Blog: Health Matters

NOTE: SARS-CoV-2 is the virus and COVID-19 is the disease caused by it.

Q. Does SARS-CoV-2 just infect the respiratory tract and lungs, like influenza?

A. Patients in China were initially presenting with an unusual pneumonia (characterized by a ground glass appearance on CAT scans) so it was initially thought to be a purely respiratory illness. Now it is known that the virus, in at least some patients, can infect or impact almost every organ in the body. 

• It can have serious effects on the lungs, and in some patients, this requires their blood to be oxygenated outside the body (with a heart-lung machine) since the ability to absorb oxygen through the lungs is lost;
• It can infect immune cells, making it harder for the immune system to fight the virus. In some patients it seems the immune system goes into overdrive and the resultant cytokine storm leads the patient to deteriorate quickly and possibly die;
• It can affect clotting factors that act on red blood cells, causing blood clots to form. Many patients who died of COVID-19 were later found at autopsy to have blood clots throughout their lungs and elsewhere in the body. More recently, a number of cases involving young and healthy adults who had sudden strokes due to cerebral blood clots have been noted; while all these patients were found to be infected with COVID-19, many of them did not know they were infected and had few or no other symptoms.
• In late stages it can lead to major organ failure (kidney, liver, heart), which can lead to death.

Q. Are there successful treatments for COVID-19? I’ve heard a lot about hydroxychloroquine (or chloroquine); what about that?

A. Hydroxychloroquine is an anti-malarial drug that is also prescribed for patients with lupus and rheumatoid arthritis. The short answer is that there is no evidence that these drugs provide benefit for treating COVID-19 and may actually cause harm. Additional ongoing studies should provide a definitive answer.

• There was a French paper describing the benefit from using it for COVID-19, however that was a small study (20 patients) with no control group (placebo control), therefore must be considered “anecdotal” as it doesn’t “prove” the benefit. 
• (Hydroxy)chloroquine cannot be considered “safe” for all people since it causes cardiac arrhythmias in some, which can lead to sudden death. 
• Ongoing studies in various countries will provide additional data.

Q. Well what about Gilead’s drug remdesivir?

A. Remdesivir is an antiviral agent originally developed for Ebola (it didn’t work in those clinical trials). Many studies with COVID-19 are ongoing, and there is some hopeful data emerging.

• Hospitalized patients who were severely ill were administered remdesivir for 5 or 10 days. The clinical outcomes were encouraging, as more than half the patients were discharged within 2 weeks. 
• Based on the encouraging early  data, the FDA has approved remdesivir for emergency use in the US. Additional ongoing studies could confirm the encouraging results.
• The studies so far were only in very sick patients, so it is unknown whether treating patients earlier might prevent them from becoming severely ill in the first place.

Q. What is the latest on how people get infected? How do I protect myself?

A. We are learning more about this virus every day.

• Originally it was thought to be transmitted primarily via respiratory droplets when symptomatic infected people sneeze or cough.
• Now it is known that up to 50% of infected people are asymptomatic but can still infect other people, through sharing air while talking and breathing. This is the reason for the 1.5 or 2 meters (5-6 feet) distancing rule. If an infected person wears a cloth mask, they can reduce the amount of virus in the air around them as well as the distance it goes. This is why some cities are demanding face masks be worn at all times in public, or in other cities when social distancing can’t be respected (public transportation).
• It is also possible to infect others by touching surfaces that then transmit virus to the hands of others, and they can infect themselves if they touch their face. The virus can live on surfaces for 1 to 4 days (generally longer on shinier surfaces). For this reason, constant hand washing or use of hand sanitizer gels should continue.
• Asymptomatic spreading of infection is why we now need to behave as if everyone is potentially infected, including ourselves. 
• Packages and groceries should be handled as if potentially contaminated on their surfaces with virus. If you can just put it aside for 3 days, that is the easiest and safest way to do it. Putting a package into the sunlight may speed up the rate of virus death. Heat also kills the virus (wash your mask at 60C and use the dryer) but the freezer will preserve it. If packages can be sprayed with disinfectant, that will also kill the virus within a few minutes. More on handling groceries below.

Q. I hear of two different types of tests. What’s the difference?

A. One test detects the virus itself, the other detects antibodies that the person developed while they were infected.

• The first type of test is conducted using a nasal swab taken from the back of the nasal cavity. It involves a method called PCR (polymerase chain reaction) and detects the RNA of the virus so it will only be positive in people who are actively infected. Once the person recovers, this test should be negative. 
• The second newer type of test is a serology test (conducted on blood, often just from a finger prick) and it detects antibodies that the person’s immune system develops during the infection. These antibodies should be present within 2 weeks of infection and should last for months, even after the person has fully recovered, so it can identify people who have been infected in the past. To date, many of the antibody tests developed do not work well, possibly giving false negatives.

