Integral Lifework Resources

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QUICK FACTS

As of March 25, 2020 (the most recent update to this web page), a surprising number of media outlets — many of which I myself have trusted and relied upon for years — are still getting some of the facts wrong about SARS-CoV-2 and COVID-19. By either interviewing experts who are uninformed, or repeating information that is inaccurate, these media doing a disservice to citizens everywhere. The following highlights my understanding of current conclusions from multiple sources — the standard disclaimer that we must remain vigilant about educating ourselves and not trust any one source of information (including this one) applies. That said, the following details appear to be either well-supported or strongly suggested by evidence from credible sources at this time:

TRANSMISSION

  • Someone who is infected can transmit virus without showing symptoms. The incubation period of COVID-19 averages about five days. For 97% of patients, symptoms appear within 11 days. During this initial period, before and during initial symptoms, the virus is the most contagious. This is one reason quarantine after suspected exposure to the virus lasts for 14 days.
  • Most transmission appears to occur via droplets that are exhaled or coughed by an infected person. Because those droplets may be inhaled by someone, this resulted in the six-foot (two-meter) distance rule. However, droplets will also settle onto surfaces, which then transfer them to anyone who touches those surfaces — who then infect themselves by touching their eyes, nose or mouth.
  • More extensive airborne transmission has been documented. Although it is not a primary mode of transmission, evidence suggests that aerosols containing virus can persist over distance and remain in enclosed areas for up to three hours after an infected person has left the area. Therefore six feet (two meters) is insufficient distancing for some situations, and perhaps especially in low-volume interior spaces, or where air is being circulated without filtration.
  • Surfaces can harbor virus for several days. On surfaces that have not been disinfected after exposure to droplets containing virus, SARS-CoV-2 can survive for three days, and possibly longer. However, this does not appear to be a primary source of transmission.
  • Bodily excretions. There is some evidence that COVID-19 can spread through fecal contamination of surfaces.
  • How contagious is COVID-19 — the reproduction ratio (R0) of the virus. SARS-CoV-2 has an R value of between 2 and 2.6, depending on measures taken to suppress transmission. For comparison, the median R value for influenza is about 1.28. Essentially, then, COVID-19 is 2-3 times as contagious as the flu.
PRECAUTIONS

  • When in doubt, wear a mask. If it is possible that someone nearby may be infected with COVID-19 — or if we ourselves have become infected —maintaining distance may not be sufficient to avoid transmission. This is true both indoors and outside, but perhaps especially in enclosed interior spaces with recirculating air. Additional precautions in light of N95 mask shortages and the need to re-use: 1) Be careful not to self-contaminate when removing a mask or putting on a re-used mask, and wash hands afterwards. 2) Store reusable masks in paper bags after use, being careful not to contaminate the inside of the mask. Consider additional avenues of disinfecting the mask (spraying mask with disinfectant, rotating masks out for ones left unused for five days, etc.). Because of commercial mask shortages, some health officials have encouraged DYI mask-making (see: NY Post article and CDC 2006 letter DYI face mask prototype) — or even using thick scarves or bandanas — and there is evidence that an infected person can greatly reduce transmission by wearing such a mask. It is less clear how effective these options are for protecting a healthy person.
  • Disinfect surfaces that may have been exposed. Many surfaces can transmit the virus for three days or more — possibly even items purchased in a store or shipped over distance. To disinfect hard nonporous surfaces, wipe down with a 1:40 bleach solution, 70% isopropyl alcohol, or disinfectant wipes (which must contain alcohol). Non-chlorine bleach (hydrogen peroxide) can also be used if it is sprayed on and allowed to dry (don’t wipe). See this CDC link for additional disinfecting information.
  • Avoid physical contact with anyone who might be infected. Shaking hands, hugging, touching, kissing, sharing food and drink, and other intimate contact can transmit the virus. Remember that someone can be contagious without showing symptoms.
  • Clean hands thoroughly after being in public, contact with animals or pets — or after coughing, sneezing, or blowing your nose. Either wash with with soap and water for 20 to 30 seconds, or use hand sanitizer or wipes with at least 60% alcohol.
  • Cooperate with social distancing measures, especially if “community spread” is already occurring. Avoid crowded places and spaces, postpone travel, work from home, and abide by restrictions from public officials.
  • Wear gloves when in direct contact with someone who is infected. Be careful not to self-contaminate when removing gloves, and wash hands afterwards.
  • Avoid touching own eyes, nose, and mouth as much as possible.
  • When someone has symptoms, they should self-isolate, consult medical professional over the phone or via a virtual checkup, and continue to wear a mask when around others — even after symptoms lessen or cease. Here again, a 14-day “self-quarantine” is recommended. It is important not to overwhelm medical facilities by showing up to an ER or Urgent Care facility for milder symptoms — the hospitals need to be able focus on acute interventions for the most serious cases.
COURSE OF SYMPTOMS
The adjacent chart is courtesy of ourworldindata.org using data from the WHO.

