COVID-19

COVID-19 Basics

Q: What is COVID-19?

A: Coronaviruses can make humans and animals sick. Some coronaviruses can cause illness similar to the common cold and others can cause more serious diseases, including severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). COVID-19 is a virus strain, first identified in Wuhan, Hubei Province, China that has only spread in people since December 2019. The virus is called ‘novel’ because it is new. It has not been detected before this outbreak. Cases of COVID-19 are now being reported in every  country, thus the term pandemic. It is likely that the virus originally came from an animal and it  is now spread from person to person. Health experts are closely monitoring the situation because little is known about this new virus and it has the potential to cause severe illness and pneumonia in some people.

Q: How does COVID-19 spread and what are the symptoms?

A: COVID-19 is primarily spread through respiratory droplets from direct contact with a person while they are infectious, which means to become infected, people generally must be within six feet of someone who is contagious and come into contact with droplets when a person with a confirmed infection coughs or sneezes as well as touching objects or surfaces that were contaminated by droplets (like those from a cough or sneeze) from a person with a confirmed infection and touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads. COVID-19 symptoms are similar to many other viral illnesses and include common symptoms like fever, malaise, fatigue and cough. Less common symptoms include diarrhea, nausea and vomiting, muscle aches and pains, chills, nasal congestion, sore throat, runny nose, headache, dizziness, loss of taste and smell, abdominal discomfort, decreased appetite and weight loss. Late complications include blood clots, kidney failure and long term neurocognitive deficits. Some patients have had ongoing symptoms for months. Currently, these patients with “long COVID” are thought to have an autoimmune type of reaction to the virus and are being evaluated to better delineate this syndrome.

Q: How long does it take for symptoms of the COVID-19 to appear?

A: CDC believes at this time that symptoms of COVID-19 may appear in as few as two days, or as long as 14 days after exposure. There are isolated reports of individuals transmitting the infection to others before they develop symptoms (asymptomatic carriers). To be cautious, many governments are requiring an isolation period of 14 days for people returning from endemic areas. The length of time that a person is infectious (that is, can spread the infection to others) is not yet known. However, there is evidence of people without any symptoms or with minimal symptoms transmitting the infection to others. It is therefore likely that a person can spread the infection from before the time they first develop symptoms until up to 72 hours after symptoms stop.

Q: Who is most at risk of having more serious infectious outcomes?

A: From previous experience with other coronaviruses and after ongoing data collection with COVID-19, the people at highest risk of serious infection are:  people with compromised immune systems (including diabetics),  elderly people, pregnant women, healthcare workers, very young children and babies (although thus far, complications in children is rare), people with diagnosed heart, lung conditions including asthma, diabetes, hypertension and/or  obesity/overweight.

Q: How long does it take for the virus to clear from nasal passages (i.e. no longer infectious)?

A: Our understanding of the resolution phase for COVID-19 is evolving. Detailed virological analysis of patients demonstrated that shedding of viral RNA from sputum and nasal secretions outlasts the end of symptoms. The duration of viral shedding is uncertain, as is the potential for a recurrent positive viral nasopharyngeal swab. It has been our experience from all of the patients whom we have treated that the point of infection to the point of complete clearing from the nasal passages by PCR testing is approximately 37 to 40 days. It is probably not a coincidence that the term quarantine stems from the Venetian word quarantine, which means “40”:(https://en.wikipedia.org/wiki/Quarantine#Etymology_and_terminology).

The detection of viral particles in the nasopharnyx however, does not necessarily mean that one is still infectious. Studies have shown that this “fossil RNA” probably does not transmit disease, but simply resides there for some time. In our experience, most of our patients who test positive clear their SARS- CoV-2 antigen in two to three weeks at which point they do not transmit the disease.

Q: What are COVID-19 antibody tests?

A: COVID-19 antibody tests provide qualitative detection of IgM and IgG antibodies against SARS- CoV-2 in people suspected of COVID-19 and after vaccine administration. After infection with COVID-19 or after being vaccinated, the virus antigen stimulates the immune system to produce antibodies that can be detected in the bloodstream. Among these antibodies, IgM antibodies appear early and are mostly positive after 3-5 days of onset of symptoms. IgM titers then decrease while the IgG antibody potency starts to rise. During the recovery phase, the titer of the IgG antibody may increase rapidly. Combined with PCR testing, antibody tests offer a valuable tool in identifying infected patients. Antibodies are not detectable before 3 days before symptoms begin. Antibody tests can also detect past infection because virus-specific antibodies can persist in the blood for several weeks/months/years after onset of symptoms. Since the time of infection is often unknown, combining nasal swab testing for active disease, RT-qPCR and IgM/IgG testing can improve the accuracy of the COVID-19 diagnosis. Specific antibody testing for IgG will also show immunity gained after administration of the SARS- CoV-2 vaccination.