Q. Many governments are starting to ease up on stay-at-home orders. Does this mean it is safe to go about life as before now?

A. No. Governments must strike a balance between public health and economic health, so easing of stay-at-home orders does not mean the risk is gone. What it means is that the infection rate is low enough that hospitals can cope with the cases that will occur. There is no way governments can guarantee safety for any individual – as a matter of fact they expect people will still get sick, but just in manageable numbers..

• Most governments will try to get at least some people back to work as early as possible as societies still have to function, and people need salaries to live. 
• Relaxation of lock-down rules may be considered when the infection rate is equal to or less than 1 (in other words, on average each infected person ends up infecting only 1 other person, so the total number of infections doesn’t skyrocket, as was seen early in the pandemic.
• To have an infection rate (also known as a reproduction rate, or R value) of less than 1 requires a high level of testing, rapid contact tracing, and quarantine for anyone infected or in contact with an infected person. Countries that do not have sufficient testing and contact tracing capabilities in place are taking a risk of a second wave, which could be worse than the first.

Q. If I think I have been exposed, is 14 days self-isolation enough?

A. Usually. The vast majority of people develop symptoms (if they are going to) within 2 to 10 days of exposure (average about 5 days). It appears that in rare circumstances a person may incubate for up to 29 days before showing symptoms. While most countries use 14 days as a standard quarantine period, some have increased it to 21 or more days to account for these outliers.

Q. If I have been infected and recover, does that mean I can’t get it again?

A. This is uncertain. At present it is unknown what type of immune response is required for protection, and how strong and long-lasting that response needs to be.

• For many viruses, having the infection once will provide long-term immunity against a second infection. However, if the virus mutates readily, as is the case with influenza, then prior infection will not prevent another infection with a subsequent exposure influenza, although the severity of the symptoms may be less. SARS-CoV2 does not seem to mutate as rapidly as influenza viruses, so recovering from infection may provide protection.
• Some people who tested negative after recovering from COVID-19 then test positive again later. This does not necessarily mean they were re-infected as it is now known that some people still have active virus deep in their lungs, but not in their throat where the swab is taken, so in fact they were never truly negative.
• Another factor to consider is that some people who have recovered from COVID-19 have no or only very low levels of antibodies. This might suggest that they won’t be adequately protected with a subsequent exposure, but it is possible the antibody assay used was flawed (many of the new tests are flawed).

Q. Does obesity play a role in getting the COVID-19 infection?

A. Obese people often have co-morbid conditions (e.g., high blood pressure, atherosclerosis) that can raise the risk of developing severe disease or death with COVID-19. 

Q. Why are death rates in men greater than in women with COVID-19 infections?  

A. The short answer is we don’t know, but this is not the first infectious disease where men fare more poorly than women

• This was first noted in China, where it was thought that it may be linked to smoking, since the majority of older men in China have smoked most of their lives while the majority of older women have not. 
• However, this has now been observed in most countries around the world, and the death rate for men can be up to 3-times higher than in women. 
• Women have better immune responses and die less of infectious disease their entire lives and vaccines also work better for women than for men. This appears to be linked to genetics, especially those related to sex hormones (estrogen and progesterone in women, testosterone in men).
• Trials are underway to see if treating men with female sex hormones can be beneficial in fighting the virus.

Q. Why are ethnic minorities in the US more susceptible in getting SARS-CoV-2 and dying from COVID-19 infection?

A. There are many contributing factors, but most of them come down to financial and social inequality. Ethnic minorities are more likely to be poor, which may result in:

• A life-long inadequate or poor diet, which results in weaker immune system and comorbid conditions such as diabetes and heart disease.
• Living and working in environmentally poor areas with increased exposure to toxins, which can affect the immune system. For example, their neighborhoods are more likely to be next to landfill or industrial waste sites, and many work in industry with daily exposure to dangerous compounds.
• Living in crowded conditions makes it more likely that they catch the virus.Inadequate or no health care insurance, which may make them hesitate to seek medical help until very late. Also, language issues can result in poorer health care due to communication issues.
• It is possible there are also racially determined genetic factors as well as cultural factors (e.g., more resistant to wearing masks, can’t stop seeing the extended family even under lock-down conditions etc).