  • Most symptoms begin between two days to two weeks after exposure.
  • 81% of COVID-19 cases studied in China experienced mild symptoms.
  • Fever usually occurs within an average of five days. (The fever may be mild.)
  • Dry cough and fatigue within an average of five days.
  • Difficulty breathing within an average of eight days.
  • In severe cases, potential onset of pneumonia/pneumonitis within an average of nine days.
  • 10-12% of COVID-19 cases have required hospitalization, with 3-5% in ICU.
  • Resolution of symptoms may take 10-14 days for mild cases, and up to several weeks for more serious cases.



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RISKS

Mortality risks vary by age and pre-existing health conditions. The adjacent chart is courtesy of ourworldindata.org, using data from China CDC Weekly.

Chronic health conditions that increase risk include:
- Diabetes
- Asthma
- Weakened immune system
- Lung disease
- Heart disease
- High blood pressure
- Heavy smoking/vaping

Of the 10-12% of COVID-19 cases that have required hospitalization, 40% have been age 20-54.

It is unclear at this time if an initial COVID-19 infection guarantees immunity from re-infection. Their have been cases (see Forbes article) of apparent re-infection after initial recovery, but more study is needed.

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WHY TAKING PRECAUTIONS IS IMPORTANT

Reducing impact on health care system. The adjacent chart from ourworldindata.org (CDC projections) shows the potential difference taking precautions can make on the rate of new infections — which then translates into the number of urgent cases that hospitals and clinics will have to manage at one time. The goal is to “flatten the curve” of that impact, and stretch it out over time.

Preventing infection of vulnerable and high risk. Everyone taking precautions helps protect those over sixty or who have preexisting health conditions, where symptom severity and mortality rate are potentially much higher. However, the 10-12% of cases that become more serious can impact everyone across all age ranges and health conditions, so at this time the concern is really about protecting everyone from harm.
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TESTING,TREATMENT & MITIGATING NEGATIVE IMPACTS

