Integral Lifework Resources

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QUICK FACTS

At long last, as of June 3, 2020 (the most recent update to this web page), many more media outlets are getting the facts right about SARS-CoV-2 and COVID-19 than they were initially, when this web page launched in early March. Many politicians, however, are still doing a disservice to citizens everywhere by offering incomplete or inaccurate information — and seemingly basing critical policy decisions in a faulty understanding. The following highlights what we know to date from multiple sources — the standard disclaimer that we must of course 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:

PRECAUTIONS

  • When in doubt, wear a mask. If it is possible that someone nearby may be infected with COVID-19 — or if we ourselves may 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. Rapid implementation of collective mask wearing has quickly reduced spread in many countries (see Science Times article). Additional precautions in light of N95 mask shortages and the need to re-use masks: 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, but it may be prudent nonetheless. One last (important) consideration: Most masks with breathing valves to ease exhalation do not filter exhaled air, so wearing an additional cloth or surgical mask over the valved mask will better protect others.
  • 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, contact with possibly contaminated surfaces — 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. See this helpful handwashing video.
  • 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, or when in direct contact with surfaces that may have been contaminated. Be careful not to self-contaminate when removing gloves, and wash hands afterwards.
  • Avoid touching own eyes, nose, and mouth as much as possible.
  • Avoid spitting onto any surface where someone else might walk, and be conscious of contaminating own shoes. It may be prudent to remove shoes worn in public places when re-entering one’s own living space.
  • 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.
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 (short-range aerosol) 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. This includes items frequently handled in retail environments, which should be quarantined or disinfected. However, this type of “fomite transfer” does not appear to be a primary source of transmission. That said, there is particular concern over public restrooms.
  • Refrigeration or freezing can extend viability of coronavirus. SARS-CoV-2 can remain viable in cold environments for extended periods of time. The storing and consuming of cold food items should be handled with care and with appropriate food hygiene, and raw or undercooked animal products should be avoided.
  • Bodily excretions can contain coronavirus. There is some evidence that COVID-19 could 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 twice as contagious as the flu.
  • There are indications that viral dosing may impact the severity of illness. There are indications that more frequent and prolonged the exposure to the virus, the more severe the contracted illness may become. See this NY Times article for discussion of “high-dose infection.” This has resulted in recommendations regarding length-of-exposure in various situations. However, at this time medical experts caution that we do not yet know what the “infectious dose” of SARS-CoV-2 actually is — and that it may in fact be quite low.

This blog post by immunologist Erin Bromage provides a helpful overview of many of these transmission risks.

  • As it becomes evident that community spread is accelerating, more aggressive precautions should be considered to prevent a wave of COVID-19 cases from overwhelming local hospitals.
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COURSE OF SYMPTOMS
The adjacent chart is courtesy of ourworldindata.org using data from the World Health Organization.

  • Most symptoms begin between two days to two weeks after exposure.
  • 81% of COVID-19 cases studied in China experienced mild symptoms.
  • Roughly 25% of those contracting COVID-19 may have no symptoms at all, but still be contagious.
  • A loss of smell or taste may be an early symptom of COVID-19. (More study needed.)
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  • Various symptoms, including soar throat, chest pains, fatigue, headache and intestinal upset/diarrhea have been reported at initial onset. (However, presentation is not consistent.)
  • 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.
  • Potential onset of pneumonia/pneumonitis within an average of nine days.
  • In the most severe cases, a “cytokine storm” has resulted in acute lung injury (ALI), acute respiratory distress syndrome (ARDS), respiratory failure, heart failure, sepsis and cardiac arrest.
  • 10-12% of COVID-19 cases have required hospitalization, with 3-5% in ICU. (There are some indications that increased/repeat exposure resulting in higher viral dosing leads to more severe illness.)
  • Resolution of symptoms may take 10-14 days for mild cases, and up to several weeks for more serious cases.
  • Even cases with mild symptoms may experience blood clots that can lead to stroke or pulmonary embolism.
  • There are increasing reports of a multi-system inflammatory syndrome in children and infants that appears to be linked to a previous infection with COVID-19, but may occur whether a patient tests positive or negative for coronavirus. This is similar to Kawasaki disease, and presents with fever, abdominal pain, rash or skin coloration, persistent fever, and difficulty breathing. (There is speculation that this may be clinical sequelae of the coronavirus, and has resulted in cardiac arrest and death in some children.)

This Science article offers an excellent overview of how COVID-19 attacks many organs and tissues in the body.

Healthcare professionals please consider reviewing these ER MD clinical notes from 3/30/20.



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

In general, of the 10-12% of COVID-19 cases that 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 and Tech Times “reactivation” article) of apparent re-infection after initial recovery, but more study is needed. There are also indications that coronavirus immunity may, at best, only last for six months (see Science Times article).

