For a printable pdf of this click here.

New information after June 26, 2020 appears in brackets.

About me: I have a masters’ degree in Infectious Disease Epidemiology from UCLA, a bachelors’ degree from Wheaton College in biology with a certificate in International Community Development, and a masters’ in Greek and Hebrew Exegesis from Gordon-Conwell Theological Seminary. Usually, I am writing and posting bible studies on the Redemptive History Facebook page, but these are not normal times.

Paul Terrill MD, FAAFP has been an invaluable collaborator in assessing and compiling many of these resources.

This post addresses these issues:

  1. What are the symptoms for Covid-19? How is “long haul” Covid-19 different from most cases?
  2. What do we know about how Covid-19 is transmitted from person to person?
  3. Who can transmit the virus?
  4. Who gets sickest?
  5. How do medications and supplements affect this disease?
  6. Face Coverings and Covid-19
  7. What does “flattening the curve” mean? How do we do that?
  8. What is the difference between social distancing and self-quarantine?
  9. How long will this last?
  10. What should we do and what should we avoid?
  11. A reflection by Kelly Ladd Bishop

People with COVID-19 have had a wide range of symptoms reported – from no symptoms to severe illness.

Fever, cough, congestion, runny nose, fatigue, chills, muscle pain, sore throat, shortness of breath, and a new loss of taste or small can occur 2–14 days after exposure. Some patients experience nausea, vomiting, or diarrhea.

https://www.mayoclinic.org/diseases-conditions/coronavirus/symptoms-causes/syc-20479963

Symptoms which require immediate emergency medical care include difficulty breathing, continuous pressure or pain in the chest, an inability to awaken or to stay awake, a new onset of confusion, and a blue tinge in the face or lips.

https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

In serious cases, people have the fever and cough for about a week before breathing problems develop. The virus works by shutting the immune system down and stripping away the lung lining. In some people, the immune system then kicks in with what is called a “cytokine storm.” It can be as deadly as the virus, damaging the lungs, heart, liver, kidneys, and brain.

https://www.wired.com/story/moderna-covid-19-vaccine-trials/

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30628-0/fulltext

Even relatively young people with mild or no symptoms are experiencing major strokes typical in elderly people. A Dutch study found that 31% of Covid-19 patients in the ICU experienced blood clotting disorders, including strokes, deep vein thromboses, pulmonary embolisms, and heart attacks.

https://www.nejm.org/doi/full/10.1056/NEJMc2009787

https://www.thrombosisresearch.com/article/S0049-3848(20)30120-1/pdf

Some patients develop hemorrhagic colitis.

In Singapore, about half of the people who test positive for Covid-19 exhibit no symptoms. Although those without symptoms have fewer opportunities to spread the virus by coughing or sneezing, some people in this category have spread the infection to others. This was especially true within households.

https://uk.reuters.com/article/uk-health-coronavirus-singapore-wong-exc/exclusive-half-of-singapores-new-covid-19-cases-are-symptomless-taskforce-head-idUKKBN23F17G

Research from the Diamond Princess cruise ship revealed that 46.5% of infected passengers remained asymptomatic. What is particularly worrisome is that 54% of CT scans performed on asymptomatic individuals revealed the characteristic “ground glass opacity” characteristic of Covid-19. How this will affect them in the years to come remains unknown.

https://www.acpjournals.org/doi/10.7326/M20-3012

Various types of skin rashes are occurring in some patients:

https://consultqd.clevelandclinic.org/skin-rashes-an-emerging-symptom-of-covid-19/

Some children and young adults who test positive for Covid-19 are developing red lesions on their feet and toes. This may be their only symptom.

In one ongoing study of approximately forty people with “Covid Toe,” none of the patients with chilblains tested positive for active infection and only one-fourth had developed antibodies by that time. None of them had close relatives who developed Covid-19. The researchers are examining three possibilities:

  • The high levels of type 1 interferon associated with chilblains fights off the infection. In general, patients with severe Covid-19 have low levels of this interferon.
  • People with these chilblains were infected but do not always produce detectable antibodies
  • “Covid Toes” result from a post-viral immune response.

https://madison.com/wsj/news/local/health-med-fit/uw-studying-covid-toes-skin-condition-apparently-linked-to-covid-19/article_1107429b-f181-5c2e-981e-a3d0c4b13975.html

https://onlinelibrary.wiley.com/doi/full/10.1111/ijd.14937

Another study conducted in Spain questions whether these patients were infected at all, attributing their chilblains to running around their homes in bare feet and getting less exercise while quarantined.

https://jamanetwork.com/journals/jamadermatology/fullarticle/2767773

While most children experience mild symptoms, if any, a small percentage of these Covid-19 patients require hospitalization for an extreme inflammatory response akin to toxic shock. It affects the heart, kidney, gastrointestinal tract, blood, skin, and nervous system. Such children may not experience any respiratory symptoms.

