PHYSICAL DISTANCING Since my last blog, five states are under “Stay at Home” orders. Here in Los Angeles it appears that most people are following the mandate. It’s good to see very few people on the road, or if they are walking keeping their distance from each other. The same can be seen in supermarkets. But, you hear stories of people meeting with multiple friends who they “know”. Or sometimes even being more cavalier. But at the end of the day, it appears that if we don’t abide by these guidelines now, it will have to lead to more Draconian measures. Forced quarantine. Martial law. Possible. So… for the love of whatever you love, please start listening. This week alone I tested five patient s with high probability of having COVID19. Two were positive. Three are pending. Yet, one of the positive ones asked me if he could go for a walk around the block (he hated being cooped up) just two minutes before I gave him the news. JEEEEEZZZZZ!!!!!!
Here is an excellent review that I stole from my friend, infectious disease expert Edwin De Jesus MD. Why improve on a great mouse trap?
From SOCIAL to PHYSICAL Distance SARS-CoV-2 (SARS-2), the virus that causes COVID-19, spreads from person to person through respiratory droplets produced from an infected person, even if that person does not know he/she is already infected. Most transmissions occur during very close contact with an infected person or when an infected person coughs or sneezes around you. A six-feet parameter between you and others is a safe distance. That is what we mean when we use the term social distancing. Social versus Physical distance? You need to keep in mind that we may not have control of our household members when they are outside our home environment, and they potentially can also get infected. What we call “social distance” may need to apply in our home setting and with our coworkers, so it is time to instead call it “physical distance”. This distance includes, for example, kids playing with others in a playground, friends and visiting relatives, even anyone entering your home (ex: a service person). Fomites? Another way of transmission, which accounts for a significantly lower number of infections, is by contact with fomites. A fomite is any contaminated surface, material, or object that others could have infected. Your personal items, such as your cell phone and keys, can become fomites when you place them over a contaminated surface, or if you touch a contaminated surface before grabbing them. Cell phones are worse because, many times, we put them in direct contact with our face. In all these instances, the infection will occur not because the object was contaminated, but because you or someone else touched it, and then you or someone else, touched your face. This fact is why the message of “washing your hands” becomes critically important. Pets? What about our dogs? Dogs cannot get the COVID-19, and because they are living creatures, we do not refer to them as “fomites” but as “vectors”. Vectors are intermediary living carriers of pathogens, in this case, contaminated droplets on their surface. If you walk the dog outside: (1) do not let anyone touch your dog, and (2) if your dog was in a potentially contaminated environment, consider giving them a quick bath. Avoid putting alcohol or chlorine solutions on your pets. Cats are much less likely to be an efficient vector for this virus, not only because they tend to avoid unfamiliar people, but they also sanitize themselves by constantly licking their fur and paws. No need to talk about other animals, and no, in the case of coronavirus, you do not have to worry about birds or insects! Cleaning versus disinfecting? There are three ways we can get rid of the potentially infected virus that someone or something may have on them: (1) using a barrier and discarding it, (2) using a disinfectant, or (3) washing the contaminated area off. 1. Using a barrier is a material that may protect your body from getting sprayed or exposed to anything potentially contaminated around you. These barriers may range from our clothing to other more sophisticated personal protective equipment, or PPE, such as gloves, face masks, eye shields, disposable gowns, etc. Sometimes when misused, face masks can be detrimental and provide a false sense of protection. Currently, there is a shortage of PPE much needed for our medical staff. Please, if you stocked up with these PPE, offer them to a local hospital for the protection of the medical team that will assist the needed ones. 2. Disinfectants have the function of sanitizing or eliminating a significant proportion of infected particles, but we are unlikely to remove them all. The small amounts that may remain behind are unlikely sufficient to cause an infection. Sterilization, on the other hand, is killing all potential particles in fomites. That requires a more invasive technique, and it is not needed in our home or outside a medical setting. Disinfectants come in different forms, from light exposure, such as direct sunlight, sprays, and other topical solutions. Fomites are less likely to be as infectious, the longer they are exposed to direct sunlight. Sunlight does not appear to be a practical way otherwise to prevent infection among humans. Qualified sanitizers, which impair the ability of this virus to become infectious, usually are available solutions mostly with