12/05/2020
Hello All,
Well then, l hope you’re all taking good care of yourselves, your loved ones, and looking out for your friends and others while under siege from this virus. I was standing by the window in my lounge room the other day - gazing out at nothing in particular, thinking about how global economies will fare post COVID-19 - when it suddenly occurred to me - what with all the information currently available and disseminated about the COVID-19, just how many folks out there are still confused and in the dark - mainly due to the medical speak and technical jargon surrounding this virus. So l set out to do some research that spoke to me in a language setting that l was comfortable with and could understand - and l came across this Question & Answer section from the John Hopkins Bloomberg School of Health. I hope it will go some way in helping you gain a better awareness of this virus.
CORONAVIRUS: THE BASICS
What is a coronavirus?
Coronaviruses are a family of viruses that typically cause mild respiratory infections like the common cold but also more severe (and potentially deadly) infections. They are zoonotic diseases, meaning they are transmitted from animals to people.
SOURCE: Global Health NOW, April 6, 2020
Why is it called a coronavirus?
Coronaviruses are named after the Latin word corona, meaning “crown” or “halo,” because they have “crown-like spikes on their surface,” according to the U.S. Centers for Disease Control and Prevention.
SOURCE: Global Health NOW, April 6, 2020
What severe diseases are caused by coronaviruses?
A coronavirus that originated in China led to the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003. Another coronavirus emerged in 2012 in Saudi Arabia, causing Middle East Respiratory Syndrome (MERS).
SOURCE: Global Health NOW, April 6, 2020
What’s the difference between coronavirus and COVID-19?
The novel coronavirus responsible for this outbreak is known as SARS-CoV-2. The illness caused by the virus is called COVID-19.
More information can be found here: Naming the coronavirus disease (COVID-19) and the virus that causes it—WHO.
SOURCE: Global Health NOW, April 6, 2020
What symptoms do coronaviruses typically cause? How severe are the symptoms in the current outbreak?
Common signs of infection include runny nose, cough, fever, sore throat, and shortness of breath. In more severe cases, infection can cause pneumonia, severe acute respiratory syndrome, kidney failure, and even death.
SOURCE: Global Health NOW, April 6, 2020
Does the virus affect the sense of taste?
It’s been a reported phenomenon that an important minority of people have lost the sense of smell or taste.
SOURCE: Tom Inglesby, April 17, 2020
Why does COVID-19 cause shortness of breath?
COVID-19 can cause damage to the lungs that impedes their ability to remove oxygen from the air. A lot of patients develop what’s known as severe acute respiratory distress syndrome. And they really benefit from having additional oxygen, particularly in hospital settings.
SOURCE: Jennifer Nuzzo, March 20, 2020
Is the loss of smell an early coronavirus indicator?
A temporary loss of smell is relatively common among people who have coronavirus and could be added to a checklist of symptoms to determine whether someone should consider themselves infected. It is not, however, a universal feature of coronavirus infection.
SOURCE: Josh Sharfstein, April 6, 2020 (via City Leadership Initiative)
Even for people who are mildly ill or moderately ill, they may have some degree of impact on their lungs that could cause shortness of breath. Is that right?
Correct. We’re seeing viral pneumonia in patients who don’t even feel that sick.
SOURCE: Jennifer Nuzzo, March 20, 2020
When and how should I seek medical attention?
Via the CDC:
If you develop any of the following emergency warning signs for COVID-19, get medical attention immediately by calling your doctor's office. Emergency warning signs include (but are not limited to):
Trouble breathing
Persistent pain or pressure in the chest
New confusion or inability to arouse
Bluish lips or face
SOURCE: Global Health NOW, April 6, 2020
How are coronaviruses transmitted between people?
Coronaviruses are typically transmitted from person to person through exhalation of respiratory droplets (from the nose and mouth) and close contact. People can contract COVID-19 if they breathe in droplets from an infected person who coughs or exhales droplets. Those droplets can also land on objects and surfaces, and people can then catch the virus from touching those surfaces and then touching their eyes, nose, or mouth.
SOURCE: Global Health NOW, April 6, 2020
What is known about young children and whether they are carriers and can transmit the virus?
Young children can be infected—this has been established by data from China. The data suggests that in some cases they can get quite ill—particularly infants. In general, children are not falling ill as frequently as older adults are, but the virus absolutely affects children
SOURCE: Josh Sharfstein, April 15, 2020 (via City Leadership Initiative)
What percentage of the population will become infected with COVID-19?
It is difficult to estimate what percentage of the U.S. population will become infected with COVID-19. However, some researchers have made educated guesses. Modeling work is based on many assumptions about infection transmissibility, population characteristics, effectiveness of policy measures, etc.—changing these assumptions changes the estimates. Some estimates put the total U.S. population that would be infected during the pandemic without intervention at between 20-60%. A modeling analysis published from the Imperial College of London predicted that in the absence of control measures and changes in individual behavior, 81% of the U.S. population would become infected.
SOURCE: Josh Sharfstein, March 26, 2020 (via City Leadership Initiative)
Of those infected, what percentage will require hospitalization? And what percentage will require care in an intensive care unit (ICU)?
Data from China show that about 20% of patients diagnosed with COVID-19 required hospitalization. Note that this is not quite the same as the percentage of all people infected, as there may be people infected who are never diagnosed. People over 60 and who have other health problems are more likely to be hospitalized. In each state or city, the percentage of people requiring hospitalization will depend on the percentage of the general population that is over 60 and who have other health problems. Without a major flattening of the curve, the number of seriously ill patients requiring intensive care unit services will exceed the health system’s capacity.
SOURCE: Josh Sharfstein, March 26, 2020 (via City Leadership Initiative)
Are there different “species” of coronavirus like there are for Ebola?
Among the thousands of samples of the long strand of RNA that makes up the coronavirus, 11 mutations have become fairly common. But as far as we know, it’s the same virus infecting people all over the world, meaning that only one “strain” of the virus exists.
SOURCE: Peter Thielen, Johns Hopkins Applied Physics Laboratory, April 16, 2020
What does this mean for a vaccine?
There are a number of scientific questions related to the vaccine. In general, manufacturers are trying to develop vaccines to parts of the virus that are conserved and not likely to mutate significantly.
