Coronavirus…Your Questions Answered

This is an unprecedented time. When did you ever think you would be relieved to be diagnosed with the flu? Did any of us think that in this first world country, we would debate the availability of masks and gloves…and toilet paper?

Our collective anxiety is increased. But, what do we know? Who should be careful? What hope do we have of treatment? I thought I would take this opportunity to answer the most frequently asked questions in an evidence-based format. We don’t know everything but let me arm you with our current knowledge:

What underlying disease/condition would increase your risk of COVID-19 infection?

In short, being human and never having been exposed to this infection before. That is, having no immunity. Immunity or ability of the immune system to combat a virus, occurs after exposure or after successful vaccination to the virus. As of yet, only people who have been infected with COVID-19 that have survived have COVID-19.

Herd immunity is absent as well because the entire population is being exposed as once. Herd immunity describes general immunity of a population, either from exposure or vaccination. When most people have been vaccinated in a population to an illness and someone in that group is exposed, that person tends to be less infectious or non-infectious to others and the illness is less able to propagate itself. This is the principal whereby vaccination of people in a population helps all, even those patients that cannot be vaccinated (like the very young or those that have a contraindication to vaccination).

That being said, close contact with an infected person increases your chances of becoming infected. This is known to be through respiratory droplets produced during coughing, sneezing, and speaking (1). These droplets are inhaled. It is this known method of transmission that has caused the CDC to promote “social distancing” and “stay at home” as well as “shelter in place” in more effected areas. There is some evidence that it may also be spread by when a person touches a surface with Coronavirus and then touches their face (1) and there is some suggestion that the novel Coronavirus may be airborne (2). These methods of transmission are seeming more likely, causing the CDC to recommend everyone to wear a mask, even one made of cloth (3). Health care workers have been particularly vulnerable: 20% of those Italian healthcare workers who have been exposed to infected patients have contracted the illness (4).

Summary of what you can do:

• Avoid people that are ill

• Social distancing is important

• Avoid public areas, especially those that might be congested

• If you do need to go out, wear a mask, even one made of cloth

• Avoid touching commonly contacted areas in public

• If you are out, avoid touching your face including your eyes, nose and mouth

• When you return from an outing, wash your hands thoroughly

What underlying disease/condition would increase your risk of severe COVID-19 infection?

In a large retrospective study (5), risk of mortality from COVID-19 was addressed in reviewing 191 patients that were admitted to several hospitals in China, of whom 137 were eventually discharged. Of the 54 patients that died in the hospital, 30% had hypertension, 19% had diabetes and 8% had coronary artery disease (heart disease). There was increased odds of death with older age, higher SOFA score (basically, the worse shape your vital organs such as lung, kidney, and liver are in, the worse the score) and high D-dimer (which reflects can reflect increased clotting, tissue damage, and inflammation).

Another small study of 102 patients from Wuhan reaffirms that hypertension, diabetes, and increased age were factors but also points out that other chronic diseases may decrease risk of survival (6). It is thought that patients with hypertension and diabetes may have issues and anecdotally those patients taking the class of drugs known as nonsteroidal anti-inflammatories (NSAIDs) because all of these states increase expression of angiotensin-converting enzyme 2 expression on the surface of cells throughout the body as this is the protein to which Coronavirus binds to enter the cells (7). The hypothesis is that the more efficient entry places these patients at risk.

Because a balanced immune system has been shown to help survival (8) and for this reason, we as physicians are concerned about those patients with a compromised immune system or taking medication that may compromise their immune system. This may be why patients with cancer have been shown to have a higher rate of infection and death. A small study from Wuhan estimated that the infection rate of its cancer patients was 0.79%, compared to those of the general population, who had a 0.37% infection rate over the same time period (9). As well, in that same cohort, 25% of those cancer patients that contracted COVID-19 have died as of March 10, 2020 (9).

Older patients are considered more vulnerable (10, 11)) include people who live in a nursing home or long-term care facility. The estimated fatality rate increases from 0.2% under the age of 40 years old to 14.8% for those over 80. The explanation for this is multi-factorial: older patients are more likely to have one or more chronic risk factors; immune function wanes with age; and older patients are more likely to respond to the infection with a cytokine storm (13). A cytokine storm is an overwhelming immune response in the infected patient in which the immune system overreacts and injures the patient as much or more than the infection.

Men may be especially at risk. Sex-disaggregated data from 14 countries demonstrate that men have a higher rate of death, up to more than double that of women, depending on the country (11, 13) This is at least partially explained by the higher rate of the chronic illnesses and possibly the habits, like smoking and drinking, that place patients at risk for death from COVID-19 (13).

