This was the somewhat chilling, although not entirely unexpected, statement from Dr. Nancy Messonnier today, the director of the CDC’s National Center for Immunization and Respiratory Diseases. CDC officials now say it is inevitable that novel coronavirus disease (COVID-19) will spread through U.S. communities, given the virus’s increasing incidence outside of China. As such, the agency is preparing for widespread transmission in the U.S. “Disruption to everyday life may be severe,” warned Dr. Messonnier,
So what do we know so far and how can you plan? Specifically, how might that impact your care with Santa Monica Primary Care should there be significant disruption? For those of you who don’t follow me on Twitter (@santa_care), I will summarize what has been learned so far and what implications it has for our community and our practice.
In general, coronaviruses are important human and animal pathogens and are widespread among birds and mammals, with bats being host to the largest variety. Human coronaviruses probably account for 5 to 10 percent of all acute upper respiratory tract infections in adults with this number rising to one-third during epidemics.
Prior to this current outbreak, two other worrisome coronaviruses have been seen. In February 2003, a severe acute respiratory syndrome coronavirus (SARS-CoV) was first reported in China. By the the end of the worldwide outbreak in July 2003, a total of 8096 cases were reported, with 774 deaths and a case-fatality rate of 9.6%. In September 2012, a case of novel coronavirus infection was reported involving a man in Saudi Arabia and was termed Middle East respiratory syndrome coronavirus (MERS-CoV). Since then, more than 2400 laboratory-confirmed human infections with MERS-CoV have been reported with a case fatality rate of 34.3%.
Fortunately, the current COVID-19 outbreak appears far less deadly although is more transmissible. To date, there are over 80,000 COVID-19 cases of which about 2500 of these are outside China. The tally of U.S. cases has risen to 57 as more people who’ve returned from the Diamond Princess cruise ship have tested positive. There is only 1 case of COVID-19 in LA County, in a non-resident traveler from Wuhan City, and there has been no subsequent community transmission of the virus.
A recent JAMA study on more than 72,000 COVID-19 cases reported in mainland China, reveals a case-fatality rate of 2.3% and suggest most cases (81%) are mild, but the disease hits the elderly the hardest. Men are more affected than women as men have a fatality rate of 2.8% as compared to 1.7% among women. Specific case fatality rates are:
• Among those with chronic conditions (diabetes, heart disease, chronic lung disease): Up to 10%
• Among those with no history of chronic disease: Less than 1%
• Among those over 80 years old: 15%
• Among those 10-19 of age: Less than 0.01%
• Among those 0-9 years of age: 0%
The press thus far has compared the deadliness of COVID-19 to SARS or MERS. However, I think a more appropriate comparison would be to the case fatality rate of seasonal influenza which results in death in about 0.1% of cases.
Adding to the difficulty in containing this novel virus is its ease of transmission. A study of analyzing data from from the Diamond Princess cruise ship to calculate COVID-19’s reproductive number (R0, or the number of people a single infected person is likely to infect) showed an R0 of 2.28. By comparison, seasonal flu has a R0 of about 1.28.
So given all of the above, what can we do to avoid contracting and spreading COVID-19? First, U.S. travelers are now encouraged to avoid all nonessential travel to China and South Korea (level 3 travel warning). Iran, Japan and Italy have been bumped up to a level 2 travel alert. With level 2, the CDC recommends that people with chronic medical conditions and older adults consider postponing nonessential travel.
Next, taking personal measures to prevent infections is one of our best defenses against the potential spread of any virus, including COVID-19. Please practice good public health hygiene, including:
1. Staying home when you are sick.
2. Staying home when you are sick. (Duplication is intentional for emphasis!)
3. Washing your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing.
If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. .
4. Avoiding touching your eyes, nose, and mouth with unwashed hands.
5. Limiting close contact, like kissing and sharing cups or utensils, with people who are sick.
6. Cleaning and disinfecting frequently touched objects and surfaces using a regular household cleaning spray or wipe.
7. Covering your cough or sneeze with a tissue, then throw the tissue in the trash. If you do not have a tissue, use your sleeve (not your hands).
8. Getting a flu shot to prevent influenza if you have not done so this season.
I get a lot of questions about masks. The WHO notes that for people without respiratory symptoms, wearing a medical mask in the community is not required, even if COVID-19 is prevalent in the area; wearing a mask does not decrease the importance of other general measures to prevent infection, and it may result in unnecessary cost and supply problems.
All testing for COVID-19 is performed through the Los Angeles County Health Department and is only performed on patients who meet specific criteria. These include (so far) patients who have cough, shortness of breath and fever who have either had direct contact with a known COVID-19 case or a history of travel from Hubei Province, China within 14 days of symptom onset. There are no commercially available test kits.
There is no specific treatment for COVID-19 beyond isolation and management of symptoms with Tylenol or Ibuprofen, rest and hydration. The WHO and CDC recommend glucocorticoids (steroids) NOT be used in patients with COVID-19 pneumonia unless there are specific indications for such. This class of medication has been shown to increase mortality among those with MERS. Investigational agents are being explored for antiviral treatment of COVID-19 and vaccine candidates are being explored.
At Santa Monica Primary Care, we have already begun contingency planning for taking care of patients should there be disruption to basic services or if our physical office be forced to close. In such an event, we have the capability to roll out a functional virtual clinic.
As always, telemedicine consultations will be available with a physician on call 24 hours a day, 7 days a week. Simply call (310) 828-411 and you will get a call back We will work closely with affected patients, the County Health Department as well as our primary regional hospitals (Saint Johns, Cedars Sinai, UCLA and USC) to identify and triage any cases with severe manifestations. Our Medicare patients already have the option for home visits which, given the propensity for COVID-19 to affect the elderly more severely, will be a useful modality of care. Lastly, we have available a HIPAA-compliant video based consultation module to provide a closer link to patients that may be in voluntary or mandatory quarantine.
Finally, for those interested in real-time updates on COVID-19 cases, the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University developed an interactive web-based dashboard to visualize and track reported cases. It also illustrates the location and number of confirmed COVID-19 cases, deaths and recoveries for all affected countries.
As always, please contact us directly at (310) 828-4411 with additional questions or concerns. I will continue to provide updates via Twitter, Instagram and Facebook as the trajectory of COVID-19 develops.