My friend’s teen daughter required oral surgery after inflammation caused her gums to grow over her molars.

Physicians are now reporting these symptoms in young adults, with increasing severity with increasing age.

https://emergency.cdc.gov/han/2020/han00432.asp

https://www.who.int/news-room/commentaries/detail/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19

https://thehill.com/homenews/news/499081-doctors-say-they-are-seeing-coronavirus-linked-inflammatory-disease-in-some

If you or a family member are sick and think it might be Covid-19, call your doctor. Do not just go to the clinic, as you will infect others.

https://www.mayoclinic.org/diseases-conditions/coronavirus/diagnosis-treatment/drc-20479976

Emory University has developed an online tool to check whether what you are experiencing matches the symptoms for Covid-19. It’s available here.

How is “long haul” Covid-19 different from most cases?

Some patients are experiencing different symptoms of Covid-19 in sequence over many weeks, often a few days after they begin feeling better. One person I know is past the three-month mark and is finally starting to feel better. She began with cardiac issues, then gastrointestinal, then painful breathing, then strange autoimmune signs, a deep vein thrombosis, and most recently returned to more severe gastrointestinal problems. In all, she made twelve trips to the emergency room.

A survey of people who fall into this category reveals some startling information. Most of the respondents were white women, which could result from being willing and able to take a survey. Note that most patients had not yet reached the 7th week of illness.

Confirming that everyone needs to take this coronavirus seriously, almost two-thirds of “long haul” patients were between the ages of 30 and 49. Ninety percent of the respondents remained ill when they completed the survey.

These patients experience an enormous decline in their physical activity levels, with 67% describing themselves as at least moderately physically active prior to becoming ill. Since becoming infected, 65% call themselves—at best—mostly sedentary. In the case of my friend, she used to hike in the mountains for five hours at a time. Now, a thirty-minute walk keeps her in bed the next day.

Almost half of long-haul patients were never testing because they did not meet the testing criteria or test kits were not available. Among those who did receive testing, 54% tested negative. Most of the 46% who tested positive were tested early in the course of their illness. Both groups had similar symptoms, with only the loss of taste and/or smell occurring more frequently in the positive patients.

While over half of the survey respondents reported at least one preexisting condition, only asthma showed a correlation with a lengthy recovery time. Among the patients who knew their blood type, O+ and A+ appear a bit protective for this form of the disease when compared to the distribution of blood types in the US and UK. The B and Negative blood groups were slightly over-represented, with B- the most extreme.

Most of these patients did not require a hospital admission. However, many sought Emergency Room care, some repeatedly.

Typically, they began with gastrointestinal symptoms and chills/sweating during the first two weeks. Respiratory symptoms started during the third and fourth weeks. In all, they reported over 200 different symptoms. The most common included a dry cough, loss of appetite, a tight chest, difficulty breathing, fever of at least 100.1 degrees, gastrointestinal problems, burning in the lungs, an increased heart rate, brain fog, an inability to concentrate, and dizziness.

Eighty-nine percent of these patients reported changes in the intensity and frequency of their symptoms, while 70% noted that new symptoms arose at different times. One patient wrote that it was like playing “Whack-a-Mole.” As soon as one symptom subsided, a new one arose.

https://docs.google.com/document/d/1KmLkOArlJem-PArnBMbSp-S_E3OozD47UzvRG4qM5Yk/edit#heading=h.tl7frov254ll

https://www.theatlantic.com/health/archive/2020/06/covid-19-coronavirus-longterm-symptoms-months/612679/?utm_source=facebook&utm_medium=social&utm_campaign=share

Between February 1st and June 20th, the number of deaths due to Covid-19 were seventeen times those due to influenza (108,684 vs. 6,455). Note that this information can take more than eight weeks to be included in the national database.

https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm

This graphic of changes in the world-wide leading causes of death since January 1, 2020 dramatically presents the severity of Covid-19. Influenza is among the conditions listed: https://public.flourish.studio/visualisation/2562261/

2. What do we know about how Covid-19 is transmitted from person to person?

Transmission occurs through respiratory droplets, surface contact, and possibly via blood or by flushing the toilet.

The CDC has upgraded their warning to state that the virus spreads very easily between people, with transmission increasing in correlation with how close they are and how long they remain together. They note that it may also spread by contacting a contaminated surface and then touching your eyes, nose, or mouth.