SOURCE: Josh Sharfstein, April 6, 2020
When people are asymptomatic, can they spread the virus?
Yes. This virus has been very hard to control, which suggests asymptomatic transmission, and there have been a number of studies documenting asymptomatic transmission. That’s one reason why you should stay home if someone in your household may have coronavirus infection.
SOURCE: Josh Sharfstein, March 19, 2020 (via City Leadership Initiative)
How long is an asymptomatic carrier shedding the virus? Can they have it for life, like the herpes virus?
There is no evidence of long-term shedding of virus. Herpes virus is a very different virus.
SOURCE: Josh Sharfstein, April 6, 2020
What does “recovered” mean?
The CDC advises:
If you do not have a test to determine if you are still contagious, you can leave home after these three things have happened:
You have had no fever for at least 72 hours (that is three full days of no fever without the use of medicine that reduces fevers), AND
other symptoms have improved (for example, when your cough or shortness of breath have improved), AND
at least 7 days have passed since your symptoms first appeared
SOURCE: Josh Sharfstein, April 6, 2020
What is the possibility of reinfection after you have recovered from COVID-19?
It is expected that there will be a low possibility of reinfection, but this is not known yet for sure. There are some reported cases of reinfection. Researchers are working to understand how best to measure immunity using tests of the antibody response.
The virus could mutate and come back like flu does, but in that case, it is unlikely to cause illness as severe as the first infection in someone who has previously been infected.
SOURCE: Josh Sharfstein, April 6, 2020
Is there a difference between hospital-acquired COVID and community-acquired COVID?
We know from infectious disease in general that the higher the inoculum size—or the higher the number of doses of particles that you get and the higher amount of virus you might be exposed to at one time—corresponds with more serious disease.
But in reality, we have no idea what our exposure actually is. In theory, if you are working in a hospital and doing procedures where you generate a lot of virus—like intubation, where a lot of virus can be expressed into the air—it’s possible to get a very high dose and pretty serious illness.
Still, we have not seen large distinctions between the severity of disease in health care workers vs. the severity in the community. What we are seeing is age and underlying conditions affecting severity, with the exception that some healthy young people on occasion get serious or even fatal illness.
SOURCE: Tom Inglesby, April 17, 2020
Is there evidence of a heightened risk to pregnant women?
So far, we haven’t seen any particular data that pregnant women are at greater risk. However, there is significant concern that this may be the case.
SOURCE: Josh Sharfstein, April 15, 2020
What is known about how this virus responds to warm weather and the potential for “seasonality?”
A recent paper by the National Academies of Sciences, Engineering, and Medicine concluded that “changes in weather alone will not necessarily lead to declines in cases without extensive public health interventions,” citing, among other factors, the current rapid spread of the virus in Australia and Iran and the lack of evidence for seasonality in other serious coronaviruses (those causing SARS and MERS). Even if warmer weather weakens the virus, the lack of immunity in the general population will ensure its continued spread. There is no reason at the moment for mayors to expect that warmer weather will slow the virus’ spread.
SOURCE: Josh Sharfstein, April 11, 2020 (via City Leadership Initiative)
RELATED: COVID-19: Immunity and Seasonality, March 30, 2020
There have been more cases in the northern hemisphere than the southern hemisphere. What does that mean?
The testing capacity in the northern hemisphere is much higher than in the southern hemisphere, particularly in Sub-Saharan Africa. It’s also possible that the number of travelers between China and the U.S., or China and Europe was greater. This will go away over time as a variable, but it may have made a difference in numbers in the beginning.
It doesn’t appear that any country is more immune or that a different environment will protect them from this virus.
SOURCE: Tom Inglesby, April 17, 2020
VULNERABLE POPULATIONS
Are some groups at a higher risk for severe COVID-19 illness?
Available information suggests that the following are at a higher risk for severe illness from the virus:
People 65 years and older
People living in a nursing home or long-term care facility
People with chronic lung disease or moderate to severe asthma
People with serious heart conditions
People who are immunocompromised (including those undergoing cancer treatment, bone marrow or organ transplantation, those with immune deficiencies, poorly controlled HIV or AIDS, smokers, and those with prolonged use of corticosteroids or other immune-weakening medications)
People with severe obesity (body mass index [BMI] of 40 or higher)
People with diabetes
People with chronic kidney disease undergoing dialysis
People with liver disease
SOURCE: CDC, April 2, 2020
RELATED: Coronavirus and Underlying Conditions, March 20, 2020
Are there options for supporting seniors who don’t have online access for getting groceries delivered?
Look for ways to identify at-risk people and get groceries delivered to their homes. If they have to go out, they should be social distancing in the grocery store and practicing hygiene. The handles on shopping carts, for example, are potentially a source of infection even if the store is empty.
SOURCE: Josh Sharfstein, March 19, 2020 (via City Leadership Initiative)
Should people on immunosuppressive drugs stop taking their medications?
They should talk to their doctors. There are different kinds of drugs, and people are on them for different reasons. Some doctors may think the risk benefits suggest they should stop and some will say to continue the medication.
SOURCE: Tom Inglesby, April 17, 2020
Will people who are on these drugs or who have immunosuppressive conditions be stuck at home much longer than others who may be able to come back out when restrictions lift?
It depends on what the underlying condition is. There may eventually be more information about which underlying immunosuppressant conditions put people at higher risk.
It also may depend on geography. In some areas of the country, the incidence of disease may be low enough that the risk of going out is also relatively low.
For the time being, anyone in this category should consider themselves to be at higher risk and should be very careful about any social interaction outside of their home.
SOURCE: Tom Inglesby, April 17, 2020
TESTING
When is testing important?
Testing is particularly important for people who are seriously ill. Knowing the diagnosis is important for clinical care, allows health care workers to protect themselves, and is necessary for research into treatments.
For people who are mildly or moderately ill, testing can help assure that they isolate themselves and alert people they have come in contact with of the potential need for quarantine. By quickly identifying individuals who are sick and isolating them, public health authorities can reduce the spread of the novel coronavirus.
To assure both that tests are available for those who need them and that the health professionals are prepared to do the test safely, adequate safety equipment is essential. Not every clinic or medical office will conduct the testing. Physicians and public health authorities should direct people to where they can be tested. Given the limited availability of testing, there is much less urgency to test people who are feeling well.
