- Tight restrictions in the United States will continue. The president has announced that federal guidelines requiring most Americans to avoid non-essential travel, non-essential work, eating at bars and restaurants, and gathering in groups of more than 10, would be extended at least through April 30, 2020. Many states and local governments have stricter directives that take precedence over the federal guidelines. When restrictions are removed, the rate of new infections may start going back up.
- Stay away from people as much as you can. The primary route of infection is person-to-person. The most common source of the virus is the air that you breathe near an infected person, since a sneeze or cough can carry respiratory droplets six feet away, and the virus can remain in the air up to three hours before dropping to the ground or the nearest surface.
- Wash your hands every time you touch something. The virus lives longest on hard surfaces such as metal, glass, cardboard or plastic. One study showed that it can live on most metals for about 3 hours, copper-4 hours, cardboard-24 hours, stainless steel-13 hours, and plastic-16 hours (NEJM, Mar 17, 2020). However, most virus particles break down in minutes or hours outside a living host, and you are far more likely to acquire the virus directly from another person. The most effective way to get the virus off your hands is to use soap and water and wash for at least 20 seconds every time you touch surfaces such as a door handle, ATM machine, toilet flusher, shopping cart and so forth. Do not wash your hands with very hot water or alcohol as they can damage your skin.
- Wear homemade face masks in public places. Most face masks will not prevent the virus from entering your mouth or nose, but they can discourage you from touching your face with hands that may be contaminated. They can also help to keep you from infecting other people, since they will block your coughs or sneezes from becoming airborne. Medical-quality masks are in short supply and should be reserved for health care workers, so ordinary citizens are now being encouraged to make their own cloth masks, which can be washed in soap and water after each use. A variety of designs and instructions for making masks are available on YouTube, and even a bandana is more effective than nothing. The CDC may soon issue new guidelines for wearing homemade masks whenever a person is out in public. Plastic or rubber gloves and disposable gloves are not very practical since they need to be washed or changed every time you touch something that might be contaminated with the virus, but you may want to use them in high-risk environments.
- At this time there are no drugs that have been proven to cure COVID-19. The FDA has authorized use of the anti-malarial drugs, chloroquine phosphate and hydroxychloroquine (Plaquinil, also used to treat rheumatoid arthritis), even though they have not been proven effective or safe for COVID-19. More on studies of these drugs below. Pain medicines such as Tylenol or ibuprofen can help patients feel better but do nothing to hasten healing, and some studies suggest that they may hinder the person’s immune system in its fight against the virus (BMJ, March 17, 2020;368:1086).
Many other drugs and combinations are being studied. For one of the best reviews I have seen on what we know so far about drugs to treat COVID-19, go to Management of Patients with COVID-19. The World Health Organization (WHO) maintains an “Outline of designs for experimental vaccines and therapeutics“, which lists drugs currently being tested.
Intravenous hyperimmune globulin injections from the blood of recovered persons, and monoclonal antibodies, look like they will be very effective and will be available very soon (JAMA, published online March 27, 2020). Blood from patients who have recovered from COVID-19 contains IgG and IgM antibodies that can kill the virus (JAMA editorial, March 27, 2020) Blood tests will soon be approved to see if a person has been infected with COVID-19 and is therefore now immune. These people may then be able to treat people who are currently infected, and to donate blood with the antibodies that could be helpful in treating COVID-19 patients.
Trials for a vaccine for COVID-19 will start in May 2020 (NIH News, March 16, 2020), and we should have a vaccine to prevent infections in 12 to 18 months.
Symptoms and Progression of COVID-19
• When you are infected, you may have no symptoms at all. Symptoms usually develop 2 to 10 days after you acquire the virus. Symptoms may begin like the flu but go on to develop fever, cough, and shortness of breath. The virus lives in your nose and throat and then can go down into your lungs. You may also suffer belly cramps and diarrhea, and the virus can be transmitted in the stool (Gastroenterology, accepted Feb 27, 2020, not yet published).
• COVID-19 is dangerous because it can infect your lungs and fill them up with mucus to smother you. It can cause your immunity to become so active that the same cells and chemicals that attack germs can attack you (called “cytokine storm”). The people most likely to suffer severe consequences from this infection include people over 65 and those who have diabetes, high blood pressure, heart disease, lung disease, kidney disease, asthma, immune defects, HIV, bleeding or clotting defects, or auto-immune diseases. Possible effects on pregnancy or unborn children are not yet known. Some patients appear to suffer long term heart damage after COVID-19 infections (Lancet, March 28, 2020;395:11054-1062).
• Infected people keep the live virus for an average of 20 days (Am J of Resp and Crit Care Med, Mar 23, 2020), and can continue to be contagious for up to 37 days, even if they have no symptoms (The Lancet, March 11, 2020). Sputum samples remain positive up to 39 days and stool samples for 13 days (Annals of Internal Medicine, March 30, 2020).
More on the Studies of Drugs to Treat Serious Cases of COVID-19: Six studies now show that three of the drugs currently being tested are helping to save lives in some of the most dificult cases of COVID-19:
• chloroquine, discovered in 1843 and used to treat malaria,
• hydroxychloroquine (Plaquenil), approved in 1955 for various autoimmune diseases as well as malaria, and
• azithromycin (Zithromax) approved in 1980 and used to treat bacterial infections.
1. Dr Stephen Smith, of East Orange, NJ, reports that he has treated 72 COVID-19 patients, most of whom were morbidly obese (over 300 pounds), diabetic or prediabetic, with hydroxychloroquine and azithromycin for five days. None of the patients required intubation (a ventilator). This followed a Seattle study of 40 patients, of whom half were diabetic or prediabetic, using the same drug combination. None had to be put on a ventilator, but two of the 40 patients developed irregular heartbeats.
2. A French study found that five days of this same drug combination completely eliminated the virus from the nose and throat in 30 patients, compared to 10 percent in the control group and 50 percent of those receiving only chloroquine (J of Antimicrobial Agents, March 17, 2020).
3. Chloroquine has been reported to reduce symptoms and hasten recovery in several small studies (Biosci Trends, Mar 16, 2020;14(1):72-73).
4. A Chinese study of 62 patients showed a marked reduction in fever and cough in patients receiving hydroxychloroquine. This is a preprint and has not yet been published.
5. Hydroxychloroquine was found to be significantly more potent than chloroquine in killing COVID-19 (Clinical Infectious Diseases, March 9, 2020). A loading dose of 400 mg twice daily of hydroxychloroquine given orally, followed by a maintenance dose of 200 mg given twice daily for four days, reached three times the potency of chloroquine given 500 mg twice daily for five days
6. Unpublished work by Dr. Vladimir Zelenko of Monroe, NY, reports that he has successfully treated patients with a five-day course of hydroxychloroquine 200 mg twice a day, azithromycin 500 mg once a day, and zinc sulfate 220mg once a day. I am concerned that both hydroxychloroquine and azithromycin can cause irregular heartbeats, and close to 10 percent of North Americans are at risk for irregular heartbeats. We will await future studies on the effectiveness and safety of this combination of drugs.