Living in a COVID-19 World

This is a rapidly changing and unfolding public health emergency. Covid-19 is a communicable virus that appears to transmit easily through close contact and more-than-negligibly by contaminated surfaces. Indications are that asymptomatic cases are a significate source of transmission. Community transmission is widespread in Canada.

We recommend 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.

Symptoms

The symptoms of Covid are surprisingly inconsistent, but four symptoms tend to cluster in Covid in a way that these same symptoms do not cluster in other alternative illnesses 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.

Generally, Covid resembles pneumonia (fever, cough, difficulty breathing). Other symptoms observed in more than 40% of cases include:

  • Diarrhea (early symptom);
  • Muscle aches;
  • Headaches; and
  • Chills.

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 until symptoms become severe. A pulse oximeter can be purchased online or at large drug stores for about $40 and is easy to use.

Covid’s incubation period is normally four to five days. The range of incubation periods is 2.2 to 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. Estimates in China (which don’t account for asymptomatic cases) indicate 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
  • 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 to 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 likely in the 30% range, probably mostly because of (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;
  • Adults have similar rates of hospitalization; children have low risk of hospitalization;
  • Morbidity risks from Covid increase rapidly with age from age 40;
  • Pre-existing health conditions (especially immunocompromise, cardiovascular disease, diabetes, smoking and obesity) 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); and
  • Viral load seems to matter; those who get larger exposures seems to get more severe effects.

This is going to go on for weeks or months, and for most of us, holing up at home and only having remote contact with other humans is not going to work. Each of us must create a new normal for now.

Some Key Facts

  1. This is a respiratory disease. Airborne transmission from droplets in coughing and speaking is the primary exposure risk. The virus can extend beyond respiratory in some cases, with effects on kidneys and heart inflammation 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.
  2. 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% or a little less. Iceland, which has the highest testing rate in the world, had asymptomatic rates approaching 50%.
  3. While the virus can survive for extended periods on hard surfaces (hours or even days), its infectivity is believed to drop exponentially (roughly a 6-hour half-life). Dry porous surfaces (like cardboard or paper) are generally virus free in 24 hours. 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.
  4. 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.
  5. 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 risk factor, contrary to initial expectations.
  6. 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 to 10% range. There are at least 79 serious vaccine development efforts underway, most in North America and mostly private sector. At least five different families of approach are being followed. Mumps was the fastest at 4 years, so even 18 months would be unprecedented. As well, 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.
  7. 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 12mo 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. That said, early testing of treatment plasma from recovered individuals was promising; Canada is a leading research centre for this treatment approach.
  8. This article discusses the issue of management strategies in the medium term: https://medium.com/@tomaspueyo/coronavirus-the-hammer-and-the-dance-be9337092b56
  9. There is some data that suggests this will abate somewhat in warmer weather, but this is far from certain. The US National Academy of Sciences thinks not and spread in summer in some countries like Iran and Australia argues for limited effect.
  10. 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 generally vulnerable. None of the vulnerable animals seems to be as vulnerable as humans. Consider this in deciding on limiting exposure to animals.
  11. Early analyses indicated that the Ro (“R Naught”) (number of people an infected person infects) is around 2.3 to 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).

Managing It

  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 to 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.
  2. 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.
  3. 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.
  4. 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.
  5. Shaking fabrics or dusting can re-suspend viral particles, so avoid this.
  6. Viral particles are preserved by cold, so freezing or refrigerating something will not reduce viral loads on surfaces.
  7. 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).
  8. While a face covering looks like a good measure, avoid consuming supplies required by first responders and health care workers. Make or buy a fabric face covering. Face coverings are primarily to protect others, not to protect you.
  9. Food transmission has not been identified, as this is primarily respiratory. Heat treating to 63C for four minutes (i.e., cooking) reduces viral contamination by a factor of 1,000, and viruses do not reproduce in food, they need a live cell to do that work.
  10. 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.
  11. In terms of grocery, cold preserves viruses, so 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.
  12. 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).
  13. Consider eliminating use of contact lenses in public, to reduce touching face in uncontrolled environments.
  14. 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 1,000IU daily. Outdoor sun exposure will begin to generate Vitamin D at Canadian southern latitudes in May (April sun intensity is generally too low).
  15. 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-weight exercises like push-ups, crunches, planks, squats etc. Lots of good resources online on technique (if you do these, try to do them right, get feedback from a friend or partner).
  16. I highly recommend meditation to manage stress. Two resources I recommend are Headspace (a subscription app) and Insight Timer (free). Both offer guided meditation.

With these measures in mind, you can socialize with family and friends, while still slowing the transmission of Covid.

Keep smiling, it will help your immune system.

-Will

Last updated: May 12, 2020

Disclaimer: This information represents the opinion of Will Gaherty (PGL’s President), and is being used by PGL as our main guidance.

To download this as a Word Doc, please click here.