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html

https://www.cdc.gov/niosh/nioshtic-2/20042357.html

Active virus also occurs in blood plasma, even among asymptomatic people who test positive.

https://wwwnc.cdc.gov/eid/article/26/7/20-0839_article?deliveryName=USCDC_331-DM31124

Researchers have recovered the virus from 41% of stool samples from patients with gastrointestinal symptoms.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767009

Aerosols are small enough to reach deeply into our lungs. We produce aerosols when singing, speaking loudly, or yelling. A recent experiment indicates that one minute of loud speech by a person infected with the coronavirus can produce 1,000–100,000 aerosols containing the virus which can remain airborne for up to eight minutes.  Sneezing can yield 40,000 aerosols, while coughing can create 3,000.

https://www.pnas.org/content/early/2020/05/12/2006874117#ref-10

https://www.journalofhospitalinfection.com/article/S0195-6701(06)00286-6/fulltext

Testing under various temperatures and humidities revealed that the aerosols generated by a sneeze or cough can travel up to twenty-seven feet. This enables the coronavirus to infect people farther than six feet away and to travel through ventilation systems.

https://jamanetwork.com/journals/jama/fullarticle/2763852

http://news.mit.edu/2014/coughs-and-sneezes-float-farther-you-think

Singing creates six times the number of aerosols produced by normal speech. This creates a significant safety hazard for churches. After two choir practices with an infected person, 87% of the attendees developed Covid-19.

https://www.nature.com/articles/s41598-019-38808-z

https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e6.htm

“Singing, the Church, and COVID–19: A Caution for Moving Forward in Our Current Pandemic” provides an outstanding examination of the issues surrounding congregational and choral singing.

https://www.drheathernelson.com/singingandcovid19

Viral transmission also depends upon how long an uninfected person is exposed to someone carrying the virus. Based upon research into similar viruses, the amount of virus necessary to produce an infection could be as little as 100 particles. The respiratory fluids of sick people contain between 1,000,000 and 100,000,000 particles per milliliter. Decreasing the number of people in a room also lowers the likelihood of contact with an infected individual.

https://www.sciencemediacentre.org/expert-reaction-to-questions-about-covid-19-and-viral-load/

We are seeing more Covid-19 infections than expected in our homes, churches, workplaces, restaurants, parties, and on public transportation. Indoor spaces with poor ventilation account for most outbreaks. This link cites several journal articles which highlight the risk of infection spreading in various types of venues, even after the expected peak of the outbreak passes.

https://www.erinbromage.com/post/the-risks-know-them-avoid-theme 

This site ranks thirty-six activities on a scale of 1–10. Note that “Dentist’s Offices 4/10” likely refers to sitting in the waiting room. The CDC has published guidelines specific to dental care.

https://www.tweaktown.com/news/73019/doctors-rank-these-activities-as-most-likely-to-spread-coronavirus/index.html

https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html

Resuming Care-Filled Worship and Sacramental Life During a Pandemic provides outstanding guidelines for re-opening churches with a focus upon safety:

https://drive.google.com/file/d/1DhfgclYRUomeWApWtRGPr_tZJ4pe5ew6/view

This virus can survive for 3 days on plastic, 2 days on stainless steel, and 1 day on cardboard. It remains viable as an aerosol for sixteen hours, making airborne particles a major mode of transmission.

https://www.nejm.org/doi/10.1056/NEJMc2004973

https://wwwnc.cdc.gov/eid/article/26/9/20-1806_article

What to wipe down daily in your own home: remote controls, alarm clocks, phones, cabinet and drawer handles, doorknobs and door locks, light switches, desk surfaces, keys, credit cards, garage door opener, and refrigerator handles. Keep wipes in your car and use them every time you return. Be aware that a pet can carry the virus on its fur or skin. A few cases of infected pets have been reported, but this is rare.

https://www.washingtonpost.com/travel/tips/what-you-should-shouldnt-do-stay-healthy-hotel/

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/pets.html

Click here for an excellent video on how to safely bring groceries into your home and how to transfer take-out food from the packaging to your plate. Restaurant and prepared foods which you can heat are much safer than those eaten cold. Note that he corrects his claim that the virus survives on cardboard from “one hour” to “one day” later in the video.

https://www.mayoclinic.org/diseases-conditions/coronavirus/expert-answers/can-coronavirus-spread-food-water/faq-20485479

Here’s a helpful post concerning how to do laundry when someone in your household is sick or may have been exposed to the virus:

https://www.consumerreports.org/laundry/prevent-spread-of-covid-19-while-doing-laundry/.

3. Who can transmit the virus?

People without symptoms can transmit the virus before getting sick or without getting sick at all. In a recent study of a nursing home, 67% of pre-symptomatic and asymptomatic patients tested positive for the coronavirus with large amounts of viral RNA. This fits with other research which estimates that 44% of new infections result from contact with a person who does not yet show symptoms of Covid-19.

https://www.nejm.org/doi/full/10.1056/NEJMoa2008457

https://www.nature.com/articles/s41591-020-0869-5

As of June 25th, 2020, the CDC reported that 5% of confirmed cases in the United States were in patients aged 0–17; 42% were in patients aged 18–44; 33% were in patients ages 45–64; 9% were in patients aged 65–74; and 11% were in patients over 75 years old.

Higher percentages have been shifting toward younger people as time progresses, likely due to a lack of social distancing. For example in Florida on June 25th, half of the new cases were reported in people under 35.