Also, wherever possible, people should not just show up at emergency departments for testing, in order to reduce the demand on hospitals as well as to protect themselves and others. It is much better to call ahead, determine that testing is appropriate and available, and follow instructions on where and when to go.
SOURCE: Tom Inglesby, March 14, 2020
RELATED: National Coronavirus Response: A Roadmap to Reopening, March 29, 2020
What does testing tell us about the rate of mortality and spread of the virus?
Variations in mortality rates across the world reflect many factors, including the age group most affected, preexisting medical conditions, and the rate of testing. In addition, mortality rates are difficult to determine early in the outbreak because most people are still in the midst of their illness. Mortality estimates that include those people who do not have an outcome yet will undercount the mortality rate. In the absence of widespread testing or understanding of the overall attack rate, mortality rates will appear higher than they actually are in areas with widespread testing because those with milder illness will not receive tests and will not be counted.
SOURCE: Josh Sharfstein, April 8, 2020 (via City Leadership Initiative)
Why aren’t there enough tests available and will this change?
The major limiting factors are insufficient reagents [the substances used in chemical analysis], swabs, and protective equipment. These shortages are being addressed and more tests are becoming available.
SOURCE: Josh Sharfstein, April 15, 2020
Why are there reagent shortages that are impacting testing?
It is unclear why these shortages are occurring, but there appears to be a lack of critical supplies needed to deploy the current tests. Addressing these potential shortages and preventing other potential issues that may limit access are urgent priorities.
SOURCE: Tom Inglesby, March 14, 2020
Is the current spike in cases a result of increased testing or because the virus is still spreading? When can we expect to see the curve flatten?
We don't know for sure. If you’re increasing testing, you'll find more positives, but that may not be the only factor. Cases are also increasing because the virus is spreading. The most important thing right now is to watch the health care system. If more patients are coming in and they are getting sicker, then you know that the situation is getting worse, regardless of the number of tests. We are seeing such increases in New York. Mayors should keep in touch with their hospitals to understand the status of the pandemic on health care systems.
SOURCE: Josh Sharfstein, April 4, 2020 (via City Leadership Initiative)
Can the COVID-19 test tell the difference between someone with an active infection and someone who was infected in the past?
Current tests for COVID-19 look for the presence of the virus in your body which means there’s an active infection.
There is another kind of test called serologic testing which looks for evidence that you may have been infected in the past.
SOURCE: Jennifer Nuzzo, March 6, 2020
NOTE: According to the CDC, the first stage of serum sample collection began during the week of March 30, 2020.
What is the difference between molecular tests and serology tests? Can serology tests be used in place of molecular tests?
Molecular tests look for evidence of an active infection. Serum antibody tests are a different kind of test that measure the body’s response to infection: antibodies, which take time to develop—about five days or more after initial infection. There are different kinds of antibody tests. In general, molecular tests and antibody tests are not replaceable with one another, because they measure different things.
SOURCE: Josh Sharfstein, April 4, 2020 (via City Leadership Initiative)
If you are tested and the test is negative, do you still have to be quarantined?
Yes. The reason is the test measures infection, not exposure. Someone can be exposed on a Monday, not develop an infection yet on a Tuesday and test negative, but then develop a clinical infection on Wednesday and then have a positive test Thursday. So, quarantine needs to last for 14 days regardless of testing results.
SOURCE: Tom Inglesby, March 14, 2020
Are false negatives a problem with COVID tests?
A false negative would mean that you actually have the disease but you get a negative test result. It’s a falsely negative test that should have been positive.
In a clinical setting, doctors and nurses have reported negative tests despite seeing compelling cases of COVID on a CT scan or the way someone presents. They proceed as though it is a positive diagnosis.
At this point, there’s no centralized database to say that specific tests have a certain number of false negatives or positives. In general, this testing is fairly reliable but there will be false results as no test is perfect. It would be good to have more information about the operating characteristics of all the tests.
SOURCE: Tom Inglesby, April 17, 2020
With limited testing available, how do we tell people to assume they have coronavirus, or have been exposed to it, without panicking them?
People who have symptoms should assume they have it, isolate themselves from other people, talk to people they may have exposed in the days prior to experiencing symptoms, and recommend that those contacts self-quarantine. Mayors should reinforce this message. Having a call center or using 311 for coronavirus response could help mayors and public health officials provide these messages. Such a system can also be a way to keep track of the epidemic. If you give people experiencing symptoms the option to go online or call for help with food delivery or other services, you can log them into a database, and, to the extent that the health department is able, do contact tracing, make referrals, and offer support.
SOURCE: Josh Sharfstein, April 6, 2020 (via City Leadership Initiative)
Should we be testing first responders before they start their work day?
Many health care settings and other first responders are already actively screening workers for fevers and other symptoms. Over time, testing may become more viable for screening on a routine basis.
SOURCE: Josh Sharfstein, April 1, 2020 (via City Leadership Initiative)
How much information about the movements of individuals who test positive should we share, and how do we avoid causing a panic by people thinking they may have been exposed?
These decisions should be made with local public health officials. With respect to COVID-19 specifically, the U.S. Department of Health and Human Services Office for Civil Rights advises that only the “minimum necessary” information be disclosed to the public. Certain communities in New Jersey, for example, have released only patient age, gender, current location (hospital vs. home), virus contraction date, and whether it was contracted from a known individual. However, depending on the situation, health officials may have reasons to release more information to help people protect themselves. For example, if someone went to a funeral during an infectious period, making an announcement to instruct funeral attendees what to do might well be appropriate.
SOURCE: Josh Sharfstein, April 1, 2020 (via City Leadership Initiative)
APPENDAGE: HIPAA Privacy and Novel Coronavirus, Office for Civil Rights, U.S. Department of Health and Human Services
What are the disparities in testing for marginalized communities and how can we address them?
We’ve largely built testing off our health care system, with all the inequities built into it. That's one of the reasons we’re suggesting a call center that’s available to everyone. Even though this virus started in the United States with people returning from cruises or international travel, the populations at greatest risk are low income, minority communities with high rates of chronic illness and insecure housing and food. The initial attention to people who got coronavirus on cruises and international trips has distracted us from the urgency of providing not just testing but also follow-up services—food, housing, and other supports—for vulnerable populations. It’s the right thing to do as a matter of justice, but it’s also absolutely critical for control of the disease.
