1. What is Covid-19?
Covid-19 is a new type of virus in the group of viruses called “coronaviruses” because under the electron microscope they look like “crowns”. It causes a more severe infection than most other viruses. It was discovered in Wuhan (a city of 12 million in China) in late December, 2019.
2. How does it compare with the Flu?
The flu causes 400,000 deaths worldwide each year, but can be prevented by the flu vaccine. Covid-19 is expected to kill many millions worldwide (at least 10 times as many) and there will be no vaccine for Covid-19 for another 12-18 months.
3. How does it compare with the greatest of past virus pandemics?
The “Spanish Flu” killed 17.4 Million people worldwide between 1918 and 1920. It started in New York City during World War I and spread from there to Europe, but was called “Spanish” because Spain was neutral during the war so reported the epidemic, whereas the other countries tried to keep it secret so their enemies would not think they were weak. Such a Flu now would be a smaller and much less deadly epidemic, but at that time most people were poor, malnourished, and undergoing devastating war so were very susceptible, and most of the deaths were due to bacterial pneumonia which now can be cured with simple antibiotics. Deaths from Spanish Flu were mostly in infants and young people, whereas deaths from Covid-19 are mostly in persons over age 60 and/or with other serious health problems.
4. How is Covid-19 spread from one person to another?
Tiny droplets of moisture containing virus enter the air when an infected person speaks or coughs, and these droplets enter another person’s nose, mouth or lungs during breathing. Some droplets land on surfaces. Also when an infected person touches any object or another person the viruses on the infected person’s hands sticks to that surface or person. Then anyone who touches the contaminated surface or object, or has been contaminated by the infected person, will have virus sticking to them and will eventually transfer it to their own respiratory tract by touching their eyes, nose or mouth, and may also transfer it to someone else.
5. How long can the virus survive outside the body?
3 hours in the air.
24 hours on cardboard.
2-3 days on plastic or stainless steel.
6. How advanced is the epidemic in the United States?
Researchers have determined Covid-19 virus has been circulating in some United States communities undetected since early January, 2020. The U.S. has been slower than several other countries to implement testing to identify and quarantine infected persons to slow the spread, so a large epidemic is expected. It was expected that between 30% and 65% of all Americans (95 to 214 Million) will become infected over the first year, 2.4 to 21 Million will require hospitalization, and 200,000 to 1.7 Million will die from the virus. The eventual numbers will depend on how successful are efforts to make it spread slowly enough that the hospitals will not run out of personnel and beds needed to keep up with the number of new critical cases (925,000 hospital beds including 100,000 critical care beds in the U.S.) It is estimated that there are 5 to 10 infected persons in the community for every person diagnosed with Covid-19 infection in the community. We are advised to assume everyone we meet may be infected and that every surface we touch may harbor virus.
7. How long will this pandemic last?
It will come in repeated waves every winter for 2 years.
8. What is the time frame of Covid-19 infection?
Onset after exposure:
1-14 days (average is 5-6 days)
Duration of Illness:
a. Mild Cases: 2 weeks
b. Severe to Critical Cases that recover: 3 weeks
c. Fatal Critical Cases: Time to death 2-8 weeks
9. What are the symptoms of Covid-19 infection?
Dry Cough 68%
Exertional Dyspnea 18%
Musculo-skeletal pain 15%
Sore throat 14%
Nasal Sx 5%
The usual course is a fever, then onset of dry cough, then if it worsens there is shortness of breath after several days. Nasal congestion and GI symptoms rarely occur and are usually due to cold or flu. Some people have loss of sense of smell as a first or later symptom of Covid-19.
10. What will happen during the course of the illness?
A. Many healthy younger persons will have mild cases with no or minimal symptoms or self-diagnosed with a “cold” and will not be diagnosed. 25% of infected persons, including 13% of infected children, are contagious and never have symptoms. Persons do not feel sick until 48 hours after they are contagious.
B. Of those with a confirmed diagnosis of Covid-19 infection the following severity of courses can occur:
81% Mild to Moderate:
Mild: Lasts 2 weeks. Usually starts with fever; sometimes a few days go by before a fever. Dry cough, sometimes achiness and fatigue. High risk patient can evolve to “Moderate”
Moderate: Cough, fever, chills, a feeling of inability to get out of bed. May progress, especially in high risk patients, to exertional dyspnea and become a “Severe” case, may become dehydrated or hypoxic and require IV fluids and/or Oxygen. Can evolve to life-threatening pneumonia
Lasts 3 weeks.
A high risk patient can progress from “Severe” to “Critical” in hours to days
Hypotension, organ failure, severe pneumonia. Require ICU care with mechanical ventilation. Nearly half can die in 2 to 8 weeks. (2.9% of cases confirmed in U.S. to date have died.)