Not enough patients had their ethnicity recorded for me to feel comfortable including those statistics here, although the CDC does report them. The US Department of Health and Human Services will begin requiring this information on August 1st.

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

https://thehill.com/policy/healthcare/504704-florida-to-close-bars-after-shattering-record-of-new-coronavirus-cases

Keeping everyone home is critically important, even when they don’t feel sick. Asymptomatic carriers can infect others for longer than fourteen days. The CDC director estimates that only 10% of infections in the United States have been identified.

https://www.acpjournals.org/doi/10.7326/M20-3012

https://thehill.com/policy/healthcare/504552-cdc-coronavirus-may-have-infected-10-times-more-americans-than-known

For each state in the US, you can track the number of new cases, the number of tests per 1,000 people, and the percentage of positive tests for the last two weeks:

https://coronavirus.jhu.edu/testing/tracker/overview

Given how difficult it is to meet the requirements to get tested, this suggests that many people who have the disease are getting false negative results. This is also likely why some people test positive, then negative, and then positive again. The second test would have been a false negative.

https://www.nejm.org/doi/full/10.1056/NEJMp2015897?query=featured_home

4. Who gets sickest?

Unfortunately, I cannot find demographic information within the entire US. So, we’ll look what has happened in Florida as of May 13th instead:

Nursing home patients and staff account for 43% of Covid-19 deaths (875).

For people over 85, as many as 1 in 4 diagnosed with the virus have died (556); for 75–84, it’s 1 in 6 patients (545); for 65–74, it’s about 1 in 12 (386). That accounts for 83% of deaths among people with confirmed cases in the state.

Within the state, 171 people aged 55–64 have died; 74 between 45–54; 31 between 35–44; and 15 between 25–34. No one younger than 26 has died.

Fifty-seven percent of those who died were men.

Overall, the death rate for black Floridians was 4% higher than expected. However, that disparity was much higher in a few counties. The death rate for Hispanics was 4% lower than expected.

Statewide, the case-fatality rate stood at 4.5%, lower than the national rate of 5.7%. This is likely due to a recent increase in testing.

https://www.tampabay.com/news/health/2020/05/17/in-florida-83-percent-of-coronavirus-deaths-are-people-65-and-older/

A 2019 study of women (XX), men (XY), and men with Klinefelter’s Syndrome (XXY) indicates that having two X chromosomes protects against a cytokine storm, the immune system condition associated with an increased death rate in Covid-19 patients.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521177/

Between March 1st and June 20th, nearly 1% of the US population had been hospitalized with Covid-19. The hospitalization rate increases as people age. For every 100,000 people aged 0–4, 8 were hospitalized; for ages 5–17, 4; for ages 18–29, 32; for ages 30–39, 59; for ages 40–49, 94; for ages 50–64, 149; for ages 65–74, 216; for ages 75–84, 358; and for those over 85, 556. That means nearly 6% of Americans over the age of 85 have required hospitalization for Covid-19.

https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html#hospitalizations

Provisional death counts for February 1, 2020 through June 20, 2020 give us the number of people who have died with Covid-19 stratified by their ages and gender. Note that it takes up to eight weeks for a death certificate to be issued, which is likely why the CDC total of 107,982 differs from the Johns Hopkins site’s 114,900 on that same date. This does not represent how likely someone in a certain age bracket with Covid-19 is to die, but it does show that the proportion of deaths rises with age.

As of June 20th, for people aged 14 and under, 28 have died (>1% of total Covid-19 deaths); for ages 15–24, 132 (>1%); for ages 25–34, 732 (>1%); for ages 35–44, 1850 (2%); for ages 45–54, 5238 (5%); for ages 55–64, 12,895 (12%); for ages 65–74, 22,429 (21%); for ages 75–84, 28,734 (27%); and for those over 85 years old, 35,946 (33%).

Fifty-four percent of these deaths occurred in men.

Table 1, Figure 2: https://www.cdc.gov/nchs/nvss/vsrr/covid_weekly/index.htm#AgeAndSex

Between March 28th and June 6th, the CDC reported 126, 687 more deaths than expected in the US, an increase of 17% despite the lag in reporting of individual deaths by up to eight weeks.

https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm

The CDC is also reporting the location where a person died from Covid-19 for the entire US and by state. That table is much easier to interpret; however, it does not indicate whether a person who contracted the disease in a nursing home died at the hospital.

https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-by-Place-of-Deat/uggs-hy5q

A CDC map enables you to hover over a state to see the number of reported cases and deaths there. Clicking on it will take you to that state’s health department web site for additional information.

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html#reporting-cases

For those of you looking for Covid-19 information in Florida, I highly recommend using Florida’s Community Coronavirus Dashboard. It includes a wealth of information on each of its six tabs from the Florida Department of Health, including some which the official state dashboard omits. Archived information is also available:

https://experience.arcgis.com/experience/7572b118dc3c48d885d1c643c195314e/

https://geojones.org/library-2/

You can find information on Florida’s population of state prisoners here.