alcohol, chlorine, and other antibacterial and antiviral products. For direct contact on our skin, we should use approved safe sanitizers, which usually consist of 60% to 70% alcohol mixed with several ingredients that make it suitable to apply on our skin and to evaporate quickly. If you use a sanitizer on your hands, do not wipe it off with a dry cloth or paper towel. Instead, allow it to dry by itself. Sanitizers are available in spray forms, which are especially helpful to decontaminate surfaces or fomites. A commercially available brand is Lysol spray, which contains a combination of alcohol and ammonia. There are also a variety of disinfecting wipes, but not all of them are effective! A popular brand is Clorox wipes which, as opposed to its name, do not contain bleach, but rather ammonium and alcohol. Disinfectant with bleach or ammonium is usually not used on living surfaces. In fact, if we have those ingredients, we should avoid not mixing them. Individually, they can be used on most surfaces, not on our hands or pets! Spray the potentially contaminated surface and, if possible, do not wipe it immediately, waiting at least a minute or so. The more time the sanitizer is in direct contact with the surface, the better. 3. Washing or cleaning your hands and surfaces Our hands are the most common transport to infect ourselves. When we wash our hands for 20 seconds with soap and running water we are cleaning our hands, not literally sanitizing them. Appropriately washing our hands is considered a safe way to “sanitize” them by scrubbing off infected organisms. We must dry them with a clean, unused towel, disposable paper towel, or venting them to air. In general, for living surfaces, we wash with soap and water, while we sanitize fomites. Sometimes it is prudent to do both.
What if I can’t get sanitizer? If you are not able to get sanitizer, you can consider making your own mixing the ingredients below in a 2 – 1 – 0.5 proportion. 1. 2 units: rubbing alcohol 60% -70%, usually isopropyl alcohol 2. 1 unit: Aloe vera gel 3. ½ unit Tea tree oil or lemon juice (optional) If you have a higher concentration of alcohol, you can dilute it using saline, or any form of clean water. (such as isopropyl alcohol which likely what most people have at home). You could also consider substituting the isopropyl rubbing alcohol for some liquors such as high-proof vodka (although the alcohol concentration may be lower). Adding a teaspoon vitamin E oil and/or vegetable glycerin helps keep the skin hydrated without affecting the potency of the recipe. There are reports of other essential oils that could have an antiviral activity such as anise, bark, bergamot, cinnamon, clary, clove, dill, eucalyptus, geranium, juniper, lavender, lemongrass, melissa , neroil, rose, rosemary, sage, and thyme; but they are likely not effective when used by themselves. Warning: some people may be allergic to some of these things!
Mitigation steps? Proper mitigation steps we can all take to prevent the acquisition of COVID-19 are, for the most part, common-sense measures: 1. Wash your hands. 2. Do not touch your face in public. 3. Disinfect the property you frequently carry (phones, keys, glasses, bags, etc.). 4. Think of your immediate surrounding space as part of you and keep it as clean as your hands. 5. Avoid greeting others with your hands or a kiss/hug. 6. Avoid directly touching public surfaces that may be potentially be contaminated with your hands. 7. When you do so, disinfect your hands (soap and water or sanitizer). 8. Exercise social distancing. 9. Increase your personal space, when possible. 10. Avoid crowds and large gatherings.
1How can I keep my home free of contamination with the virus? 1. Designate only one entrance for anyone to enter your home, ideally close to a sink. 2. Put a sign on your door that everyone must take their shoes off (or if available, to wear shoe covers) before entering, AND to wash their hands immediately after entering your house. 3. At the handwashing station, have available liquid soap and individual towels. 4. Disinfect the property you frequently carry (phones, keys, glasses, bags, etc.). 5. If you are coming from an environment potentially contaminated (in close contact with many people or a healthcare setting) consider placing a hamper near the entrance and do not proceed inside the house with contaminated clothing. 6. When going to the supermarket or to a place where you might touch to may potential “fomites”, consider using gloves. If you do not have disposable gloves, you can use regular ones, but you must sanitize them after each use. 7. Don’t forget about the risk of handling money currency. It is an excellent transport for many infectious organisms. 8. Limits trips outside the house and the travelers. Consolidate trips among various people. 9. These measures are as reasonable as their implementation from everyone in the household. It only takes one person to bring the infection home! 10. Discard any bags and wraps soon after entering the house and wash all produce! Lastly, any person >65 years of age, especially if they have an underlying medical condition such as DM, respiratory, or cardiovascular disease should stay put, and isolated from the rest of the public. The older the age, the higher the risk! However, 20% of the US COVID-19 deaths were aged 20-64. Stay well informed, and do not lower your guard!