SOURCE: Josh Sharfstein, April 6, 2020 (via City Leadership Initiative)
RELATED: How Health Disparities Are Shaping the Impact of COVID-19
PREVENTION AND INFECTION CONTROL
How can I protect myself against coronaviruses?
The World Health Organization suggests avoiding close contact with anyone showing symptoms of respiratory illness such as coughing and sneezing; covering your mouth and nose when coughing and sneezing; and regular hand washing to protect yourself against infection and limit the spread of the virus.
The best way to prevent illness is to avoid exposure to the virus through the following steps:
Regularly and thoroughly wash your hands with soap and water for at least 20 seconds or clean them with a 60% alcohol-based hand sanitizer.
Maintain at least 6 feet of distance between yourself and anyone who is coughing or sneezing.
Avoid touching your eyes, nose, and mouth.
Cover your mouth and nose with your bent elbow or a tissue when you cough or sneeze, then dispose of the used tissue immediately.
Clean and disinfect frequently touched surfaces daily, including doorknobs, tables, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks.
Stay home if you feel unwell. If you have a cough, fever, and difficulty breathing, seek medical attention but call in advance.
Keep up-to-date on the latest COVID-19 hotspots (cities or local areas where the virus is spreading widely) and avoid traveling to those places, especially if you are an older person or have diabetes, heart disease, or lung disease.
SOURCE: WHO, March 30, 2020
Is hand sanitizer effective to protect against coronavirus?
Good hand hygiene is a way to reduce the possibility of getting infected and plain soap and water is quite effective. But if you’re on the go, hand sanitizer is a good, convenient alternative.
SOURCE: Jennifer Nuzzo, March 6, 2020
How long does the virus stay on your clothes?
The coronavirus may remain detectable for hours to days on surfaces made from a variety of materials, including clothing. It is not known how infectious this virus is, and it is less infectious over time. In addition, the absorbent fibers in some clothing may cause the virus to dry up more quickly than it does on plastics and metals. Washing clothing is thought to be sufficient to inactivate the virus. Wash clothing on the warmest possible setting appropriate for the material and dry completely.
SOURCE: Josh Sharfstein, April 1, 2020 (via City Leadership Initiative)
Cleaning produce brought home from the grocery store: should you do anything differently or use any particular cleaning products?
Here is general guidance on fruits and vegetables: (via CDC). There is not specific guidance for coronavirus. In general, the risk of transmission is low, but will be reduced further with cooking.
SOURCE: Josh Sharfstein, April 6, 2020
Is takeout food safe? What precautions should people take?
In general, takeout food is low risk—particularly if the food is cooked. You should wash your hands after touching the packages, but the risk of contracting coronavirus from food delivery, takeout, groceries, or mail is low. Mayors should make sure that restaurants understand the importance of preventing people from coming to work sick. The FDA offers guidance for food processing facilities and farms.
SOURCE: Josh Sharfstein, April 6, 2020 (via City Leadership Initiative)
Is the public water supply safe from the virus?
There is no evidence of transmission through the public water supply.
SOURCE: Josh Sharfstein, April 6, 2020
If two people are positive, can they quarantine together or do they have to be separated?
This is a bit of a trick question: They can be isolated together as long as we’re sure they’re both positive. There’s no problem in having multiple people isolate together. But, ideally, people should quarantine separately.
It’s also important to distinguish between isolation and quarantine: isolation is for people who are sick. Quarantine separates and restricts the movement of people who may have been exposed to the virus.
SOURCE: Eric Toner, Public Health on Call Podcast, April 3, 2020
Is it correct that if someone in your home is ill then you should also be staying at home?
Yes. If people in the home are coughing, have fevers, or other symptoms of the coronavirus, this is good advice. As testing scales up, advice may change.
SOURCE: Josh Sharfstein, March 19, 2020 (via City Leadership Initiative)
What should you do if someone in your household is sick?
See: COVID-19 Infection Control in Your Home
Can you avoid the virus by drinking warm water every 15 minutes?
There’s no evidence behind that claim. Certainly you want to stay hydrated. But there is no evidence at all to support that internet meme telling people that they should only drink warm water, and that if they drink cold water, their lungs will become fibrotic. Stay hydrated, and don’t worry about drinking cold water.
SOURCE: Jennifer Nuzzo, March 20, 2020
There’s a holding-your-breath test sweeping the internet: is it true that if you can hold your breath, you know that you do or you do not have COVID-19?
There’s no way to tell if you have COVID-19 without a laboratory test. There is some evidence that a CT scan could provide some pictures of your lungs that may raise suspicions, but at this point, the only way we can really tell if you have COVID-19 is if you get a laboratory test.
I can’t say that without following it with a plea: At this point, particularly given that testing is limited, we very much have to prioritize those people who are quite ill, and to let doctors and nurses in hospitals decide who needs to be tested.
SOURCE: Jennifer Nuzzo, March 20, 2020
Should the general public cover their faces with bandanas or other makeshift masks?
The CDC now recommends that people without symptoms wear cloth masks in public to reduce the risk of asymptomatic spread. A reasonable position would be to encourage wearing masks while emphasizing that it's social distancing and not just the mask that prevents spread from person to person.
SOURCE: Josh Sharfstein, April 6, 2020 (via City Leadership Initiative)
Is there official guidance on the efficacy of DIY face masks and can these be donated for use in health care settings?
The CDC has posted instructions on its website for making and using cloth masks. If used properly and in conjunction with social distancing techniques, cloth masks can help slow the spread of the virus in the general population. Importantly, the CDC does not recommend that individuals wear surgical masks or N-95 respirators, as there is still a critical shortage of these supplies for health care workers and first responders.
Efforts to crowdsource effective PPE should precede calls for improvised masks. (This website helps match unused PPE to health care providers.) The CDC permits the use of cloth masks by health care providers only as a last resort, cautioning “[H]omemade masks are not considered PPE (personal protective equipment), since their capability to protect [providers] is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.”