An early study in China found that 13% of cardiac patients died, compared to 9% of diabetics; about 8% of those with COPD or hypertension died.

https://www.worldometers.info/coronavirus/coronavirus-age-sex-demographics/

Obesity (BMI>29) has emerged as a major risk factor for severe illness and death. One study found that obese individuals were over seven times as likely to require critical care.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7217103/

Chronic kidney disease, liver disease, sickle cell disease, and immunocompromisation—from an organ transplant or from being over 65 years old—also carry increased risk.

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html

A recent study of cancer patients in the US, Canada, and Spain found a 13% case-fatality rate.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31187-9/fulltext

Hospitalization rates roughly follow the pattern for death rates, although even children have required admission. In Florida, by May 13th, 15% of hospitalized people were younger than 45; 7% were younger than 35. Overall, 19% of Floridians with confirmed cases were admitted to hospitals.

https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html#hospitalizations

https://www.tampabay.com/news/health/2020/05/17/in-florida-83-percent-of-coronavirus-deaths-are-people-65-and-older/

A study conducted in Italy and Spain determined that patients with the blood type A+ were 50% more likely to get sick and too require a ventilator, while the O blood type conferred some protection from Covid-19. The increased severity is likely due to the propensity of blood type A to form blood clots. In one Chinese study, 71% of the patients who died had disseminated intravascular coagulation, a form of abnormal clotting.

https://onlinelibrary.wiley.com/doi/epdf/10.1111/jth.14768

5. How do medications and supplements affect this disease?

On April 24, 2020, the FDA released a warning against taking chloroquine or hydroxychloroquine. Please be aware that these drugs can have life-threatening side-effects for 10% of people in the US, and do not attempt to prevent or treat infection by using them on your own.

https://www.fda.gov/drugs/drug-safety-and-availability/fda-cautions-against-use-hydroxychloroquine-or-chloroquine-covid-19-outside-hospital-setting-or

https://www.mayoclinicproceedings.org/article/S0025-6196(20)30313-X/fulltext

Furthermore, hydroxycloroquine decreases the effectiveness of remdesevir, a drug which improved the clinical course of 65% of severely-ill patients in five days.

https://www.raps.org/news-and-articles/news-articles/2020/6/fda-warns-of-potential-drug-interaction-with-remde

https://www.gilead.com/news-and-press/press-room/press-releases/2020/6/gilead-announces-results-from-phase-3-trial-of-remdesivir-in-patients-with-moderate-covid-19

A widely available steroid shows very promising results for extremely ill patients. In a randomized controlled trial of dexamethasone, patients on ventilators who received the drug were one-third less likely to die (29% vs. 41%). Those who received supplemental oxygen were one-fifth less likely to die (22% vs. 25%). People who were not given respiratory support were more likely to die with dexamethasone (17% vs 13%). Consequently, people with Covid-19 should not take this drug unless they are receiving oxygen or mechanical ventilation.

https://www.medrxiv.org/content/10.1101/2020.06.22.20137273v1

Transfusions of blood plasma from people who have recovered from Covid-19 are safe to receive. How effective they are is still being determined, although patients who receive it before severe illness sets in show more improvement.

https://els-jbs-prod-cdn.jbs.elsevierhealth.com/pb/assets/raw/Health%20Advance/journals/jmcp/jmcp_ft95_6_8.pdf

https://jamanetwork.com/journals/jama/fullarticle/2766940

 

I strongly recommend checking how every supplement you take would affect you if you become infected. You can do this by doing a search with the name of the supplement, the word “cytokine,” and the word “journal.” If you see that what you are using increases cytokine levels, and your doctor has not prescribed it, stop taking it immediately.

Taking a vitamin D supplement appears to boost the protective immunity of people with weak immune systems and decrease the strength of autoimmune reactions. It may help prevent infection and, should the virus establish itself in a person’s body, may decrease the likelihood of the severe reaction caused by a cytokine storm. The Recommended Dietary Allowance is 600 IU for people under 70 and 800 IU for people over that age.

Some research indicates that 30 minutes of summer sun exposure, which also increases vitamin D, is more protective than a supplement.

