COVID-19 Update Jean Siebenaler MD, MPH July 22, 2020
Jean Siebenaler MD, MPH u Navy veteran (USNR Medical Corps); u Retired board-certified family physician with over 20 years experience; u Over 15 years experience in the design and management of epidemiology research studies; u Lives with husband and dog in Milton on Blackwater Bay since 2008. u Member of UUCP since 2019
Why This Talk? u We are now 5 months into experiencing the most significant medical crisis since the Spanish Flu Pandemic of 1918; u There is a daily deluge of overwhelming amounts of media reports and misinformation about this virus; u Consequently, it is hard to know who or what to believe.
We went from disbelief in March to ………………………………
Roller Coaster Ride – July 21, 2020
How Should We Deal With Our Emotions?
u Data is knowledge u Knowledge is power
We have learned a lot but…
COVID-19 Demographics & Disease Course
Coronaviruses: viruses that cause illnesses such In December 2019, a as: the common cold, novel new Coronovirus severe acute respiratory was discovered in a syndrome (SARS), and disease outbreak in Middle East respiratory China. syndrome (MERS) COVID Virus Terminology The virus was named The disease it causes the severe acute was named coronavirus respiratory syndrome disease 2019 coronavirus 2 (COVID-19) (SARS-CoV-2)
*July 21, 2020 case fatality rate in US = 3.7 % and is decreasing with increased testing and finding more cases that survive.
Risk of COVID Severity by Age – July 22, 2020
COVID Incubation Period u Median time = 4-5 days from exposure to symptom onset u Extends to 14 days u One study reported 97.5% of persons with COVID-19 develop symptoms within 11.5 days of exposure u Length of the incubation period is a major factor in COVID’s high rate of infectiousness u For comparison – influenza incubation period is only 1-4 days
Illness severity can range from mild to critical: u Mild to moderate (mild symptoms up to mild pneumonia): 81% u Usually managed at home u Severe (dyspnea, hypoxia, or >50% lung involvement on imaging): 14% COVID-19 u Usually managed in the hospital non-ICU ward Clinical Severity u Median time from exposure to hospitalization = 7-10 days u Critical (respiratory failure, shock, or multiorgan system dysfunction): 5% u Median time from exposure to ICU admission = 10-12 days u Mortality rate in the ICU = 39-72%
Conditions assoc. with the highest COVID severity at any age (CDC 6/25/2020) CHF , CAD COPD Solid Organ Transplant Diabetes II Obesity (BMI > 30) Most common risk factor < 55 years old Chronic Kidney Failure Sickle Cell
Florida COVID Race & Ethnicity July 22, 2020 u According to the 2010 census, racial distributions in Florida are as follows: u 77.3% White (53.5% Non-Hispanic White), u 16.9% African American (includes Afro-Caribbeans), u 25.6% Hispanic or Latino (of any race).
Why the Racial & Ethnic Disparities? u High prevalence of pre-existing medical conditions u Diabetes, hypertension, kidney disease, asthma, obesity, others u Live in more multi-generational households u Unjustly over-represented in jails, prisons, and detention center hotspots u Represent a high percentage of service industry workers (e.g., NH/ALF staff, grocery clerks, postal carriers, agriculture industry, bus drivers, etc.) u Jobs more likely to lack paid sick leave or health insurance u Jobs more likely to be low wage with greater inability to afford health insurance copays that impede access to health care u Workers more likely to use public transportation to access jobs u Long histories of medical bias in health care prior to pandemic u Anecdotal reports of COVID symptom dismissal, refusals to test, ER discharges instead of hospitalizations u Systemic racism contributes to lifetime ravages of chronic stress and immune suppression, with subsequent negative health effects of susceptibility to diseases.