Q: Who should be tested?

A: It is our belief that there should be universal testing, however, given the limited number of available tests, antibody tests are recommended to be used on patients at least 3 days after symptoms begin or 7-10 days after infection with the virus. It is our belief that  all people especially at risk people like older adults over 65, people with chronic medical conditions like hypertension and diabetes, obesity  and/or an immunocompromised states that may put them at higher risk for hospitalization and who within 14 days of symptom onset had close contact with a suspect or laboratory-confirmed COVID-19 patient, or who have a history of travel from affected geographic areas within 14 days of their symptom onset.

Q:  Test limitations?

A: The tests are not yet approved by the FDA. The tests are for use in clinical laboratories by doctors under the Emergency Use Authorization Act. A negative result does not rule out infection, particularly in those who have been in contact with the virus. Follow-up testing with a molecular diagnostic assay should be considered to rule out infection in these individuals. Antibody tests results should not be used as the sole basis to diagnose or exclude infection or to confirm infection status. Positive results may be due to past or present infection with other coronavirus strains, such as coronavirus HKU1, NL63, OC43, or 229E.

Prevention and Treatment

Q: Is there a vaccine?

A: Currently, there are three approved vaccinations against SARS- CoV-2 that have also been approved under the Emergency Use Authorization Act. Two are novel mRNA vaccines that are given in a two dose series and have shown great efficacy. The third is a viral vector vaccine that is also very effective in protecting people against the most serious complications of the disease.

For further information about SARS-CoV-2 vaccines, please refer to the CDC website link here: 

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines.html

Q: How can I best protect myself and staff?

A: Practice the following:

1. Wash your hands often with soap and warm water for at least 15-20 seconds and dry them well. If soap and water are not available, use a hand sanitizer with at least 60% alcohol or benzalkonium chloride foam.
2. Wear a face covering that covers the mouth and nasal passages if you are in a public space that is distanced less than 6 feet or in direct contact with a known index case./suspected.
3. Avoid touching your eyes, nose and mouth with unwashed hands.
4. Avoid close contact (within 6 feet) with people who are sick.
5. Stay home when you are sick.
6. Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
7. Cough into your elbow when necessary. 
8. Standard household cleansers and wipes are effective in cleaning and disinfecting frequently touched objects and surfaces; however, in a certain  environments, hospital grade disinfection is suggested.
9. During flu and respiratory disease season, we strongly recommend getting vaccinated, taking everyday preventive actions to stop the spread of germs, and taking flu antivirals if prescribed.

Q: Should I wear a face mask? Will that help protect me?

A: It has been shown that masks do help to stop the spread of infection, especially if someone who is actively sick wears them. However, when it comes to COVID-19, it is unclear how effective protective masks are to the general public and they should be reserved for front line health care personnel. Currently the CDC does not recommend masks for healthy individuals. If you are not sick and do not have symptoms, maintaining proper infection control such as frequent hand washing and cough etiquette is the best form of protection. New evidence from the CDC has had them recommended wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies) especially in areas of significant community-based transmission.  The additional use of  a protective mask for those that are not sick is also to remind one to avoid touching one’s face.

Q: How is COVID-19 treated?

A: There is currently no outpatient FDA approved medication for COVID-19, although three are a few new oral antiviral medications currently in Phase III clinical trials that appear promising. Treatment outside of the hospital includes giving bamlanivimab and casirivimab plus imdevimab that are available under FDA EUAs for patients at high risk of disease progression and severe illness. Data suggest that some outpatients may also benefit from receiving anti-SARS-CoV-2 monoclonal antibodies early in the course of infection. Inpatient treatment includes care to support vital organ functions. Remdesivir is an antiviral medication approved by FDA to treat COVID-19 in the hospital. Dexamethasone is a steroid medication that is also recommended for patients who need supplemental oxygen to stop lung and systemic inflammation. In some cases, noninvasive mechanical ventilation may be appropriate. Avoidance of aspirin and nonsteroidal medications for pain and temperature control should be considered as there is evidence that a fever can induce a more robust antibody response, unless the symptoms are intolerable or potentially life threatening. There are times however when use of these medications is prudent as in situations where a patient has the potential to develop a blood clot.

Q: How long do you anticipate the situation will continue?

A: Currently, these measures should remain in place until most of the population is vaccinated and there is development of an effective outpatient oral medication.  COVID-19 is a new disease and the public health response to it has been one of constant learning and adaptation. Health experts and scientists around the world have responded quickly and the scientific literature is expanding daily, but there is still a lot to learn. It is anticipated that this new way of life will be in effect for at least the next year and a half until these other measures come to fruition.