People seeking treatment for Covid-19 should have their blood tested to determine whether they need additional vitamin D.

https://ods.od.nih.gov/factsheets/VitaminD-health%20Professional/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276229/

Vitamin C and zinc also appear to protect against infection and to reduce the severity of respiratory infections when they do occur.

https://www.hsph.harvard.edu/nutritionsource/2020/04/01/ask-the-expert-the-role-of-diet-and-nutritional-supplements-during-covid-19/

Curcumin, the active ingredient in turmeric, protected patients who contracted the Ebola virus from cytokine storms when it was given intravenously. Turmeric alone absorbs poorly in the digestive system. However, formulations with black pepper have improved bioavailability by 2000%. Resveratrol also protects against cytokine storms.

http://iv.iiarjournals.org/content/29/1/1.long

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5664031/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3504991/

Sambucol, the active ingredient in elderberries, does help protect against viruses like influenza. Unfortunately, one of the ways it works is by increasing cytokines. That’s what we need to avoid with Covid-19.

https://www.ncbi.nlm.nih.gov/pubmed/11399518

It is safe to take NSAIDs like ibuprofen and naproxen while sick with Covid-19. In fact, one study found that hospitalized patients who used NSAIDs were 45% less likely to die.

https://www.who.int/news-room/commentaries/detail/the-use-of-non-steroidal-anti-inflammatory-drugs-(nsaids)-in-patients-with-covid-19

https://onlinelibrary.wiley.com/doi/10.1111/joim.13119

To protect your immune system from the damaging effects of long-term exposure to the stress-induced hormone cortisol, it is important to practice gratitude and develop empathy for others. By shifting your focus to following the precautions of washing your hands and social distancing as a service to help other people avoid Covid-19—rather than doing them from fear of the virus—you will strengthen your immune system’s ability to fight it if you do become exposed.

https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress/art-20046037

6. Face Coverings and Covid-19

Wear a mask but don’t trust it by putting yourself in situations you would avoid if you were not wearing one. Some protection is better than none.

Due to the significant number of infected people without symptoms, the CDC now recommends wearing cloth face coverings in public settings where social distancing measures are difficult to maintain, such as grocery stores and pharmacies. Surgical masks and N-95 respirators should still be reserved for medical personnel.

This is intended to protect other people from you in case you are infected; it will not keep you from getting sick. Scientific evidence does not indicate that this will work well. When wearing a mask, you should never do something you would avoid while not wearing one.

It is extremely important to avoid touching your mask while wearing it. If you do, wash your hands immediately. Children under two should not wear face masks.

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html

https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-mask/art-20485449

Effectiveness of cloth coverings against particles ranging from 0.02 to 1 µm in a lab. All were near zero for 0.3µm, a size which easily enters the lungs:

T shirt 10%     Scarf 10–20% cloth mask 10–30%   sweatshirt 20–40%      towel 40%

https://www.cidrap.umn.edu/news-perspective/2020/04/commentary-masks-all-covid-19-not-based-sound-data

In their June 5th guidance, the WHO advised that cloth masks include three specific layers: an inner cotton layer to absorb fluid; a polypropylene filter in the middle; and an outer layer of non-absorbent material, such as a polyester polypropylene blend.

https://www.cidrap.umn.edu/news-perspective/2020/06/who-unveils-covid-19-mask-guidance-uk-group-pulls-plug-malaria-drug-study

While adding a HEPA filter does remove virtually everything down to 0.3µm, smaller virus particles can pass through. Even in a hospital setting, coronaviruses can pass around the edges of filtration systems: https://msystems.asm.org/content/5/2/e00245-20. This problem is even greater for people wearing masks which do not form a complete seal on the face.

Effectiveness of N95 respirators and surgical masks designed for eight hours of use in prevention of respiratory virus transmission among medical personnel trained to use them:

N95 respirator 80%     surgical mask 80%

https://www.cebm.net/covid-19/what-is-the-efficacy-of-standard-face-masks-compared-to-respirator-masks-in-preventing-covid-type-respiratory-illnesses-in-primary-care-staff/

https://www.tandfonline.com/doi/full/10.1080/15459624.2013.866715

A small study in which Covid-19 patients coughed into a petri dish while wearing a 100% cotton mask or a surgical mask revealed that neither type would prevent disease transmission.

https://annals.org/aim/fullarticle/2764367/effectiveness-surgical-cotton-masks-blocking-sars-cov-2-controlled-comparison

However, an expert in bio-mechanical engineering recently devised an ingenious way to make a standard surgical mask airtight with three rubber bands or a sheet of thin rubber. You can download the instructions here: https://www.fixthemask.com/make-it.

View at Medium.com

7. What does “flattening the curve” mean? How do we do that?

The initial mathematical model which spurred people into action estimated that doing nothing to prevent the spread of the new coronavirus would result in up to 2.2 million deaths in the United States. In the US in mid-March, the number of new cases was starting to double rapidly. If that continued, we would have had one hundred million American cases by May.

https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf

https://www.washingtonpost.com/graphics/2020/world/corona-simulator/

https://www.healthaffairs.org/do/10.1377/hblog20200317.457910/full/

A flat curve does not mean that we have eliminated the risk, but that the number of new cases per day is not growing. People in the US initially responded to the call to flatten the curve. The goal remains to have fewer people get sick at once to avoid overwhelming our medical system.

https://www.tampabay.com/news/health/2020/05/10/how-florida-slowed-coronavirus-everyone-stayed-home-before-they-were-told-to/

https://coronavirus.jhu.edu/map.html

I live in Florida. During the first week of March, I moved up my visit to my mother by six weeks to help her gather supplies and to show her how to protect herself. We were not the only ones preparing. Cleaning supplies were so scarce that I almost did not bother to check that aisle when we stopped by the grocery store. An employee was stocking the shelf with six containers of disinfectant wipes. We split them with a woman who was right behind us.