TESTING & TREATMENT

  • There is no universally recommended treatment for COVID-19 at this time. Importantly, many supposedly effective treatments that are circulating on social media (sipping water frequently, gargling with salt water, taking extra vitamin C, etc.) are actually not effective.
  • Testing is critical to understanding COVID-19 spread and containment, but where supplies are limited (most notably in the U.S.) only those with symptoms and whose physician recommends testing will receive a test. There have been issues with false negatives with current PCR tests, but others are in development and PCR is currently the most reliable test method. Antibody testing is another promising test method as well, and several antibody tests are under rapid development and testing.
  • A vaccine could be developed within the next 12 to 18 months, and some have already begun Phase 1 clinical trials.
  • Remdesivir is under clinical trial, but efficacy is not yet clear. Other drugs that have shown some promise in treating COVID-19 are Favilavir/Avigan and chloroquine/hydroxychloroquine.
  • A hydroxychloroquine + azithromycin combination may reduce viral loads of SARS-CoV-2, and clinical trials evaluating efficacy are underway. (See: Science Direct article and Clinicaltrials.gov) However, although the use of hydroxychloroquine alone has already demonstrated some effectiveness in treating COVID-19, the combination with azithromycin could result in cardiac complications (see: Cardiology article), and so it requires careful monitoring may be reserved for treatment of severe acute respiratory syndrome at this time. Prophylactic use of hydroxychloroquine is also being evaluated.
  • Revisiting the time-proven technique using blood plasma from survivors of COVID-19 could provide both immunity and speed healing in the infected. Plasma-derived therapy is already being used in China to combat COVID-19, and improved techniques under development could be fast-tracked for approval.
  • Most patients with mild symptoms (81%) appear to recover on their own.
  • 10-12% of those infected require hospitalization due to more serious symptoms and 3-5% require ICU. Some 40% of those hospitalized have been age 20 to 54.
  • The most serious COVID-19 cases require a respirator.
  • Use of steroids is not advised, unless necessary to treat another condition.
  • There are some indications that fluids (even maintenance fluids) in severe cases may increase risk of cardiac arrest.
  • There is a hypothesis that NSAIDS (like ibuprofen and aspirin) may worsen COVID-19 infection or lower the body’s natural immune response — however, there is no data to confirm this hypothesis at this time.
MITIGATING NEGATIVE IMPACTS
(on economy and society)
  • Cultures and regions that have reacted swiftly, collectively and uniformly to COVID-19 have been the most successful at eliminating local transmission. Several regions in Asia have been able to rapidly contain infection rates — though those measures will have a major impact on economic productivity.
  • Testing anyone who has been exposed, and then tracking all of their movements and interactions, has allowed effective targeting of containment measures. Here again Asia has led the efforts to “test and track.” For example, China and South Korea have utilized smartphone apps to gather data and notify citizens and services about each individual’s level of risk and safety, and developers in other countries are now working on equivalent smartphone utilization (see: Wired article).
  • Many governments are implementing massive economic stimulus packages to cushion the the economic damage and hardships created by COVID-19. At this time, it is unclear if these efforts will slow a global recession, restore lost jobs and reopen closed businesses, or otherwise reverse the downward spiral.
  • Where available, efforts are being made to continue K-12 and higher education via virtual classrooms all around the globe.
  • Expanded use of the Internet is also allowing those under “stay at home” isolation orders to work remotely, participate in virtual gym workouts, order grocery and meal deliveries, and remain socially and culturally engaged.

DURATION OF COVID-19 DISRUPTION TO SOCIETY

SUPPRESSION EFFORTS

To control spread and reduce fatalities, some combination of mitigation and suppression will likely be needed for up to 18 months. The adjacent charts from an Imperial College COVID-19 Response Team study indicate how different strategies impact fatalities and ICU demand over time — with the clear indication that even aggressive measures will require repeat application until a vaccine can be developed and made widely available (i.e. up to 18 months from now) to avoid new outbreaks of COVID-19. Alternatively, if an effective treatment is made widely available that can relieve symptoms and prevent hospitalization, this has the potential of reducing disruptive social and economic impacts.

In the second chart, the orange line represents new ICU cases, and the blue line represents repeat triggering of suppression strategies (quarantine, social distancing, school closures, etc.) whenever ICU cases begin to spike.
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ADVANTAGES OF INCREASED TESTING AND MONITORING — SOUTH KOREA

It may also be possible to relax suppression measures more quickly with the right testing, tracking and prevention strategies.
Evidence from South Korea indicates that the right testing, tracking and prevention approaches could allow a more rapid return-to-normal, at least for a time. For example, not only can anyone and everyone in South Korea be tested at pop-up mobile facilities — and receive their results in 12 hours — but pharmacies have provided South Koreans up to two face masks per person per week. However, it is not clear that these measures alone will prevent a resurgence of infections; they may perhaps only allow a quicker relaxation of social distancing, quarantine, schools closures, and other suppression measures. See Science article on South Korea’s strategy and results. Also consider reading this STAT article that compares different approaches around the globe.