Q. Is this virus going to go away in the hot summer months?

A. This is unknown for certain but is unlikely. 

• Influenza is a seasonal virus that peaks during the colder winter months and largely disappears during the summer months, but not all viruses have seasonality.
• At present it is unknown whether SARS-CoV2 will have seasonality, but evidence that it won’t comes from rapid spread in the Southern Hemisphere (Australia, New Zealand) during their summer or equatorial countries (Singapore), where it is hot all year.
• The virus may reduce during the summer, even if only because of the lock-down orders in place in many countries (not because of the weather).
• While we cannot count on the virus disappearing in the warmer summer months, if it does, then a second wave might be expected around November in the Northern Hemisphere.
• We need to accept that this virus is not going to just disappear. Once a vaccine is available, it should be greatly diminished, but it is possible that it will continue to circulate for years, like influenza.

Q. If I wear contact lenses, does that increase my risk of infection?

A. While the eye can be a site where the virus enters the body, it is not thought to be a primary route – the nose or mouth are more likely sites. In any event, wearing contact lenses per se should not increase your risk compared to someone who doesn’t have contacts or glasses. However, it is critical to wash your hands extremely well before inserting or removing your lenses, as your fingers could be contaminated. Wearing glasses may offer some protection from aerosolized virus getting in the eye, and may stop the wearer from touching their eyes.

Q. Is there a risk that my groceries can be contaminated and pass the virus to me?

A. Experts say that the risk of infection from your groceries is very low and that no special handling of groceries is required beyond washing your hands before and after. However there is no definitive data on this exact question and it is possible that another shopper sneezed or coughed on the food that you bought. Remember that the virus can live on cardboard for about 1 day and on shiny surfaces for up to 3 days, and while heat kills the virus, cold does not (a freezer will actually protect it). So if you want to be prudent, here are some helpful tips:

• Ideally you have a place outside your kitchen where you can sort your groceries (garage, laundry room), so that you don’t spread viruses around your kitchen. If you don’t, then mark a section of counter that can be contaminated, and make sure you disinfect that area well when you are done. 
• Wear latex gloves and wash or sanitize your gloves regularly as you work.
• Items that can be left at room temperature for 3 days can just be put somewhere out of the way, then unpacked once the 3 days is up.
• Items in plastic or cardboard packaging (e.g., mushrooms, green beans, carrots) can be opened and the contents dumped into clean bowls or other containers that you placed nearby before you touched your groceries. Make sure you don’t touch the contents as you dump. If for environmental reasons you typically avoid buying produce in plastic wrap, bags or containers (example: broccoli, carrots, tomatoes, mushrooms) you may want to make an exception during the pandemic.
• Items in bottles, jars, cans, etc. can be sprayed with disinfectant (example Lysol, Dettol), let dry, then rinsed in water.
• Solid fruits and vegetables (apples, eggplant, avocado, zucchini) can be dumped into a tub of soapy water (use dish soap), allowed to soak for several minutes, then rinsed well and allowed to dry.

Q. What is the best way to use cloth masks and sanitize them? 

A. Remember that masks are worn to protect others from infection in the event that you are infected, even without symptoms. Therefore, if you are infected, any mask you wear will have a lot of virus deposited on it from your breathing. To avoid contamination of others, masks should be handled correctly and only worn once before washing.

• The mask should cover your nose and mouse and fit under the chin.
• After use, remove the mask touching only the tie straps or the ear loops and drop it directly into the laundry basket. If you are out when removing your mask, for example after shopping, drop the mask into a plastic bag. If you drop it directly into your purse it may contaminate other objects in your purse, which could lead to spreading the virus to others.
• Wash in hot water (60 °C) and ideally also put in the dryer since heat destroys the virus.

Q. I still have trouble finding alcohol-based sanitizing gels. What can I use instead? Can I replace it with essential oils?

A. Essential oils will not kill virus – it is critical you use an alcohol-based product with at least 60% alcohol content (per CDC).

• If you find a hand gel with less than 60% alcohol, you can buy rubbing alcohol and add some to the gel to raise the alcohol level.
• You can also make your own hand gel with this recipe:
  • Mix 2 parts isopropyl alcohol or ethanol (must be 91-99%) with 1 part aloe vera gel and add a few drops of essential oil (clove, peppermint etc) or lemon juice. Whisk until well blended. Store in a clean jar or other container.
  • Make sure your hands and utensils are clean. Also have a clean work surface, which can be wiped down with diluted bleach.