As the number of cases rose in our state, health professionals entreated the governor to impose restrictions. Not until two weeks later, on April 1st, did our governor order a statewide lockdown. Hospitals expected a huge wave of admission which never came. What happened? An analysis of cell phone date revealed that many Floridians did exactly what my family did. We began limiting our exposure without a government order.

https://www.tampabay.com/news/health/2020/05/10/how-florida-slowed-coronavirus-everyone-stayed-home-before-they-were-told-to/

A study published on June 8th examined the effects of lockdowns and social distancing in China, South Korea, Iran, France, Italy, and the United States. In those six nations alone, the number of expected cases was off by 62 million. Without intervention, the US should have had fourteen times the confirmed cases that we saw by April 6th, for a total of five million cases. Instead, we reached two million during the second week of June.

The US government is using a model which accounts for social distancing practices in each American state. It initially concluded that the first wave of the pandemic would end in June, when the weather warmed. That had been extended to August, and now to October. This model has a state-by-state breakdown of the expected number of deaths; the peak date of the first wave; and the number of hospital beds, ICU beds, and ventilators needed during this phase.

On May 18th, researchers updated the model used by the US government to account for the lifting of restrictions by many states and increased travel. Through August 4th, the Institute for Health Metrics and Evaluation doubled the number of expected deaths to 143,357 in the US, with a range of roughly 115,000 to 207,000, even with increased testing and contact tracing. This represents an increase of approximately 9,000 more deaths than the model anticipated two weeks earlier, before the easing of restrictions.

The June 24th update of the same model runs through October 1st. It now predicts 179,000 deaths, with a range of roughly 159,000 to 214,000 on October 1st. On August 4th, it predicts 145,490 deaths, an increase of 2,133 more than the modelers anticipated five weeks previously.

However, taking a snapshot of this model on June 27th reveals something disturbing. The last confirmed number was posted on June 19th (117,574). Only seven days later, the upper end of the projected range of deaths was 122,978. However, at 6:33 pm on June 27th, the dashboard maintained by Johns Hopkins University posted 125,472 confirmed deaths, a difference of 2,494.

https://covid19.healthdata.org/united-states-of-america

https://coronavirus.jhu.edu/map.html

During June, Texas, Florida, Arizona, and California have all reported records in the number of new daily cases. That number is increasing is over half of states in the US. Since there is about a three-week lag between transmission and confirmation of a case, this reflects viral transmission which began over the Memorial Day weekend.

https://thehill.com/homenews/administration/504791-fauci-warns-latest-outbreaks-could-spread-widely

Those who recover should have at least temporary immunity, making spread of the disease less likely once they no longer shed the virus. We do not yet know how strong an antibody response must be to confer protection.

https://jamanetwork.com/journals/jama/fullarticle/2766097

https://www.cdc.gov/coronavirus/2019-ncov/lab/serology-testing.html

Covid-19 antibody tests are becoming more widely available. Knowing the sensitivity and specificity of a specific test is extremely important. The FDA determines sensitivity by using samples of a manufacturer’s test on blood which came from a Covid-19 patient. The percentage of those tests which detected the antibodies represents the sensitivity.

Researchers determine the specificity of an antibody test by using blood which was drawn prior to 2020, when there were no known Covid-19 cases in the US. The percentage of tests which did not detect antibodies represents the specificity.

As you can see from this link, there is a wide range of accuracy among tests submitted to the FDA:

https://open.fda.gov/apis/device/covid19serology/

On May 4th, the FDA announced that any company which failed to prove that their Covid-19 antibody test is accurate within ten days must remove their product from the market. This reverses a policy which allowed manufacturers to sell products without evidence that they worked.

https://www.ajmc.com/newsroom/what-were-reading-fda-reconsiders-antibody-tests-fauci-discusses-concerns-death-toll-estimates-rise

Flattening the curve also gives us time to develop a treatment or vaccine. Although experts are testing vaccines now, expedited development of a safe and effective one should require 12–18 months.

A combination of the entire population staying home (social distancing), tracing and quarantining entire households where an individual has come into contact with a sick person, placing sick people into isolation except when they require supportive treatment, and closing schools and universities provides the best chance of slowing the infection rate to a manageable level until a treatment or vaccine becomes available.

https://www.newyorker.com/science/medical-dispatch/its-not-too-late-to-go-on-offense-against-the-coronavirus

This brief video by the Ohio Department of Health provides an excellent object lesson concerning how social distancing works: https://www.youtube.com/watch?v=o4PnSYAqQHU.