SOURCE: Josh Sharfstein, April 11, 2020 (via City Leadership Initiative)
Are there acceptable designs of PPE that local manufacturers and hobbyist 3D printers can create for medical staff?
It’s very hard to make health care-ready PPE. Local businesses and hobbyists should be advised to manufacture for the public market than try to make health care-quality masks. Other local industries may have stockpiles of certified equipment that could go to health care workers. The community can come together to make masks and other protective equipment for essential workers outside health care.
SOURCE: Josh Sharfstein, April 6, 2020 (via City Leadership Initiative)
If someone goes for a jog through a neighborhood where there might be a patient with novel coronavirus, are they at risk?
No. The majority of transmissions of this virus occur through droplet transmission. This means that a sick patient who coughs or sneezes is expelling virus through droplets that don’t travel that far. They tend to fall to surfaces within a six-foot distance. If you touch a surface that is contaminated with droplets from someone who has coughed or sneezed on it and then you touch your eyes or nose or mouth, you could potentially become infected that way.
SOURCE: Jennifer Nuzzo, March 6, 2020 (updated April 1, 2020)
How should I help a friend, neighbor, or family member who is ill?
If they are ill from coronavirus, you can drop off food or other supplies for them, call them, and make sure they’re coping well. If they are getting sicker, you can help them notify their doctor or local public health agency to arrange for medical care.
SOURCE: Tom Inglesby, March 14, 2020
Will I get sick if I help care for them?
If you’re caring for them directly without adequate protective equipment, the chance of infection is very high. If people need that extra care, they may need to be hospitalized.
SOURCE: Tom Inglesby, March 14, 2020
Are my pets at risk of getting sick?
Some animals, like ferrets and maybe cats, are susceptible to this virus. Dogs were shown to be more resistant. The recommendations right now are to keep your distance from pets if you are diagnosed with COVID-19. The good news is we don’t think that pets are very likely to get sick if they are actually exposed to or infected with SARS-CoV-2 virus. But out of an abundance of caution—since we don’t know this virus well just yet—it’s a good idea to play it safe.
SOURCE: Meghan Davis, April 14, 2020
How much food should people have on hand? Are there concerns about the food supply at this point?
There’s no evidence that there’s a shortage of food. I think people have gone to the grocery stores and seen some empty shelves, which probably alarms them. That’s probably more due to people going out at once trying to buy things before the grocery stores have had the ability to restock. That said, I think it makes sense to keep food on hand so that you don’t have to go out to the grocery store frequently. Because right now, what we’re telling people is to try to stay home as much as possible to limit your possibility of being exposed to the virus. So if you can keep some food on hand to enable you to stay home for longer, I think that’s a good idea.
SOURCE: Jennifer Nuzzo, March 20, 2020
RELATED: Feeding Others and Staying Fed, April 2, 2020
IMMUNITY
Can people expect to be immune once they’ve had the virus? Can the virus “reactivate?”
This is unanswered so far. In terms of reports [of potential reactivation] that have come out of Korea, the majority of people in public health and medicine who have been working on COVID believe that this reflects a testing phenomenon. So, when people were retested, they still had the presence of viral RNA in their system but didn’t actually have any replicating virus.
There have been a few cases where people were considered “recovered” a little too soon and weren’t clear yet. But there has not been compelling evidence of someone getting sick, getting better, and then becoming clinically ill again.
SOURCE: Tom Inglesby, April 17, 2020
Are people who are sicker likely to be more immune than those who didn’t feel any symptoms at all?
It’s possible, but we don’t know that yet and it’s one of the open questions about immunity: whether a worse infection gives you a better immune response.
SOURCE: Tom Inglesby, April 17, 2020
Is it possible that some people may be exposed and have mild illness but still produce antibodies that could prevent them from getting a more serious infection?
Yes, and we hope that will happen. We will learn more about this once serologic surveys begin. We need to see what percentage of the population has been exposed by a certain date and then find out if that antibody test correlates with immunity.
SOURCE: Tom Inglesby, April 17, 2020
TREATMENTS AND VACCINES
What treatments are there for coronaviruses?
Currently, there are no licensed vaccines or therapeutic agents for coronavirus prevention or treatment, though accelerated research into potential treatments is underway and will be tested through clinical trials.
SOURCE: The Hub, March 13, 2020
What progress is being made on therapies or treatments for COVID-19?
There are many studies underway. One example is research on convalescent serum, meaning the antibodies made by people who have already recovered from COVID-19. It’s possible that giving these antibodies to people at high risk for exposure (like household contacts or health care workers) or to people early in infection will be beneficial.
SOURCE: Josh Sharfstein, April 4, 2020 (via City Leadership Initiative)
Is there evidence for using hydroxychloroquine as a treatment for COVID-19?
There is some anecdotal evidence that there may be some benefit to using chloroquine at different stages of infection, and a little bit of lab data suggesting it might have some effects on the virus, but there isn’t good data that it works at a particular point in the infection or even that it works at all. There are ongoing studies, the results of which are coming. We should get some results soon telling us not just whether it works, but also when it works, at what dose, and other actionable information.
SOURCE: Josh Sharfstein, April 4, 2020 (via City Leadership Initiative)
At Johns Hopkins, there’s now a study about using convalescent serum from people who have recovered from coronavirus as a treatment or other prevention intervention. If that might work, what about using breast milk from recovered patients as therapy? Breast milk also concentrates antibodies.
It’s an interesting question. As far as I know, this has not been studied. But it would be interesting to look at it.
SOURCE: Eric Toner, April 3, 2020
Does Tamiflu work for coronavirus?
No.
SOURCE: Jennifer Nuzzo, March 6, 2020
Is it a good idea to get a flu shot if you haven’t already gotten one this season?
It’s a great idea to get a flu shot if you haven’t gotten one. And next season, please absolutely get a flu shot.
Flu is an important public health problem and it’s important to be protected. The vaccine may not keep you from getting sick, but it can help reduce serious infection, hospitalization, and death.
In this situation, where we are potentially looking at many people becoming severely ill with COVID-19 and requiring hospitalization, it would be very helpful if we could reduce the number of flu cases in our health systems. That means more beds and more medical resources for the people who need them.