Other patients that are regarded as at-risk (10) include those with chronic respiratory issues including moderate to severe asthma; patients with severe obesity (BMI of 40 or higher); patients with chronic kidney disease or liver disease; patients with HIV; patients that are pregnant; and homeless patients.

We do not know if a pregnant woman can transmit the Coronavirus to her fetus, and we do not know if a woman can transmit the Coronavirus to her baby during breastfeeding (10).

This is an evolving question as those of us in the medical profession have noted that there are patients who have died from COVID-19 with “no known risk factors”.

Summary of people that may be at greater risk:

• Patients with Diabetes

• Patients with Hypertension

• Older patients

• Patients with Chronic Respiratory issues, including moderate to severe asthma and COPD

• Patients with Cancer

• Patients with Immune System issues

• Patients with unhealthy lifestyle habits

• Patients that are obese

• Patients with one or more chronic medical issues, like chronic kidney disease or chronic liver disease

• Patients with HIV

• Patients that are homeless

• Patients that live in a nursing home or long-term care facility

• Patients who are pregnant or breastfeeding

What extra measures should someone with this disease/condition do to protect themselves from COVID-19?

Because approximately 81% of patients have mild disease (14) and because many patients are thought to be asymptomatic or mildly symptomatic when they are most infectious (15), Coronavirus can be spread rapidly.

Coronavirus is spread rapidly from person-to-person and since there is no vaccination or proven protection from a severe course of infection, the CDC recommends avoiding exposure to the virus (3 Their current recommendations (3) are:

• Avoiding close contact by keeping 6 feet away from others

• Washing hands often and well and avoiding contact with your face, eyes, nose and mouth

• Staying home as much as possible

• Covering your mouth and nose when around other people, even with a cloth mask

• Avoiding people that are ill

• Thoroughly covering your mouth and nose when coughing and sneezing

• Washing your hands well after coughing and sneezing

• Cleaning and disinfecting surfaces that may have been touched regularly

Vaccine development is underway. When this happens, hopefully in time for the next wave of Coronavirus, those of us who have not had exposure or who have had questionable exposure and are safely able to take the vaccine, will be able to vaccinate themselves to reduce the rate of severe disease and death. If enough of us are either exposed or able to receive the vaccination, herd immunity will protect those of us in which receiving the vaccination is contraindicated.

How can patients best maintain their health at this time?

• Eat a healthy diet

• Get enough sleep

• Exercise regularly

• Maintain (or strive to achieve) a healthy weight

• Drink in moderation

• Stop smoking

• Manage your stress

• Control of chronic illnesses that could put you at risk (via Telemedicine)

Could any medications associated with underlying condition/disease worsen COVID-19 symptoms?

Because they may increase the chemical that aids in entry of Coronavirus into cells, the FDA warns against using nonsteroidal anti-inflammatory drugs (NSAIDs) (16) but the risk is not clear. It is unclear whether ACE inhibitors and Angiotensin Receptor Blockers affect infection (17, 18). Studies of the effect of all these medications on viral entry are ongoing.

Those patients that are taking drugs that may cause immunosuppression should consult their physicians. In certain cases, those drugs may be necessary to control an already dysfunctional immune system. On the other hand, if the current risk outweighs the benefit and if treatment can be delayed, the patient should discuss pausing or delaying treatment with their physician. As in all of medicine, this balance of risk and benefit is imperative and currently, the medical community is still learning about this infection.

What should I do if I begin developing symptoms of COVID-19?

81% of infections are considered mild (14). Patients with mild illness should be treated symptomatically: rest, keep hydrated, eat a healthy diet and keep as comfortable as possible. For the sake of others, self-quarantine. The current recommendations have been 72 hours after the last symptom disappears (19, 20).

If you need to see your doctor, call ahead. It may be that they will treat you via Telemedicine to avoid exposing non-infected patients. If not, your doctor will have a protocol to reduce the risk that you infect their other patients.

If you are in a household with others, try to isolate yourself to avoid spread; wash your hands regularly; cover your mouth and nose when you sneeze and cough; avoid sharing personal items like toothbrushes; and regularly clean items that you touch (20).

For more severe symptoms, such as shortness of breath, wheezing, chest pain, confusion, bluish lips or face or other respiratory distress, go to the nearest emergency room (19). If at all possible, hospitals are requesting that you call ahead so that you can be isolated. However, as “the surge” approaches, this may not be necessary. Stay tuned in to your favorite hospital as patients that are likely to have contracted COVID-19 may be routed to one hospital and severely ill but non-COVID-19 patients may be routed elsewhere for their safety.