I’ve skipped a few days of writing. Too much going on with the office and trying to make everything as safe as possible. Incredible thanks to my partner Kevin Mock who literally spent Saturday cleaning all of the office with Clorox. I didn’t ask him to…It’s how he copes. Me on the other hand… I think and worry and try to implement strategies and try to educate you guys. This is going to be long but important blog. So read on.
FIRSTLY: This is so real. If you are allowed to work from home, absolutely do so.
This virus, officially known as SARS-CoV-2 , has an “infectivity” quotient known as R0 of 3. That is INCREDIBLY high. It’s estimated that the Spanish Flu had an R0 of approximately 1.8. This means that the if you have the virus and just go out there, and just talk to whomever, kiss whomever, not take precautions, you will infect three people. Let’s say you don’t infect anyone else, those three people will infect three people and so on…here is how many people will get infected without social distancing….
DAY 1 1 Day 2 3 Day 3 9 Day 4 27 Day 5 81 Day 6 243 Day 7 729 Day 10 2,187 Day 11 6,561 Day 12 19,683 Day 13 59,049 Day 14 177,147 Day 15 531,441 Day 16 1,594,323 ETC….
You get the picture.
SECONDLY. This is not like Seasonal FLU… this is NOTHING LIKE SEASONAL FLU. This is a new virus to humans. Our body has no, none, zero defenses against. You don’t have immunity against it. Which is why being so cavalier about not caring is so infuriating. Because those of you that don’t want to take precautions are putting ALL of us at risk. Not just older people. EVERYONE. Here is really good explanation of this that I swiped from someone else:
“Feeling confused as to why Coronavirus is a bigger deal than Seasonal flu? Here it is in a nutshell. I hope this helps. Feel free to share this to others who don’t understand… It has to do with RNA sequencing…. I.e. genetics. Seasonal flu is an “all human virus”. The DNA/RNA chains that make up the virus are recognized by the human immune system. This means that your body has some immunity to it before it comes around each year… you get immunity two ways…through exposure to a virus, or by getting a flu shot. Novel viruses, come from animals…. the WHO tracks novel viruses in animals, (sometimes for years watching for mutations). Usually these viruses only transfer from animal to animal (pigs in the case of H1N1) (birds in the case of the Spanish flu). But once, one of these animal viruses mutates, and starts to transfer from animals to humans… then it’s a problem, Why? Because we have no natural or acquired immunity.. the RNA sequencing of the genes inside the virus isn’t human, and the human immune system doesn’t recognize it so, we can’t fight it off. Now…. sometimes, the mutation only allows transfer from animal to human, for years it’s only transmission is from an infected animal to a human before it finally mutates so that it can now transfer human to human… once that happens..we have a new contagion phase. And depending on the fashion of this new mutation, thats what decides how contagious, or how deadly it’s gonna be.. H1N1 was deadly….but it did not mutate in a way that was as deadly as the Spanish flu. It’s RNA was slower to mutate and it attacked its host differently, too. Fast forward. Now, here comes this Coronavirus… it existed in animals only, for nobody knows how long…but one day, at an animal market, in Wuhan China, in December 2019, it mutated and made the jump from animal to people. At first, only animals could give it to a person… But here is the scary part…. in just TWO WEEKS it mutated again and gained the ability to jump from human to human. Scientists call this quick ability, “slippery” This Coronavirus, not being in any form a “human” virus (whereas we would all have some natural or acquired immunity). Took off like a rocket. And this was because, Humans have no known immunity…doctors have no known medicines for it. And it just so happens that this particular mutated animal virus, changed itself in such a way the way that it causes great damage to human lungs.. That’s why Coronavirus is different from seasonal flu, or H1N1 or any other type of influenza…. this one is slippery AF. And it’s a lung eater…And, it’s already mutated AGAIN, so that we now have two strains to deal with, strain s, and strain L….which makes it twice as hard to develop a vaccine. We really have no tools in our shed, with this. History has shown that fast and immediate closings of public places has helped in the past pandemics. Philadelphia and Baltimore were reluctant to close events in 1918 and they were the hardest hit in the US during the Spanish Flu. Factoid: Henry VIII stayed in his room and allowed no one near him, till the Black Plague passed…(honestly…I understand him so much better now). Just like us, he had no tools in his shed, except social isolation… And let me end by saying….right now it’s hitting older folks harder… but this genome is so slippery…if it mutates again (and it will). Who is to say, what it will do next. Be smart folks… acting like you’re unafraid is so not sexy right now.” #flattenthecurve. Stay home folks… and share this to those that just are not catching on.”