SOURCE: Jennifer Nuzzo, March 6, 2020
The flu vaccine isn’t 100% effective; some years it may be 25%, 50%, or 75% effective. Will a vaccine for COVID-19 be more effective than the usual flu vaccine?
We don’t know what the effectiveness will be. We’re still doing the studies to see exactly that. An important point about the flu vaccine is that even though it doesn’t protect as many people from being infected as we would like, it does seem to be quite helpful in preventing severe illness and death in people who are vaccinated. So definitely get your flu shot every year. It is helpful to keep people out of the hospital.
SOURCE: Jennifer Nuzzo, March 6, 2020
We have a new flu vaccine every year with a new strain. Why is it so hard to get a coronavirus vaccine?
We use the same flu vaccine strategy every year that’s been developed over many decades. We know the dose of antigen—the protein—required to cause immunity and we know basically how to swap in and out the latest strain to use the same system.
We don’t know yet what system will be used to create a COVID vaccine or what vaccine candidates will be safe and not cause side effects. We don’t know what will cause the right level of immunity. We are starting from scratch and have a lot to learn.
SOURCE: Tom Inglesby, April 17, 2020
Is interferon Alfa 2B an effective treatment? Should we be encouraging our medical community to obtain this?
There are over 30 treatments currently being tested around the world. Interferon Alfa 2B has historically been used to treat diseases such as dengue fever, HIV, and hepatitis. However, no treatments have been demonstrated to be safe and effective in high quality studies. This treatment, like others, is considered experimental for COVID-19 at this time.
SOURCE: Josh Sharfstein, April 8, 2020 (via City Leadership Initiative)
SOCIAL DISTANCING AND OTHER PUBLIC HEALTH MEASURES
Why is the world’s response to COVID-19 so much greater than the response to other outbreaks like H1N1 or SARS?
One reason is that this virus is more easily transmitted than SARS (SARS caused an epidemic in 2003.). People with SARS were most likely to transmit the virus when they were quite ill, so a lot of transmission occurred in health care environments. Once we were able to improve infection control in health care environments, we were able to bring the epidemic under control. The 2009 pandemic caused by the new flu strain H1N1 was similar to COVID-19 in the sense that people transmitted their infections quite easily. But it was a milder virus; it didn’t produce the same level of severe illness or death that we so far have seen with this novel coronavirus.
COVID-19 is not as deadly as SARS was. On average, SARS killed about 10% of the known cases, and the estimates for this virus are much lower. But the fact that it’s so easily transmissible— much more like a flu than SARS—has made response to this pandemic quite difficult.
SOURCE: Jennifer Nuzzo, March 20, 2020
According to the CDC, the flu kills 24,000–62,000 people annually in the U.S. Why are we shutting everything down for COVID-19 when we don’t shut down for flu?
The coronavirus is more contagious and far more lethal than the seasonal flu, and we are all susceptible to illness. There is no coronavirus vaccine. As a result, the coronavirus is infecting so many people so quickly with serious illness that there is a real risk of overwhelming the health care system. This does not happen from seasonal influenza.
SOURCE: Josh Sharfstein, April 6, 2020
What metrics should cities be looking at to understand the real-time spread and anticipate the timing of the surge?
It is very difficult to accurately predict the surge without having sufficient testing capacity for the population. Depending on the scale of testing in the area, cities may be able to look at test results to understand the likely surge in patients coming in the ensuing 2–4 weeks. Cities should also closely monitor the hospital system to assess the number of hospitalized and ICU patients, as well as the doubling time in the growth of the number of these patients. If there is a single call center for people with symptoms, the number of calls should be tracked as one measure to watch. There are other emerging sources of data, such as fevers reported by companies that make internet-enabled thermometers.
The Johns Hopkins Coronavirus map is a good resource to examine the spread in other states and countries around the world. The map is updated in real time as additional information is made available from a variety of sources, including the World Health Organization and the CDC.
SOURCE: Josh Sharfstein, April 1, 2020 (via City Leadership Initiative)
For businesses that remain open, what are best practices they should be using to stop the spread?
CDC has released guidelines for infection control in workplaces. These guidelines include the critical guidance that workers with any symptoms of illness should stay home.
In addition, businesses that remain open should ensure that customers are maintaining social distancing on their premises. They can do this by limiting the number of people allowed inside at a given time and putting colored tape on floors to help customers keep their distance from one another, as well as cashiers at checkout lines. They can also encourage customers to abide by sanitary guidelines—including hand washing and sanitizing and limited touching of products—and offer disinfecting wipes and hand sanitizer stations.
Many stores now close early to give workers time to completely sanitize the store or periodically sanitize high-use items. For customers who are 60 or older, some stores have started to offer dedicated shopping hours to limit interaction with other customers. Cities can encourage stores to enact these measures to create a safer shopping environment for customers.
SOURCE: Josh Sharfstein, April 1, 2020 (via City Leadership Initiative)
What should we do to protect employees at businesses that are still open, like grocery stores, hotels, and restaurants?
The CDC has some specific guidance on this. It’s imperative to maintain and enforce social distancing measures. Public spaces should be regularly decontaminated in accordance with the CDC guidelines. Mayors should work to help essential businesses follow the rules. But the most important thing businesses should do is remind workers with any symptoms of illness to stay home. Mayors can help by enacting citywide sick leave policies.
SOURCE: Josh Sharfstein, April 4, 2020 (via City Leadership Initiative)
Does the science support limiting the number of people in grocery stores at one time?
Yes. We should be practicing social distancing of at least six feet apart, all the time, including in grocery stores.
SOURCE: Josh Sharfstein, April 6, 2020 (via City Leadership Initiative)
How do we get through to the youth who feel they are immune to the disease or not affected by it?
From Josh Sharfstein: “Young people often believe they’re invincible. Combine that with all the messages that young people are unlikely to get seriously ill from the coronavirus, and you get kids congregating even though they’re being told not to. Changing youth behavior is hard. The best way to reach them is through their peers. Engage directly with young people and try to develop a youth corps to spread the message. Find your youth advisory boards and the youth leaders who can say to their peers, ‘We don't want to be bridges to infection to our parents and grandparents.’ I recently participated in a webinar with well over 100 Baltimore youth, and they asked great questions. I told them, ‘You all have this responsibility to get the word out there because what you do really matters’.”