VERTICAL INDERTICTION PROPOSAL

A “vertical interdiction” alternative that targets high risk populations is another (controversial) option. As proposed by David L. Katz, the idea would be continuously isolate only those with the highest risk factors (“especially vulnerable,” EV), while allowing lower-risk populations to return to work and school after a period of self-isolation and symptom resolution that clears them of being contagious. This approach could also potentially offer a more rapid return-to-normal, but it is dependent on several factors, including the following:

  • A more accurate understanding of who is really at highest risk for more serious symptoms and mortality.
  • A more accurate understanding of mortality rates overall (Dr. Katz notably downplays data from Italy and elsewhere that suggest a higher mortality rate than initial data from China).
  • Highly reliable and widely available tests (PCR, antibody, etc.) that can provide the ongoing data necessary for this scenario to work.
  • Ongoing, regular monitoring efforts of the entire population (as is being done in China and South Korea) to track new vectors and outbreaks.
  • Healthcare workers, routinely tested for COVID-19, who provide care preferentially to high risk populations.
  • Confirmation of individual and herd immunity, duration of immunity, and non-transmissibility as conditions for ongoing implementation.

And here are some additional questions and concerns raised in response to the vertical interdiction proposal:

  • It would require extensive systems to support the EV population and their immediate family, committed partners, and loved ones while in isolation — which would continue until effective treatments or vaccines become available. Without support that extends to all immediate significant relationships, vertical interdiction has the potential of permanently fracturing or injuring those relationships.
  • There is the real potential for stigmatization of EV populations, and hostility toward them, as they become associated with social distancing, economic slowdowns, an increased cost burden to society, and with the coronavirus itself.
  • The “who decides” problem: Will a faceless government agency make the EV designation, as well as who will be considered immediate family and loved ones? Will an overworked, highly stressed medical professional make this decision? An insurance company that is constrained by profit considerations? Will individuals and families have any say in the matter? This poses profound questions about both skillful care and fairness…but also raises issues of personal freedom and justice.
  • What about undiagnosed EV populations — those whose chronic conditions are not well-documented or clearly identified (even to them)?
  • And how can we avoid a deepening stratification of society between those who have the means, supportive relationships and privilege to weather their EV status in relative comfort, and those who lack the economic security, social capital or supportive relationships to do so?

I would further submit that piloting any such approach on a small scale, to see if it is actually workable, will be a critical first step….

ORIGINS, SPREAD AND CHARACTERISTICS OF VIRUS


  • COVID-19 is a consequence of zoonotic spillover, which is caused by human incursions into natural habitats and increased interactions with new wildlife populations. Our understanding so far is that this novel coronavirus originated in bats and transferred to humans either directly or via another animal in a Wuhan, China wet market (adjacent image from Wikipedia article). The first human case would have been exposed to the uncooked bodily fluids of an infected animal, likely while slaughtering it.
  • COVID-19 spread so quickly because it went undetected and unmitigated throughout December, 2019 through January 23, 2020. Because of the extensive travel in China around the Chinese New Year, the virus spread quickly throughout the country prior to its discovery and the subsequent lockdown measures. International travel that spread the virus from China to other countries was also unrestricted for most of January. At this point containment was no longer possible, and most travel restrictions put in place around the world came too late. An animated map of the spread can be viewed here: NY Times.
  • COVID-19 became a pandemic because humans have no resistance to it, it is highly contagious, and produces a relatively low mortality rate. In other words, COVID-19 can reproduce and spread quickly without always killing its host.
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ADDITIONAL RESOURCES



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