11. How many who get infected with Covid-19 will die from it?
The only measurement available is called the Case Fatality Rate. It is the percentage of cases that have a confirmed diagnosis who die. It varies with the number of people who are actually diagnosed so depends on having symptoms and having testing available so is not the percentage of all persons who are infected. It also depends on factors that influence survival, including the level of medical care available and the training of medical personnel, as well as the ability of individuals to recover which depends on their age and medical comorbidities.
Data From China: In January the Case Fatality Rate (CFR) was >20% in Wuhan and 17.3% in China overall. During that time the standard of care was evolving and in February the CFR was 5.8% in Wuhan and 0.7% in the rest of China.
Global Data: The CFR was 3.48% globally 3/18/20 (3.86% in China and 2.34% in the rest of the world.)
12. What is the effect of age on dying from Covid-19 infection?
The risk of dying from Covid-19 is about 10 times as high as dying from influenza at any age:
Age 0-50: <1% vs. <0.1%
Age 50-59: 1.3% vs. 0.06%
Age 60 and older: 6% vs. 0.8%
Risk of death by Age
Risk of Death by Comorbities
13. What are the expected statistics in Tulare County (population 465,000)?
140,000 to 310,000 cases of Covid-19 infection over next year
2,100 to 31,000 require hospitalization (conservative estimate 7,250)
175 to 2,480 die (conservative estimate 700)
14. Center for Disease Control (CDC) scenarios for U.S. (population 330 Million):
Conservative (more optimistic) Scenario
96 Million (30%)
5 Million (5.2%)
Worst Case Scenario
New Cases: 160-214 Million (50-66%)
Hospitalizations: 2.4 to 21 Million (1.5%-10%)
Deaths: 200,000 to 1.7 Million (0.125%-0.8%)
15. How can I prevent spreading Covid-19 infection to others and prevent catching the infection?
If you have been exposed to someone known to have the virus, or if you have a fever and any cough, stay home and away from other people until 3 days after all symptoms of the virus have resolved. If it is a severe hardship to stay home, get tested to find out for sure if you have Covid-19 infection. Until certain, stay home. Always wear a mask when outside your home or less than 6 feet from another person, especially if you have a cough, to reduce the risk of others contacting your respiratory droplets. If no mask, always cough or sneeze into your elbow, sleeve, or a large tissue which should be immediately discarded in a secure waste container.
A 14 day Quarantine is required for your household if even one household member is infected with Covid-19 virus (no one can leave the house and no one else can come in for 14 days)
Stay away from any person with any symptoms of a viral infection and from areas of increased risk such as nursing homes, medical waiting rooms, public transportation, churches, schools, crowded stores and any other large gatherings of people such as professional and business meetings and public sports and entertainment events. Shop only for essentials, going when the store is least busy, disinfecting the shopping cart, and washing hands after unpacking at home.
The severity of the crisis was just being recognized about 3/18/2020, so that these restrictions were tightened as follows: avoid traveling, shopping, visiting and receiving visitors, going into a restaurant or bar, and being in any gathering of more than 10 people.
High risk persons (over age 60 and/or with cardiovascular disease, Diabetes, COPD, cancer or immunocompromised state) under the latest guidelines must stay home and stay away from other people, especially children. Low risk persons should resupply them with food, medicines and other essentials. (These guidelines were tightened 3/18/2020 because, when these vulnerable patients are infected with Covid-19 virus, they are much more likely to have a severe case requiring hospitalization or a critical case requiring ICU care with mechanical ventilation and high risk of death. If too many of this group becomes infected, the hospitals will not have enough beds and staff to treat them all and many more will die.)
Social Distancing: Stay 6 feet away from other people, even when wearing a mask. Avoid shaking hands; instead use alternate types of greeting such as bumping elbows or a variety of gestures shown on social media. Avoid traditional kissing on the cheeks or lips.
Wash your hands with soap and water for 20 seconds, or 60-95% alcohol-based hand rub, compulsively and frequently, every time you come in contact with someone or with any surface or object that could have become contaminated by a cough or touch, or if you yourself are infected. Turn off the water faucet with a paper towel or with your elbow to avoid recontamination. If available use gloves for touching doors, keypads, shopping carts, etc.
Disinfect surfaces frequently with bleach, alcohol or EPA approved disinfectants if there is a possibility they could have been contaminated by you or someone else. Medical facilities should disinfect all exposed surfaces frequently at least daily, and areas with high use such as exam and treatment rooms after every patient. If supplies run out, use soap and water.
Avoid touching your own face, nose, mouth or eyes with your hand for any reason. Instead touch with a tissue.