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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 or A, blowing hot air up nose, 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 some early PCR tests, as well as a processing bottleneck at labs that have delayed the normal 24-hr turnaround time, but additional molecular tests are in development and molecular PCR is currently the most reliable test method. Rapid antibody testing using lateral flow immunoassay technique is another promising test method as well, and several antibody tests are under development and testing. You can read about these efforts here: Nature article.
  • Under FDA Emergency Use Authorization (EUA), rapid molecular testing at point-of-care (“POC diagnostics”) became available in late March, 2020. Rapid RT-PCR and isothermal nucleic acid amplification are two point-of-care methods that can provide results in under 30 minutes. Companies that have received COVID-19 EUA authorization are listed here: FDA EUA
  • A vaccine could be developed within the next 12 to 18 months, and some Phase 1 clinical trials have already begun.
  • Remdesivir is also 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) Evidence for using the anti-malarial drugs hydroxychloroquine/chloroquine alone to treat COVID-19 is minimal, and smaller trials have demonstrated that it may not be effective (see Science Magazine article). One larger VA study has also indicated increased lethality using the anti-malarial drug (see VA Study), which has been further confirmed in a more recent study (see Lancet article). In addition, both the antimalarial’s use alone, and in combination with azithromycin, can result in cardiac and pulmonary complications (see: Cardiology article) — so use for treatment requires careful monitoring. The prophylactic efficacy of hydroxychloroquine/chloroquine is also being evaluated, but there were shortages of both hydroxychloroquine and chloroquine prior to the COVID-19 pandemic, so they may not be practical option for widespread prophylactic use in the short run, regardless of efficacy.
  • 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.
  • In the most severe cases, cytokine storm may potentially be attenuated by the use of 3 to 10mg/day melatonin. Melatonin’s reduction of pro-inflammatory cytokines could make it a candidate for adjuvant treatment for COVID-19. See this Life Sciences article.
  • 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 pulmonary or cardiac complications.
  • There was a hypothesis that NSAIDS (like ibuprofen and aspirin) could worsen COVID-19 infection or lower the body’s natural immune response — however, there has been no data to confirm this hypothesis. Contrary to this hypothesis, there is a competing theory that 100mg/day of aspirin may have multiple positive impacts on COVID-19 infection. There are currently clinical trials to test the safety and efficacy of aspirin.
  • Proning patients (turning onto stomachs) appears to be an effective way to improve breathing for patients suffering from ARDS.
  • There are also currently clinical trials underway to evaluate the effectiveness of nitric oxide, which appears to assist with oxygenation, slow coronavirus replication, and speed up healing. See this Medpage Today article.

Healthcare professionals please consider reviewing these ER MD clinical notes from 3/30/20.
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.


May 13, 2020 update on South Korea’s success. The adjacent graph from Our World in Data shows how effective South Korea’s approach COVID-19 has been. Date range: February 11 — May 13, 2020
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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….

SWEDEN’S “NO LOCKDOWN” HERD IMMUNITY APPROACH

Sweden attempted to avoid the worst economic consequences by promoting individual choice without any state-mandated lockdowns. Although we won’t know the ultimate consequences of this decision for some time, as of this writing (05/07/2020) the results are not great:
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  • The adjacent graph from Our World in Data illustrates the consequences of Sweden’s approach as compared to other countries. Date range: February 17 — May 7, 2020. Currently, COVID-19 death rates in Sweden are more than ten times those of its neighbors, Norway and Finland…and still rising.
  • About 30% of those deaths have occurred among the elderly.
  • There is another notable statistical difference in Sweden: it is experiencing considerably more fatalities than recoveries from COVID-19.
  • While personal spending in Sweden has decreased about half as much as neighboring countries, GDP is still expected to contract at about the same rate as other developed countries.
  • Sweden’s population may be nearly a third of the way to achieving herd immunity, when 70% of population will have antibodies to the initial strain of SARS-CoV-2. However, herd immunity is usually accomplished with the help of vaccines — especially if illness, disruption to society, and fatality rates are either high or catastrophic.
  • Both the infection and death rates are still rising, and have not flattened out or been reduced as they have in other countries.
  • Sweden’s healthcare system has not yet been overwhelmed, and has been operating at about 80% capacity.

So far, the trade-off for leaving much of the Swedish economy open has been clear:
more people have died so far, and without a clear economic benefit to Sweden. These are only short-run results, however; we simply will have to wait to see how this strategy plays out over the next few months.

For more info, please see:
Business Standard article; Thaiger article; AFR.com; Science Alert article on herd immunity

ORIGINS, SPREAD AND CHARACTERISTICS OF VIRUS


  • COVID-19 is very likely 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 is a naturally occurring recombinant hybrid of strains originating in bats and pangolins — with a key contribution of the pangolin strain being a spike protein that interacts with proteins on human cells. It was then transferred to humans in a Wuhan, China wet market (adjacent image from Wikipedia article). The first human case could have occurred after exposure to the uncooked bodily fluids of an infected animal, likely while slaughtering it. There is a possibility that SARS-CoV-2 evolved into its pathogenic form after jumping to humans.
  • 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 (pictured at right) can be viewed here: NY Times.
  • COVID-19 became a pandemic because humans have no resistance to it, it is highly contagious, it produces a relatively low mortality rate, and many people do not present severe symptoms when infected. In other words, COVID-19 was able to spread quickly, without people even knowing they were carriers, prior to precautionary measures like social distancing.
  • Conspiracy theories abound, of course. But there is no evidence to suggest, for example, that the novel coronavirus is an engineered bioweapon. In fact, there is increasingly clear evidence that it evolved in nature — see Science News article.
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Pangolin image by gmacfadyen is licensed under CC BY-NC-ND 2.0
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ADDITIONAL RESOURCES



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