SOURCE: Josh Sharfstein, April 6, 2020 (via City Leadership Initiative)
Why aren’t we seeing human temperature monitors in public places like airports, hospitals, grocery stores, warehouses, etc.?
Taking temperatures is a very insensitive and imprecise tool. People can have elevated temperatures for all sorts of reasons that don’t correlate with illness, such as exercise. People can also suppress their fevers by taking Tylenol or other over-the-counter medications.
Having ubiquitous temperature monitors is not likely to be a great benefit and may result in a huge number of false positives and false negatives.
SOURCE: Eric Toner, April 3, 2020
What are the best ways to do contact tracing? Is there an app or tech platform that can do this effectively?
A great resource on contact tracing is this new report from Johns Hopkins and the Association of State and Territorial Health Officers.
Multiple technology platforms are emerging, but technology should be seen as an enabler of a smart, well-explained, coordinated, contact-tracing strategy—not as a solution unto itself. Moreover, an effective public health response requires people to be able to explain quarantine and link people to resources that make quarantine possible. Scaling up human resources will be necessary for contact tracing. The report cited above has a section on technology as a force multiplier for contact tracing, as well as cautions about appropriate safeguards.
SOURCE: Josh Sharfstein, April 11, 2020 (via City Leadership Initiative)
As we approach peak infection, are there recommended restrictions beyond closing non-essential businesses?
To limit community spread of COVID-19, it is important to consider a variety of measures that limit close social interaction. Most U.S. cities have already closed school buildings, mandated the temporary closure of public-facing activities for non-essential businesses, and urged residents to stay home unless absolutely necessary. Some have also limited the size of social gatherings and have closed or limited access to public places such as parks, playgrounds, and beaches. Cities should also take steps to enforce key measures.
For example, to prevent large gatherings in city parks, New York has experimented with removing basketball hoops from parks, closing parks, enforcing park closures with police resources, and imposing fines on rule-breakers.
SOURCE: Josh Sharfstein, April 8, 2020 (via City Leadership Initiative)
As we move into this significant period of isolation, how do we address the psychological needs that people will be facing?
Physical distance doesn’t have to mean social and emotional distance. It’s a natural reaction to be anxious and to withdraw. Figuring out how to step up socially and check on isolated people, by electronic or other means, is really important.
SOURCE: Josh Sharfstein, April 8, 2020 (via City Leadership Initiative)
REOPENING
How long will social distancing measures need to be in place?
[Opening up our country] may be something gradual based on what’s happening with the virus in your community and hospital capacity: Do hospitals have enough ability to take care of patients with this condition and do you have enough diagnostic tests to be able to find new cases when you lift restrictions? New cases will occur because this virus won’t just disappear. So, you have to be able to find those cases and isolate them.
I don’t think things will be completely back to normal until we have a vaccine, especially for things like mass gatherings. There is a cost to keeping everything closed down and not just an economic cost, but peoples’ health. There is a psychological impact of being locked up and not being able to live your life that really has to be measured.
Everybody wants to get back to normal, but it’s going to take a little bit of time and it has to be done in a really measured and mindful way.
SOURCE: Amesh Adalja, April 10, 2020
RELATED: National Coronavirus Response: A Roadmap to Reopening, March 29, 2020
Are we worried that once we get over the peak of infections and we’re starting to think about opening again, we’ll suddenly have new surges of infections that will require us to close down and have to do social distancing all over again?
This is a concern. As we start to dial back various social distancing measures, we’ll have to monitor very carefully for recurrence of disease, which is somewhat likely. We hope that it’s not as bad as these initial waves, but it is likely that we’ll see some recurrence and have to tighten up on social distancing measures for a period of time.
SOURCE: Eric Toner, April 3, 2020
In Wuhan, they’re loosening some restrictions. What do you think the leading factor is for giving the green light in China right now?
It’s certainly not herd immunity. It relates to the fact that the Chinese authorities feel that they have ubiquitous testing and the ability to do contact tracing on all identified patients. They have also greatly expanded their health care capabilities so they can handle the people who do get sick.
SOURCE: Eric Toner, April 3, 2020
ADVICE FOR POLICYMAKERS AND OFFICIALS
Is there a model city that we can look to for best practices for testing or social distancing?
People often cite Singapore. In the Asian countries that experienced SARS in 2003, citizens really understand the importance of social distancing. When older adults were told they should stay home, they stayed home. We hope that with a number of similar steps being taken, our path will look more like Singapore, Taiwan, and South Korea, and less like Italy, France, and Spain, but there is now evidence that our experience may be more like Europe. The urgency of a strong response is very high.
SOURCE: Josh Sharfstein, March 19, 2020 (via City Leadership Initiative)
What questions do we need to ask or answer right now in order to start thinking about a plan for a swift and equitable recovery?
This won’t be a case of, “Now we’re ready, flip the switch.” It’s going to be gradual. An important question to bring up with businesses is, what could that look like? How do you operate at a level of one or two out of ten? In Singapore, for example, they had restaurants open but with tape blocking every other chair. The more you can think about and plan those gradations, the more you may feel comfortable saying, “Okay, everyone, let’s go to phase one.”
If you’re investing in public health solutions, building that call center or the capacity to isolate and trace and quarantine, then you’re going to be able to stay higher on that dimmer switch longer. It’s an investment in being able to turn on more things faster. In Singapore, they have hundreds of people to jump on infections when they happen and that gives them confidence to be able to open businesses.
SOURCE: Josh Sharfstein, March 19, 2020 (via City Leadership Initiative)
Is street sanitation effective, or should we focus resources on other prevention strategies?
Many cities have been loosening their street parking restrictions to reinforce the importance of sheltering in place, which may impede regular street cleaning. In the short term, cities should prioritize the recommended social distancing measures and resume street cleaning and other sanitation measures when consistent with public health guidance on social distancing.
SOURCE: Josh Sharfstein, April 8, 2020 (via City Leadership Initiative)
How can we help people experiencing addiction and substance abuse issues?
“Addiction medicine doctors are worried both about their current patients and about people who are still using drugs but seeking treatment. All the social disruptions are disrupting drug markets, and we’re seeing more people seeking treatment even as the clinics are thrown off by social distancing. There are opportunities for drug treatment programs to take advantage of this situation through innovations in telemedicine. This could be a moment to treat more people, in new ways.
