Living in a COVID-19 World
What is Covid?
Covid-19 is a communicable virus that appears to transmit easily through airborne droplets generated by speaking, sneezing, coughing, and possibly breathing. Contaminated surfaces are a risk primarily in spaces occupied by individuals ill with the disease and is probably not an important source of infection. Indications are that asymptomatic cases are a significant source of transmission.
PGL recommends you follow your local health jurisdiction’s guidance closely, but we will also provide information and advice based on what experts are saying in addition to the generic (and frequently non-specific) advice from government sources. Much of what we are seeing seems to be dated or repetitive.
The symptoms of Covid are surprisingly inconsistent but four symptoms tend to cluster in Covid and tend to appear before fever or difficulty breathing:
- Loss of taste or smell;
- Loss of appetite (skipping meals);
- Severe fatigue; and
- Severe or persistent cough.
Lost sense of smell/taste should trigger immediate self isolation.
Mostly, Covid resembles pneumonia (fever, cough, difficulty breathing). Other symptoms observed in more than 40% of cases include:
- Diarrhea (early symptom);
- Muscle aches;
- Headaches; and
Cases have presented as similar to heart attacks. Covid can also cause strokes, which always need to be managed early and aggressively.
Particularly in seniors, one feature of Covid can be depressed blood oxygen that they are not aware of (“walking pneumonia”). A pulse oximeter (can be purchased online or at large drug stores for about $40) is an easy way to monitor blood oxygenation.
Covid’s incubation period is normally 4-5 days. The range of incubation periods is 2.2-11.5 days (97.5% of cases). This is the basis for isolating for 14 days after potential exposure. Viral shedding appears to start about 2.4 days before symptoms occur and peak about 17 hours before. In-home transmission is likely about 10%.
Guidance on self-isolation if you have been exposed to someone with coronavirus disease (for example: http://www.bccdc.ca/health-info/diseases-conditions/covid-19/self-isolation) indicates 14 days at home, no contact with others to the extent possible, including not doing your own shopping. After experiencing potential coronavirus disease, recommendations are isolation can end after all these are true:
- No sooner than seven days after onset of symptoms;
- Three days fever-free with no fever medication; and
- Marked improvement in respiratory symptoms.
When hospitalization occurs, it is roughly five days after onset of symptoms. Fever is absent in as much as 30% of ICU admissions. Cases that don’t become serious generally fully recover in 7‑14 days after symptoms appear. Median hospitalization is 11 days from admission (or 16 from first symptoms).
Based on US experience, false-negative rates on testing are declining, but remain high (probably 10%). Factors include (a) poor timing of the test, (b) poor sampling technique, and (c) variable viral shedding that is not well understood.
Available information indicates that:
- For 80% of humanity, this is a mild illness. Hospital admission occurs in about 19% of cases. 5% will be admitted to ICU;
- Severe cases present themselves in various ways and appear to be as much caused by aggressive immune responses as by the virus itself;
- Adults have similar rates of hospitalization; children have low risk of hospitalization;
- Morbidity risks from Covid increase rapidly with age from age 40;
- Smoking and pre-existing health conditions (especially immunocompromised, COPD and serious heart conditions, type 2 diabetes, sickle cell disease, and obesity (BMI>30)) seem to dominate risk of serious complications/morbidity;
- Serious cases seldom require less than a week of respiratory support, and often require weeks of respiratory support;
- Case fatality rates (effectively, percentage of diagnosed cases that die) are higher than the actual fatality rate (what are your chances of death if you contract it) but how much will likely never be known. It is likely under 1% for those with no underlying conditions. Country/province experience varies tremendously for statistical, testing as well as population and health system reasons. For context, a bad flu season typically runs 0.1%, and the Spanish Flu is estimated to have been in the 3-3.2% range (high uncertainty).
- Viral load seems to matter; those who get larger exposures seems to get more severe effects
Some Key Facts
This is a respiratory disease. Airborne transmission from droplets generated by speech is probably the mechanism in the vast majority of cases.
The virus can extend beyond respiratory in some cases, with effects on kidneys and clotting among the most common; whether this is indicative of infection or the viral inflammation syndrome is uncertain, but initial infection appears to be upper respiratory.
- Whether people are actively displaying symptoms is not a good indicator if they are infectious, the virus is essentially silent in a significant number of people. The number is uncertain, but informed estimates suggest it is 20-70%, and likely over half.
- While the virus can survive for extended periods on hard surfaces (hours or even days), its infectivity is believed to drop exponentially (roughly a 6hr half-life). Dry porous surfaces (like cardboard or paper) are generally virus free in 24hrs. For people who aren’t immunocompromised to get sick requires either a load of viral particles to lungs or mucous membranes, so surfaces are generally a low risk. Exposure to sun reduces infectivity.