Policy for Preventing COVID-19 Transmission and Mortality
1. Patients older than age 60 or those with known cardiovascular disease will not be seen for routine office visits until the epidemic has sufficiently subsided or they become infected and are fully recovered.
2. Patients older than age 70 or those with Diabetes, COPD or cardiovascular disease will not be given immunosuppressive therapy if the risk of Covid-19 death is greater than the risk of not treating their other disease. After they check in, such patients will be asked to wait in their cars instead of the waiting room
3. All patients will be notified to not come into the office if they have had a fever or dry cough or any other flu symptoms within the past 24 hours, or if they have been near someone with proven Covid-19 infection or traveled outside the country within 30 days, but to call to reschedule their appointments.
4. Visitors are not to accompany patients into the office unless a special exception is made for special needs. No guests, only patients, will be allowed in the chemotherapy area.
5. All persons coming to the office must put on a mask when leaving home and must wear it the entire time they are at the office and afterwards until they arrive home.
6. When patients first arrive, they must wait outside until they have been cleared by medical personnel. They must have their temperature checked, and they must leave if they have a fever >100.0 degrees, a cough, or other flu symptoms, or if they have had any of these within 24 hours. They must complete a questionnaire to identify their risk factors for having the virus and for dying if they catch the virus. Those at high risk of having the virus will not be allowed in the office but will be sent home, for the protection of other patients. Those at high risk of dying if infected will be sent to wait in their cars, and their cell phone number or car description will be recorded so they can be called in at the right time.
7. All personnel have been tested at baseline for Covid-19 infection and are negative. Any personnel who later develop fever, cough or other flu symptoms, or have a known exposure to the virus, must be immediately retested and stay home until the results are available.
8. All personnel must wear masks at all times when near other employees and to wear M95 masks and eye protection when near patients. They are to avoid shaking hands with anyone but to use alternative greeting methods. All personnel must make every effort to stay more than 6 feet away from other persons. They must follow the same precautions outside work as they do at work, including wearing a mask, to protect others and to avoid developing Covid-19 infection and then bringing it into the office.
9. All surfaces that could be contaminated by cough or other respiratory secretions or by patient or employee touch are to be disinfected with bleach, alcohol or other EPA-approved disinfectant daily. This includes all keypads, phone keyboards, computer keyboards, computer mouses, countertops, and waiting room chairs. Exam room counters, chairs, tables, and anything else a patient might touch, and chemotherapy recliners, bed, IV poles and chemo carts, should be disinfected after every patient. Finally, surfaces frequently touched such as all door handles, toilet and faucet handles, should be disinfected multiple times throughout the day. The patient schedule must be shortened to permit personnel time to complete all essential disinfecting procedures.
10. Magazines are to be made unavailable in exam rooms, waiting room and treatment areas, and the public drinking fountain is to be closed.
11. All personnel must obsessively wash their hands for 20 seconds with soap and water, or with alcohol hand rub, after every patient contact or after touching any object or surface that might have become contaminated with virus. All personnel must always refrain from ever touching their face, eyes, nose or mouth with their hands. (Rarely, in special circumstances this may be done if thorough hand washing is performed beforehand and afterward.)
12. N-95 masks will be reused no more than 5 times and 2 masks will be alternated, using each every other day, with the last used mask kept in a paper bag for 38+ hours between reuses. Personnel are to wash hands before and after touching any mask to avoid contaminating it or themselves. They are to take off a mask by grasping the strings or bands. They are to perform a user seal check when donning the N-95 mask and then wear it continuously without touching it to readjust it for comfort or to allow the nose out. They must never pull in down to eat and then pull it back up. Any mask should be immediately discarded if it is contacted by any patient body fluid or if it is used within 6 feet of a patient with known or suspected Covid-19 infection. Eye shields, goggles or glasses are to be disinfected after removal before they are reused, and personnel are to wash hands before and after touching them.
13. In the lunch room only plastic eating utensils and cups, and paper plates and bowls, are to be used. All tables and counters are to be disinfected daily after lunch. Drug representatives and other vendors are not to come into the office until the epidemic has sufficiently subsided.
14. Precautions must be taken in receiving and opening shipments of drugs and supplies that have gone through the transportation system and potentially been exposed to the virus. If possible, wait 24 hours to open cardboard containers to allow for any virus to become nonviable. Wash hands for 20 seconds with soap and water after handling any shipment.