That about says it all. Yes. Different medications are being tried and some show promise. Yes. Vaccines are in development, this takes a LONG time. Yes, the summer may see a natural decrease. But until then, a lot of damage can occur if we don’t follow social distancing. So, until then….Stay calm. Stay healthy. Stay vigilant. (Stop with the toilet paper already!)
Today has been a very depressing day. Maybe it was the rain. I warn you… you’re not going to get the funny until the end of the blog. It must feel the same for most of you.
I lived through the worst of the HIV epidemic, where in total 25 million people died. A million Americans died in that plague and are dying still. But this feels different. Maybe because during the AIDS epidemic it was just “us” . The rest of the world kept marching along because it didn’t really care. But at least there was a sense of stability outside of “our” disaster. Now it is all of us. It is “quicker”, if that makes any sense. The social impact is more abrupt. The financial impact is hugely obvious COVID19 needs to be taken seriously. Yet people who have never even heard of Pythagoras’ Theorem, let alone solved a problem using it, are leading this country. The divides that are ripping our county apart are making this epidemic even worse. There are no teams here people. There are no walls. We are in this together . Anyway. I am rambling. So here are my pearls of wisdom for today.
If you have a cough, fever, sore throat or shortness of breath, call your health care professional FIRST. They will advise you. DO NOT COME into any office. You will be triaged via telehealth or advised to come into an office or an ER.
Slowly test kits are arriving. For now, symptomatic people are the ones being tested. But we need almost everyone tested. We need information about what is really happening. It is not sufficient to tell people to just stay home. Don’t get me wrong… it is crucial at this time to not spread this virus. But when new studies show that people who are not symptomatic can spread the virus, it is crucial that we know patterns of spread. Along with risks for acquisition and severity. If nothing else, by doing so we can get real data and probably reassure people that the death rate is less than we thought. Therefore, less panic. We can hopefully predict sooner when this epidemic is ending.
In the meantime, take social isolation seriously. Tempting fate and laughing at fate doesn’t make you cool. It makes you stupid.
Hang in there. I will get over today’s funk and so will you.
So here is the bright, funny part. I had a really sweet patient of mine come in to the office last week. He is one of my favorites. He said the he had been having a cough, but that he did not have a fever. I congratulated him for taking his temperature. At least he had a thermometer. He hesitated and said that he didn’t have a real thermometer. When I asked how he took his temperature he said sheepishly: “with a meat thermometer”. I didn’t ask. People, buy a real thermometer.
O.K. People! Calm DOWN! Yesterday, the President of the United States spoke on national T.V. and the pandemic became real. The same pandemic that we have been talking about for months. Except it was finally called such. And perhaps because a huge travel plan was put in place without anyone’s notice and because it was clear that perhaps there was no other clear plan in place people have become anxious today. CALM DOWN. Unless this virus was created in some lab (which is doubtful) there is no one to blame for its existence. Unless you want to have a long talk with mother nature. Viruses happen. But guess what? Humans happen too. And our gift is intelligence. So, let’s start using it.
The key now is to decrease the spread of this virus. Flattening the curve, if you will. The postponement of major events is vital. The washing of hands. The covering when you cough. The cleaning surfaces. All of them are vital. The rest is theatre. Don’t become part of the drama. The drama is currently a big problem. This is exactly why doctors sometimes do not tell people the whole story. Because panic sets in. It is not time to panic. It is time to be careful.