- You should expect that you will get it eventually, as it is very communicable. The idea here is to spread out the cases as much as possible so that those who are seriously affected can get adequate medical care with the available capacity, and to allow time for effective treatments to be developed. Responsible estimates suggest 30-70% of humanity will contract this within a year.
- People with respiratory diseases are considered seriously at risk, but it isn’t simple. Smokers appear to have been very high risk based on the Italian experience. Liver disease is a notably high risk. Asthma does not appear to be a high-risk factor, contrary to initial expectations.
- At this time, responsible estimates suggest the earliest we might expect a vaccine is early 2021, with mid-2021 more realistic. Vaccine development success rates generally have been in the 5-10% range. There are at least 224 serious vaccine development efforts underway (as at May 24), most in North America and mostly private sector. At least five different families of approach are being followed. Mumps was the fastest vaccine developed, at four years, so even 18 months would be unprecedented. Any vaccine that might be given to billions of people needs to be thoroughly tested, to ensure that side effects are infrequent, understood and acceptable.
- Vaccines for coronaviruses particularly, and upper respiratory tract infections generally, are known to be difficult. Experience in developing a virus for SARs confirms that the upper respiratory tract has a weak immune response generally, and that vaccines that materially enhance the immune response there can make things worse by increasing inflammation. Reading between the lines, it looks like a vaccine is a bit of “hail Mary”, but a target because it would solve many problems and make a tonne of money for the vaccine industry even if they didn’t own it (we are talking billions of doses, after all). In any event, prevention and treatments are going to be more important in the short term.
- That Covid provides immunity is being assumed by many of the public, but this has yet to be demonstrated. Early indications are that it will not be like chicken pox (one bout gives lifetime immunity). The common cold (a coronavirus) gives about a 12-month immunity period. Early indications are that many but not all people develop blood markers of immunity after recovering, so blanket immunity following infection is unlikely.
- Although the virus may abate somewhat in warmer weather, it does not appear to be enough to prevent outbreaks from spreading.
- Coronaviruses are common in animals of all kinds. Testing indicates that ferrets and cats can be infected and are symptomatic hosts of Covid, dogs can be infected but are poor hosts and generally asymptomatic if infected, and pigs and poultry are not vulnerable. None of the vulnerable animals seems to be as vulnerable as humans. Consider this in deciding on limiting exposure to animals.
- Early analyses indicated that the Ro (“R naught”) (number of people an infected person infects) is around 2.3-2.7. Some research indicates that where vigilance is not high, Ro numbers for Covid are over 5. This is significant because Ro determines the threshold for herd immunity. At around 5.6, herd immunity would require that 82% of the herd be immune, instead of 55% (this level of herd immunity gets Ro down below 1).
- Social distance – 2m – is believed to be the best protection we have. This is because droplets from speaking and coughing will seldom, if ever, travel this distance. If you are outdoors, so much the better. The virus seems to do best in the 10-15C degree range, and at moderate humidity, not doing so well at high or low humidity. Most viruses have low UV-resistance. Gardening is probably an excellent activity.
- This article discusses the issue of management strategies in the medium term: https://medium.com/@tomaspueyo/coronavirus-the-hammer-and-the-dance-be9337092b56
- The advice not to touch your face is extraordinarily difficult to implement. I’m not suggesting you ignore it, but you won’t be able to, so just be realistic.
- After you have been in spaces where surfaces might be affected, wash your hands with soap and water for at least 20 seconds (sing “Happy Birthday”), and then dry thoroughly. If soap and water is not available, hand sanitizer with at least 66% alcohol is second best. Higher alcohol is not better, as the water content actually helps the sanitizing effect. Sanitizers are meant to disrupt the lipid layer that protects viral particles. Soap is better, as the foam helps disrupt this lipid layer. Warm water helps melt the lipids and warm water foams better. 65% alcohol is required to dissolve the fat layer. Bleach actually attacks the protein load of the virus (1 part bleach to 5 parts water). Bactericides are ineffective, as viruses are not alive. Vinegar or acids do not affect the fat layer.
- The virus cannot go through healthy skin, but avoid cracked or chapped hands, as this makes you more vulnerable. Use moisturizers to minimize hand damage.
- Shaking fabrics or dusting can re-suspend viral particles, so avoid this.
- Viral particles are preserved by cold, so freezing or refrigerating something will not reduce viral loads on surfaces. The exterior of items that are refrigerated, in plastic, glass or metal containers, or covered with plastic film will be the most likely to host viable virus picked up during the handling process.
- Gloves or mitts are an option (even regular winter gloves), but think about having something washable, or rotate your gloves to allow them time to naturally disinfect (leave them in the sun, which will help).