What do I do if I have a chronic lung disease or another chronic illness or cancer?

• Take good care of yourself now

• Avoid contracting the virus

• Avoid those that are sick

• Keep your lung disease or chronic illness as well controlled as possible

If you need help from your doctor or have questions about your medications, as much as possible attempt to use Tele-visits.

Are there any treatments of vaccines or medications available that can cure Coronavirus?

None yet. However, there are 52 vaccines, 33 antibodies, 16 anti-virals, 7 cell-based therapies, 10 treatments for other issues that are being repurposed, 2 discontinued products that are being reviewed, 4 RNA-based therapies and 25 miscellaneous compounds that are currently being investigated (21). So have hope. Management is on the horizon.

REFERENCES:

1. How Coronavirus Spreads. CDC 2019. Link: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html

2. Lewis, D. Is the coronavirus airborne? Experts can’t agree. Nature 2020; published online April 2; doi: 10.1038/d41586-020-00974-w

3. Prevent Getting Sick. CDC 2020. Link: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/index.html

4. Remuzzi, A. and Remuzzi, G. COVID-19 and Italy: what next? Lancet 2020; Published online March 12. doi: 10.1016/ S0140-6736(20)30627-9

5. Zhou, F, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395: 1054-62

6. Cao, Jianlei, et al. Clinical Features and Short-term Outcomes of 102 Patients with Corona Virus Disease 2019 in Wuhan, China. Clin Infectious Dis 2020. Published April 2. doi: 10.1093/cid/ciaa2433

7. COVID-19 Brief. Bios Research. Updated April 3, 2020. Link: biosres.com.

8. Thevarajan, I, et al. Breadth of concomitant immune responses prior to patient recovery: a case report of non-severe COVID-19. Nature Medicine 2020; doi: 10.1038/s41591-020-0819-2

9. SARS-Cov-2 Transmission in Patients With Cancer at a Tertiary Hospital in Wuhan, China. JAMA Oncology 2020. Published online March 25. Link: https://jamanetwork.com/journals/jamaoncology/fullarticle/2763673

10. People Who Need Extra Precautions. CDC 2020. Link: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/other-at-risk-populations.html

11. Age, Sex, Existing Conditions of COVID-19 Cases and Deaths. Worldometer 2020. Updated February 29. Link: https://www.worldometers.info/coronavirus/coronavirus-age-sex-demographics/

12. Why Covid-19 is so dangerous for older adults. Vox 2020. Published online March 12. Link: https://www.vox.com/2020/3/12/21173783/coronavirus-death-age-covid-19-elderly-seniors

13. Sex, gender and COVID-19. GlobalHealth5050. Reviewed April 4, 2020. Link: http://globalhealth5050.org/covid19/

14. Guan, W-j, et al. Clinical characteristics of Coronavirus Disease 2019 in China. N Engl Med 2020; published February 28; doi: 10.1056/NEJMoa2002032

15. Wolfel, R, et al. Virological assessment of hospitalized patients with COVID-19. Nature 2020; published online April 1; doi: 10.1038/s41586-020-2196-x

16. FDA advises patients on use of non-steroidal anti-inflammatory drugs (NSAIDs) for COVID-19. FDA 2020; Link: https://www.fda.gov/drugs/drug-safety-and-availability/fda-advises-patients-use-non-steroidal-anti-inflammatory-drugs-nsaids-covid-19

17. Vaduganathan, M, et al. Renin–Angiotensin–Aldosterone System Inhibitors in Patients with Covid-19. N England J Med 2020; published online March 30; doi: 10.1056/NEJMsr2005760

18. Angiotensin-Converting Enzyme 2 and Anti-Hypertensives (Angiotensin Receptor Blockers and Angiotensin Converting Enzyme Inhibitors) in Coronavirus Disease 2019 (COVID-19). Mayo Clin Proceedings 2020; published online March 30; link: https://els-jbs-prod-cdn.jbs.elsevierhealth.com/pb/assets/raw/Health%20Advance/journals/jmcp/jmcp_ft95_3_5-1585588116123.pdf

19. What to Do if You are Sick. CDC 2020. Link: https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html

20. Steps to help prevent the spread of COVID-19 if you are sick. CDC 2020. Link: https://www.cdc.gov/coronavirus/2019-ncov/downloads/sick-with-2019-ncov-fact-sheet.pdf

21. COVID-19 Treatment and Vaccine Tracker. Milken Institute. Accessed April 4, 2020. Link: https://milkeninstitute.org/covid-19-tracker