A separate challenge is harm reduction. Not too long ago, our message for people using opioids was always do it in a group to reduce the risk of death from overdose. Now we’re supposed to be doing social distancing. It’s a big challenge. I recommend talking to harm reduction groups in the area to learn about the challenges they are facing and what might be done to help.”
SOURCE: Josh Sharfstein, April 6, 2020 (via City Leadership Initiative)
Are there techniques for reaching seniors and others who do not have easy access to technology and the internet?
It’s so important to protect older adults in the community. Nursing homes should implement a range of recommended policies, including keeping individuals apart, isolating people who are sick, and screening staff for symptoms. Nursing homes may require investments in extra staff or new technology.
There needs to be a public health response that monitors for potential infections anywhere that elderly people are living in close quarters and intervenes immediately with testing, isolation, infection control, and quarantine.
SOURCE: Josh Sharfstein, April 4, 2020 (via City Leadership Initiative)
What should we do to support high-risk populations like the homeless or those in jails or prisons?
Consider a moratorium on detaining people for low-level crimes or releasing older, non-threatening prisoners to reduce the burden and allow more social distancing. For homeless people, work to find them housing or temporary shelter as quickly as possible to decompress shelters. Infection-control procedures need to be put in place for these settings—but the best thing is to have as few people as possible in them.
SOURCE: Josh Sharfstein, March 19, 2020 (via City Leadership Initiative)
Are residents of homeless shelters a vulnerable population?
Yes. Homeless shelters are often overcrowded and understaffed, making it difficult to properly enforce social distancing and appropriate hygiene measures, so individuals living in shelters—and unhoused individuals more broadly—are at high risk for contracting COVID-19. Further, homeless individuals disproportionately suffer from asthma, diabetes, heart disease, and other chronic illnesses, which contribute to the severity of COVID-19 symptoms and effects. While the federal government’s stimulus package includes funding to help shelters and the homeless population, capacity and hygiene issues at shelters will persist.
SOURCE: Josh Sharfstein, April 8, 2020 (via City Leadership Initiative)
How do we support undocumented people who are not receiving stimulus money and may have other reasons to not engage with the government?
People without immigration documents have at least the same risk of getting sick as anyone else and the same risk of passing it on to other people. Aggressive immigration enforcement at this time makes fighting the virus harder. Work with trusted organizations on some approaches to addressing this challenge.
SOURCE: Josh Sharfstein, April 6, 2020 (via City Leadership Initiative)
How should we address rising domestic violence?
It’s important to have domestic violence shelters for people who are not safe at home. It’s also important to help families address stress in these incredibly stressful circumstances. Cities should reach out to their network of organizations that deal with this every day to develop ideas. In Baltimore, a pro bono network of mental health clinicians offers support.
SOURCE: Josh Sharfstein, April 6, 2020 (via City Leadership Initiative)
What are the things a mayor or a city council needs to communicate to the public, and when is it better to have the city management and safety leaders be the messengers?
“It is important to have a trusted communicator convey public health-related news. It does not necessarily have to be a doctor—nurses can be tremendous communicators. It should be someone who can speak to the science and answer questions alongside mayors. I think the kind of calm that we feel when Dr. Fauci opens his mouth speaks to the value of this kind of communication approach.”
SOURCE: Josh Sharfstein, April 6, 2020 (via City Leadership Initiative)
For mayors in cities without a county health department, how can we communicate and make sense of the numbers? What does it mean to double capacity of ICU beds? What would it mean to reopen a hospital that recently closed? How can we contextualize those numbers?
Surge planning is a fundamental responsibility of the state, with support from the federal government. Mayors need to communicate plans for what they will do to prepare for things getting worse. The stress on health care workers, from custodial workers to CEOs, is enormous. Whatever you can do to support health care workers will be very appreciated.
SOURCE: Josh Sharfstein, March 19, 2020 (via City Leadership Initiative)
My city doesn’t have its own dedicated health officer because the health department is run by the county. What actions should we be taking to make sure all bases are covered?
The county health department should be actively engaged in your city’s response and helping to brief citizens. If the health department is not, you should raise targeted questions about important issues like the county’s plan for testing, contract tracing, isolation, and quarantine. However, I would encourage striking a constructive tone. It’s not just, ''Are you doing these things?'' but, ''How can I help you do these things?'' The amount of contact tracing and support for isolation that will be necessary far exceeds what any jurisdiction or local public health department can do. One of the most important roles for mayors is to mobilize the business community (especially hotels) and universities. Offer and solicit help from all quarters.
SOURCE: Josh Sharfstein, April 4, 2020 (via City Leadership Initiative)
How should local governments engage with state agencies that might not yet understand the gravity of the pandemic or are not following safety protocols?
“This is a big challenge in some states, and it shows the gap in national leadership. My best advice is to stand with people in your health care system strongly to call on the state to follow the best-known scientific protocol. Rather than government-to-government communications, partner with emergency room doctors and nurses. Stand with them and say with one voice that this is a threat to the whole community; health care workers are putting themselves and their families at risk, and we need you to take this seriously.”
SOURCE: Josh Sharfstein, April 4, 2020 (via City Leadership Initiative)
MORE INFORMATION
What are good sources of information?
The Centers for Disease Control and Prevention
The World Health Organization
Coronavirus disease (COVID-19) advice for the public: Myth busters
Johns Hopkins University and Medicine Coronavirus Resource Center
Are there books for people to learn more about the public health response to similar situations?
The Public Health Crisis Survival Guide is for anyone involved in a public health operational role who may have to think about how to manage a crisis and maintain credibility in the face of uncertainty. D.A. Henderson’s Smallpox, the Death of a Disease has great information about operational challenges to confronting the spread of disease and the goal of trying to reduce its impacts on society.
SOURCE: Jennifer Nuzzo, March 6, 2020
How can I learn more from experts?
The Johns Hopkins Bloomberg School of Public Health also hosts a daily podcast called Public Health On Call featuring interviews with experts and others on the front lines.
The Johns Hopkins Bloomberg School of Public Health has a big vision: Protecting Health, Saving Lives – Millions at a Time.