- Face coverings have not been demonstrated to be directly effective, but indirect evidence suggests that they are useful to protect others, and may offer some protection to you. We recommend wearing face coverings inside public spaces.
- Activities with face-to-face talking and singing nearby are likely to be high risk.
- Food transmission has not been identified, as this is primarily respiratory. Heat treating to 63C for 4 min (i.e., cooking) reduces viral contamination by a factor of 1000, and viruses do not reproduce in food, they need a live cell to do that work.
- Disinfecting surfaces before you touch them is probably not practical. Instead, consciously avoid eating and drinking in “uncontrolled” spaces, and wash your hands first thing you return to spaces where the risk is low.
- If you want to reduce risk of transmission inside your family, one measure you can implement is having dedicated towels (wash towels, then have assigned towels for each person).
- Consider eliminating use of contact lenses in public, to reduce touching face in uncontrolled environments.
- A very small hospital study has linked vitamin D deficiencies to serious cases. The logic that this might be the case is compelling. Given that Vitamin D is benign, it might not be a bad strategy to make sure you are getting 1000IU daily. Outdoor sun exposure will begin to generate Vitamin D at Canadian southern latitudes in May (April sun intensity is generally too low). Similar effects have been related to Vitamin K.
- Exercise is important to maintaining the health of your immune system. Being at home will make it easy to overeat, so consider this as a great opportunity to start doing those runs/rides/extended walks. You don’t need equipment or much space: do body exercises likes pushups, crunches, planks, squats. Lots of good resources online on technique (if you do these, try to do them right, get feedback from a friend or partner).
- I highly recommend meditation to manage stress. Two resources I recommend are Headspace (a subscription app) and Insight Timer (free). Both offer guided meditation.
- I have been asked why, if risks from surfaces are so low, that handwashing etc. is still being so consistently recommended. The same things might be said about the use of thermometers in relation to air travel. Neither is particularly protective, but they give a psychological boost, by giving us some sense that we have control. That you can’t get it easily from surfaces, and that elevated temperature (a) probably lags infectivity (b) is absent in a significant fraction of those with Covid isn’t comforting, so no one talks about it.
- In considering how to protect yourself in the case of necessary air travel, a respirator and goggles or face shield will be highly likely to protect you. The air filters in aircraft are very effective, but the ventilation systems have to pick up the air before it can be filtered, so if someone behind you sneezes (or talks), droplets will be released. In aircraft you share the air space with a chunk of the passengers, but not everyone.
With these measures in mind, you can socialize with family and friends, while still slowing the transmission of Covid.
Where is this Going?
Looking at Canada, we seem to have been lucky so far. While we were hit hard, we seem to have been successful in suppressing the virus, pushing it to declining numbers. The American “experiment” however demonstrates that at this point, relaxing distancing in public is hazardous. The US has a number of strikes against it in fighting the virus at the moment compared to Canada, most notably (a) poor wage support and many losing health insurance, forcing people to work when risks are not controlled, (b) resistance to mask-wearing and contact tracing, (c) confusing and inconsistent leadership response leading to inconsistent participation in distancing, mask wearing and tracing, and (d) complacency/lockdown fatigue.
Until we understand the disease better, masks and distancing are likely here to stay.
We have not yet had a second wave. At the moment, what we are seeing in countries further along this process, are outbreaks at the tail of the first wave (see Tomas Pueyo’s article above). For jurisdictions that can test, trace and isolate, they will likely retain control unless or until they have a vaccine. However, in places like Brazil, the US, Russia, and the UK, the disease is so widespread in the community right now (late June) that even good test and trace is inadequate, only physical distancing and similar measures will be adequate to have the curve going the right way. Test/trace/isolate is a late stage process that requires high compliance in the population (willingness to support tracing, specifically).
That said, public health isolation orders need to be targeted to be seen as fair and reasonable. For example, enforcing isolation across a county is not going to be seen as granular enough until it is proven that this is only way to do it. People have limited tolerance for the shutdown features, and will likely only comply at appropriate levels if the measures are seen both as strong and fair. Whether Canadian jurisdictions are wise enough, remains to be seen.
Insofar as a second wave is concerned, if we don’t relax, the first wave is just going to flatten out and there will be no recognizable second wave. Covid will just continue in the background. As people move inside in the fall, whether we have a second wave as such is going to depend on whether we do a decent job at physical distancing, and test/trace/isolate. Treatments and vaccines will likely make things worse in the short run, as they will likely promote complacency. So we are going to have to learn to make some of these lockdown habits, to protect ourselves and others.
Last updated: June 30, 2020
Disclaimer: This information represents the opinion of Will Gaherty (PGL’s President), and is being used by PGL as our main guidance.
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