15. Also follow the same precautions in opening and distributing the mail.
Recent Developments in COVID-19
1. Who is Contagious?
a. 25% of infected persons will never have symptoms but will be contagious up to 16 days.
b. Infected persons will be shedding virus and are contagious for 48 hours before they have any symptoms (2 days out of the average 5-6 days incubation, that is 36% of the average time between infection and symptoms.)
c. These asymptomatic infected persons are the main cause of the ongoing virus spread.
d. No one who isn’t sick can tell if they have the virus or not. Even if they have a negative swab test, they might catch the virus soon after the test. For this reason, every single person needs to wear a mask to protect others. Each of us must realize that we may have the virus and may be spreading it to others as we talk, even though we feel well. Each of us must wear the mask, not to protect ourselves, but to save the lives of others.
2. What will be the future of the pandemic?
a. The number of deaths per day will reach a maximum in California by about April 16, 2020. Then the number will gradually decline. Over the next 4 months by August 4, another 4,700 persons will die of the virus in California.
b. Other states and countries will peak and decline at different dates and rates, and will have different death tolls, depending on population density, when the virus first arrived, and how soon and how aggressive were the measures to stop the virus spread.
c. In late spring/early summer, 2020, the number of cases will be declining in the Northern Hemisphere and increasing severely in the Southern Hemisphere as winter arrives there. North America, Europe and Northern Asia will experience a second wave of the pandemic arriving in late fall 2020 as the weather cools. This cycle will continue until the third wave comes in the fall of 2021, but by then vaccines may be available in time to begin containing the pandemic so that the third wave is not as severe. However, it is expected that COVID-19 will continue to be a major problem for 24 months until the late spring of 2022.
d. A high percentage of Americans will eventually become infected, but nearly 98.5% are expected to recover. But there will be permanent social and economic changes and changes in how medicine is practiced.
3. Risk of Hospitalization for COVID-19 by age and other risk factors (study of 7,000 cases)
Based on Age:
Based on Underlying Conditions (Study of 7,000 infected patients with 300 deaths-2.9%):
a. 40% of infected patients had underlying conditions
b. 78% of patients admitted to the ICU had at least one underlying condition:
29% Cardiovascular Disease
37% Hypertension or Cancer
c. 94% of deaths had underlying conditions. The death rate of those with underlying conditions was 6.7% and the death rate without underlying conditions was 0.3% overall and about 0.5% for healthy persons over age 18.
4. Exposures to COVID-19 Patients by Medical Personnel
4 Types of Exposure
Very High Risk: Performing aerosol-generating procedure on infected patient or collecting/handling specimens from living or dead victims.
High Risk: Prolonged close contact at less than 6 feet for more than a few minutes with an infected patient who is not wearing a mask when the medical worker is not wearing a mask and eye cover.
Medium Risk: Brief interaction without contact with a patient who is not wearing a mask, when the medical worker is not wearing a mask, or several minutes of close contact with a patient wearing a mask when the medical worker is not using a mask, or with a patient not wearing a mask when the medical worker is wearing a mask but not wearing eye cover.
Low Risk: Prolonged close contact with a patient wearing a mask when the medical worker is also wearing a mask but not using either eye cover, gown, or gloves or is using a non-N-95 mask.
Management of Exposures by the Medical Facility
High or Medium Risk: Medical worker is quarantined for 14 days starting with the date of exposure.
Low Risk: Careful Self-Monitoring with supervision
Local COVID-19 Statistics
Population 40 Million.
306 Deaths (2.4% of cases—the same percentage as in other states and countries)
5,068 deaths are expected by 8/4/2020 (4 months from now), less than originally expected, due to measures taken
2. Central Valley: (Tulare, Fresno, Kings, Madera, Merced Counties):
Population 2,029,645 (5% of California population)
272 cases (2.1% of total California cases, so the odds of infection are only 42% of the rest of the state)
8 deaths (3% of cases)
First case diagnosed 3/6/2020 in Tulare County.
Madera County has 42% more cases than the average number of cases
Tulare County has 70% more than the average in the Central Valley as well as a higher death rate.
3. Tulare County:
Has 39% of the Central Valley cases and 62% of the Central Valley deaths, even though it is only 23% of the Central Valley population, so the risk of infection in Tulare County is 220% of the risk in the rest of the Central Valley.
So far there have been 5 deaths (4.7% of cases) and 234 persons have been quarantined.
Is unique among all Tulare county communities for its much higher risk of infection. It has 58% of the cases in the county, even though it has only 29% of its population. Its risk is closer to the risk of the state as a whole (72% of the average statewide risk.)
The City of Tulare also has increased risk of infection. Compared to the rest of the county outside Tulare and Visalia, the risk of infection is 6.3 times higher in Tulare and 7.35 times higher in Visalia. The risk in Tulare is 70% of the risk in Visalia
5. Method of getting infected in Tulare County:
Travel: 17 (16%)
Person to Person: 64 (60%)
Unknown: 26 (24%)
6. Age of COVID-19 Patients in Tulare County