COVID-19 Symptoms
COVID-19 Presenting Symptoms Fever (83-99%) HA, sore throat, Cough (59-82%) N/V/D (<10%) Shortness of breath or difficulty Myalgias (11-35%) breathing (31-40%) Sputum production Fatigue (44-70%) (28-33%) Anorexia (40-84%)
u Vascular (i.e., arterial and venous blood clots); u Neurological (i.e., strokes, confusion, impaired consciousness, poor motor control, numbness/tingling of extremities, paralysis, delirium, hallucinations, loss of taste/smell); Development u Abdominal pain and bowel infarctions; u Cardiovascular (i.e., angina, myocardial infarctions, of Multisystem heart failure, dysrhythmias) COVID-19 u Liver and kidney dysfunction; u Skin rashes Symptoms u Conjunctivitis u Every organ can be affected because every organ is vascularized
Hyperinflammation Leads to activation of the blood clot u pathway and arterial inflammation Cytokine storm u u Cytokines are inflammatory immunologic proteins that are supposed to fight off infections, but they sometimes go out of control u Symptoms include high fever, enlarged spleen, excessive bleeding, low counts of all types of blood cells (red, white and platelets) and, potentially, multiple organ failures leading to death u Cause is unknown
14 cases in Florida – July 22, 2020 (ages 2-17) Pediatric Multisystem Inflammatory Syndrome
u COVID-19 virus is related to the Severe Acute Respiratory Syndrome (SARS) virus, which was epidemic in 2003 primarily in Asia. u SARS survivors have been studied and many show long-term suffering and poor QOL >10 years. Survivors of u Impaired lung function u Poor immunity with susceptibility to common COVID-19 -– infections u Chronic fatigue u Higher incidence of cardiometabolic and Many unanswered neurologic disorders u Given COVID-19 prevalence, we may see chronic questions health problems for many years in hospitalized survivors, with a heavy impact on our health care systems u We will be studying and learning about COVID-19 survivors for a long time.
COVID-19 Infectiousness
u USS Roosevelt -- >60% of the crew who tested positive were asymptomatic. u Iceland tested 6% of its population (the highest per COVID-19 capita globally) and found that 43% of those who tested positive were asymptomatic. Asymptomatic u A 2-week study of almost all pregnant women in two NYC hospital Labor and Delivery wards found that Spread a Major 88% of test-positive patients had no symptoms. Problem u As mass testing expanded in prisons , large numbers of inmates showed no symptoms. In four state prison systems — Arkansas, North Carolina, Ohio and Virginia — 96% of 3,277 inmates who tested positive for the coronavirus were asymptomatic.
Asymptomatic vs. Pre-symptomatic COVID-19 u Asymptomatic u Never develop any symptoms u Degree of infectiousness under debate u Pre-symptomatic u More common u Peak infectiousness time u Symptoms that develop may be very mild (e.g., body aches, fatigue, sniffles) u Lumped under the label of “asymptomatic”
US COVID-19 Transmission Risk in Indoor Crowded Places
u Superspreader events typically involve indoor gatherings with many people (e.g., weddings, funerals, church services, restaurants, work environments, exercise classes, etc.) u New research finding that ~10-20% of Importance of infected people are responsible for ~80% of cases. Super-spreader u Associated with the 3 Cs: Events u Close contact u Crowded u Closed space u 4 th C -- Continuous exposure
Indoor Church Choir March 10, 2020; state of Washington u 2.5-hour choir practice with 61 u members, one of whom was sick for a few days with cold symptoms u Choir median age = 69 u Only 1/3 with pre-existing conditions Members avoided physical contact but u were <6 ft apart, singing, snacked on cookies and oranges, put away stacked chairs together when done 32 confirmed cases and 20 probable u COVID-19 cases Developed symptoms 1-12 days after u exposure 3 patients hospitalized; 2 deaths u
Indoor Restaurant Outbreak u Sketch showing arrangement of restaurant tables and air conditioning airflow at site of COVID outbreak, Guangzhou, China, 2020. u Yellow-filled red circle indicates index case-patient who was asymptomatic and spent 1-1.5 hr dinner with 9 friends. u Red circles indicate seating of future case-patients. Lu J, Gu J, Li K, Xu C, Su W, Lai Z, et al. COVID-19 outbreak associated with air conditioning in restaurant, Guangzhou, China, 2020. Emerg Infect Dis. 2020 Jul [ date cited ]. https://doi.org/10.3201/eid2607.200764
Indoor Call Center Outbreak u Over a week, 94 of 216 employees on 11 th floor in S. Korean call center became infected (blue chairs); mostly one side of office u Estimates were that 94% of infections were from respiratory droplets/respiratory exposure, and 6% from fomite transfer (door handles, shared water coolers, elevator buttons, etc.) u Example of being in enclosed space, sharing same air for prolonged period increases chances of exposure and infection. Park SY, Kim YM, Yi S, Lee S, Na BJ, Kim CB, et al. Coronavirus disease outbreak in call center, South Korea. Emerg Infect Dis. 2020 Aug [ date cited ]. https://doi.org/10.3201/eid2608.201274
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