope.
- Coronavirus doesn’t appear to be airborne. This is very much a good thing. Some viruses can be transmitted easily by aerosolized water droplets; influenza is one of these. The flu is so good at transmitting itself this way that people with the flu can put infectious water droplets in the air by simply breathing quietly or talking. As far as we can tell, coronavirus doesn’t do this. So, while the HazMat suit on people looks impressive, it’s probably not necessary. How would you feel if your doctor walked in to examine you with a HazMat suit on when they didn’t really need one? Remember, nothing spreads like fear.
- People with coronavirus are shedding virus during the incubation period. If you aren’t familiar with these terms, let me explain. Shedding virus is the fancy medical way of saying, “You’re contagious.” Basically, if you’re shedding virus, you’re putting it out in the environment for other people to catch. The incubation phase is when the virus is replicating in your body, but you’re not having any symptoms yet. So, yes, people with the virus can be contagious even when they don’t have any coronavirus symptoms.
- The incubation phase is now, clearly, much longer than the incubation phase of influenza which is about a day. It looks like (and again, coronavirus is difficult to study) the incubation phase is somewhere between 5-14 days and this presents another problem for containment – you can pass it along without knowing it for a fairly large window of time.
- We’ve seen this before. Do you remember SARS? SARS stands for Severe Acute Respiratory Syndrome, but really SARS was a specific strain of coronavirus. There was an outbreak in 2003, and according to the World Heath Organization, 8,098 people were infected and 774 of them died. Those are very striking statistics; a virus that kills 1 in 10 people who get it is certainly very noteworthy and scary. SARS has a cousin, MERS (Middle East Respiratory Syndrome), which isn’t as deadly but is also a coronavirus.
- Now, this point actually makes a big difference. One of the problems in containment is the variable presentation of the symptoms. A majority of the patients (young healthy patients) will have cold like symptoms, and therein lies part of the problem…those people don’t feel motivated to get tested. See, one of the reasons SARS and MERS were (relatively) easy to contain was because their constellation of symptoms was really severe and it was really obvious who needed to be tested, quarantined, and given intensive care. COVID-19 hasn’t been doing this and please keep reading for a rather impassioned rant below.
The point is that while some strains of coronavirus certainly are deadly—again, 774 people died in the SARS ’03 outbreak—the outbreaks are relatively well-contained. If you’ve had a travel contact from China or you yourself have been to China and you’re feeling ill, best to go get checked out. We can do our part to contain the outbreak and we can test for this specifically, but it’s important to note that COVID-19 won’t be on a regular filmarray panel. A sample will have to be sent off to the CDC to test for it and you’ll get the results back in 48-72 hours, most likely.
- This…THIS RIGHT HERE is the absolutely inexcusable part of the handling of this. I wrote that back in late January, thinking it was true because I thought this is the USA and OF COURSE we’d have this under control.
We did not.
The test kits weren’t available and THE SINGLE MOST IMPORTANT THING in controlling a disease outbreak is knowing who has the virus and who doesn’t. The lack of testing kits has been absolutely inexcusable. If you look at the way South Korea has handled this, they’ve done it beautifully. South Korea has 8,000 cases with 71 deaths. This lower death rate doesn’t have anything to do with a younger population, it has to do with quick identification of who has the virus and immediate care of them.
Testing kits are the most important thing that needs to happen, along with our social distancing efforts and our efforts to stop spread amongst ourselves. Please keep reading…
I can absolutely understand why people get scared by these things because outbreaks of disease from foreign lands are very captivating. That said, I wouldn’t be doing my job if I didn’t point out one other thing: you are far, far, far more likely to have a serious complication due to influenza. The flu is more easily transmitted and is all over the United States…and has already, in the flu season of 2019-20, killed an estimated 8,200 people. So please get your flu shot because we’re currently right in the middle of flu season and it can still benefit you.
- This was written back in January – at this point, get your flu shot if you’re already *at* the doctor’s or pharmacy, but I wouldn’t make a special trip in the middle of March.
Coronavirus outbreaks captivate people, but it’s fairly unlikely this outbreak will affect you. If you do find yourself with a respiratory infection and you have difficulty breathing, get to a medical provider right away to be evaluated. If you know you have a chronic lung disease and you feel a respiratory infection coming on, get to a medical provider to be evaluated. If you are diagnosed with a respiratory tract infection, keep a close eye on your breathing and stay away from people who shouldn’t be around one—kids, the elderly, and especially immunocompromised people.
- Again, this was originally written too casually. Obviously, this has affected you. Also, it needs to be reiterated, if you’re sick and you’re having trouble breathing, you need to be seen. If you’re just not feeling well, call your medical provider and tell them what’s going on, rather than just coming in. If you’ve got risk factors or concerning symptoms (the biggest is a fever which is defined as a temperature above 100.4), you may need to be tested, but you also need to minimize your contact with other people. At this point, if you have a respiratory tract infection, but you’re otherwise doing well, stay away from everybody.
We have a responsibility to each other to make sure it doesn’t affect those of us who can’t handle an infection. This means that we have to stop going to social settings. We have to stop shaking hands, we have to cancel basketball tournaments and we have to limit our social interaction for a while. The majority of us don’t do this because we’re at risk of something terrible, we do it because we must protect those that are, because we have that responsibility.
You have probably read about “flattening the curve” which is trying to spread out the spike in cases so that the healthcare system isn’t overwhelmed. There’s a particularly good article in the Washington Post that shows how this works.
If you know somebody who’s sick and shouldn’t leave their house, HELP THEM. Buy them some groceries and leave them on the door step. They can Venmo you the money or whatever the kids are doing these days (or pay you back later) (or you could just buy it for them). If you know an elderly person who needs medications but is scared about going to pick them up, HELP THEM. Wash your hands, pick up the meds, wipe down the bottles with Clorox wipes, and leave them on the door step.
Schools are closing and for some children, this is the most consistent two meals they get. If you hear about this, HELP THEM. Contribute money so they can get a meal. There are ways we can help that don’t involve contact which would contribute to viral spread.
Hand washing and common sense go a really long way here and remember, fear spreads farther and faster than coronavirus does. If you have to travel, make sure you stay as healthy as you can while you’re away. We’ll be here if you need us when you get back.
- Well that hasn’t changed. We’ll be here if you need us, because that’s what we do.
The expert family medicine providers at the Des Moines University Clinic are here to help you and your loved ones stay healthy year-round. If you or your family have cold and flu symptoms, make an appointment with us by visiting the DMU Clinic website or calling 515-271-1710.