We need more test kits and they should be free. We should test as many people as possible to get some FACTS. It is the lack of facts that make us all nervous. We will all make sacrifices in one way or another. It will not last forever. Hopefully for weeks or months only. Let’s not CREATE the apocalypse. So, you want to do something useful? Call your representative in D.C. and tell them that if they don’t work toward providing testing, you will never vote for them again.
Stop hoarding. It only goes toward creating an atmosphere of panic. It is reasonable to buy groceries for a couple of weeks. But that is all. Toilet paper? Really? If you don’t have toilet paper, then you can always shower after a BM.. Come on people, where is the common sense?
Next. The really important thing. Buy a thermometer. Be aware of your body. If you have fever or a new cough that does not go away or shortness of breath. Call your local hospital or doctor. Do not go to the health care office immediately. Tell them your symptoms and they will guide you. Remember. It is estimated that 80% of all infections will be mild. Another 15% will have more intense symptoms. Only a small percent will require hospitalization. Do not overuse the healthcare system like it was toilet paper.
There is a saying in medicine: “in an emergency, always take your pulse first”. That means that the last thing you need, when you need to think clearly, is to panic. So, take your pulse first. Don’t panic. We will get through this. And I predict better than expected.
What a day. The World Health Organization declared this a “pandemic”. Before you freak out let me clarify what that means. It means that this infections have crossed geographic boundaries and is affecting an exceptionally large number of people. It does not mean that it is necessarily deadly. The truth is that those of us in the health profession, especially those have been in my field have known that this is what was probably going to be happening. The physician assigned to Congress and the Supreme court supposedly stated that there will be approximately 75-150 million Americans affected. That may true. Or it may not. The difference starts NOW. It should have started two months ago. This is what is called #FlatteningTheCurve. Which means that the greater the number of people that get infected, the more other people will get infected. Some people I have spoken to have thought it is no big deal because 80% of the people get only mild symptoms (see yesterday’s post). Well, it is a big deal, because the more people get infected the more there will be of really sick people. Which will possibly put a huge drain on our health care system. That being said. DO NOT GO TO YOUR DOCTOR JUST TO GET TESTED. (Hopefully in the near future that will be the case) Firstly there are not nearly enough tests. If you feel sick CALL YOUR DOCTOR’S OFFICE FIRST or CALL YOUR HOSPITAL. They will guide you to testing if appropriate and to treatment. But when in doubt call your physician. (Make sure to buy a thermometer! Most places with telemedicine are going want to physically see you take your temperature!). All is NOT bad news. Many will be putting pressure on government to increase testing production. Research on potential treatment is proceeding at a speed that I have never seen before. Research on a vaccine is also proceeding in lightning speed, with the first human tests possibly starting in a few months. But right now, YOU can make the biggest difference. In conclusion, the time to make a difference is NOW. Hygiene is crucial. WASH those hands. Use towels to close and open doors. Avoiding places that are too crowded is also helpful. If you feel sick, stay home and CALL your health care professional. And remember, this is NOT a foreign virus. This is a virus. Period. It does not discriminate. So, chin up. Let’s stay healthy.
What about our dogs? Dogs cannot get the COVID-19, and because they are living creatures, we do not refer to them as “fomites” but as “vectors”. Vectors are intermediary living carriers of pathogens, in this case, contaminated droplets on their surface. If you walk the dog outside: (1) do not let anyone touch your dog, and (2) if your dog was in a potentially contaminated environment, consider giving them a quick bath. Avoid putting alcohol or chlorine solutions on your pets. Cats are much less likely to be an efficient vector for this virus, not only because they tend to avoid unfamiliar people, but they also sanitize themselves by constantly licking their fur and paws. No need to talk about other animals, and no, in the case of coronavirus, you do not have to worry about birds or insects!
Sanitizers are available in spray forms, which are especially helpful to decontaminate surfaces or fomites. A commercially available brand is Lysol spray, which contains a combination of alcohol and ammonia. There are also a variety of disinfecting wipes, but not all of them are effective! A popular brand is Clorox wipes which, as opposed to its name, do not contain bleach, but rather ammonium and alcohol.