Noting the similarities of this pandemic with the Spanish Influenza pandemic of 1918–1919, epidemiologists expect a second wave of infections with this coronavirus in the fall. Unfortunately, the coronavirus spreads more easily than influenza. The two viruses are expected to circulate in the population at the same time, putting great strains on our medical system.

https://www.cidrap.umn.edu/sites/default/files/public/downloads/cidrap-covid19-viewpoint-part1_0.pdf

Johns Hopkins maintains a worldwide map of diagnosed cases, deaths, and recoveries here. They have recently added a feature which enable you to see what is happening in your county. Go to the upper right of the US map and select your state and county.

The Critical Trends section has several important features:

  • Timeline of Covid-19 policies, cases and deaths in your state
  • Have states flattened the curve?
  • Have countries flattened the curve?
  • How did events unfold in Hubei, China?
  • Which states have released breakdowns of Covid-19 data by racee?
  • Where are Covid-19 cases increasing?
  • How is the outbreak growing?
  • How does mortality differ among countries?

According to the American Medical Association, the four essentials that must be in place to reopen community facilities and non-essential businesses are: 1) a two-week downward trend in the number of new cases and new deaths; 2) readily available testing; 3) a strong public health system to observe trends and facilitate contact tracing; and 4) hospitals and healthcare workers with sufficient supplies to manage an increased number of Covid-19 patients.

https://www.ama-assn.org/delivering-care/public-health/ama-states-should-follow-4-signposts-safely-reopen-america

https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html

As people begin venturing out, public health experts determine what they will do by considering whether an activity is outdoors, which is safer, or indoors; whether they can remain at least six feet apart from others; and how long an activity will take. The longer you remain in one place where people have gathered, the greater the risk.

Before entering a business, they make sure that all employees are wearing masks and remaining six feet away from each other, that hand sanitizer or soap and water is readily-available, and that there are few enough customers to maintain the six foot rule.

They also recommend carrying hand sanitizer with at least 60% alcohol or disinfectant wipes to use whenever entering or exiting a building, avoiding touching your face, and not using public restrooms or water fountains.

Specific guidelines regarding getting haircuts, dining out, attending church services, going to a mall or department store, working out at a gym, visiting a nightclub, socializing in your backyard, attending outdoor events like weddings, going to the beach, camping, staying in a hotel, allowing a friend to use your bathroom, using public restrooms, and participating in sports are discussed here. Note that the level of risk is based upon the people around you practicing social distancing.

On May 19th, the CDC released a sixty-page document with specific three-step guidelines for the reopening of childcare programs, schools and day camps, employers with workers at high risk, restaurants and bars, and mass transit administrators.

CDC-Activities-Initiatives-for-COVID-19-Response

The CDC released Interim Guidance for Communities of Faith on May 22nd for the use of churches and other places of worship.

https://www.cdc.gov/coronavirus/2019-ncov/php/faith-based.html

On June 12th, the CDC posted these guidelines for large group events:

https://www.washingtonpost.com/context/cdc-s-considerations-for-events-and-gatherings/1f366f60-a5e6-4694-8f60-3d93749bbf45/?itid=lk_interstitial_manual_10

https://twitter.com/neil_ferguson/status/124329481520012492

  1. What is the difference between social distancing and self-quarantine?

In early March, I moved up my visit to my elderly mother by six weeks to help her gather supplies and to show her how to protect herself. I taught her to disinfect counters daily, wash or wipe her hands every time she touched something away from home, and shower at night if she walked out of her gate, even just to get mail.

My second night there, a woman died in her local hospital. We decided getting haircuts was too risky. After gathering supplies at times when we knew few people would be shopping, we treated ourselves with a visit to an antique store we knew would not be crowded. Then, we visited my brother without touching him.

Self-quarantine is for those who suspect they have been exposed. The current guideline is to remain in quarantine for fourteen days. It involves using standard hygiene and washing hands frequently, not sharing things like towels and utensils, staying at home, not having visitors, and staying at least 6 feet away from other people in your household.

Since a possible exposure in mid-March, I have been doing this. The incubation period is 2–14 days, so I bought cleaning supplies and groceries on Days 0 and 1. In addition to educating people about this virus, I have been doing lots of gardening. I am using alternative ways to exercise, rather than going to the gym. Wearing my hair in a ponytail helps me touch my face less often.

Due to increasing rates of infection in our community, I am assuming everyone I meet has been exposed. So, I am repeating the process by remaining in quarantine until Day 14, doing necessary errands on Days 0–1, and returning to quarantine until Day 14.

Infected people must be strictly isolated from others, either at home or in a treatment center. Viral shedding lasts for 8 to 37 days, with an average of 20, so patients must remain in isolation even after they feel better.

https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-social-distancing-and-self-quarantine

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext

9. How long will this last?

We really don’t know. It could be as much as 12–18 months, when we have an effective vaccine or treatment. In April, China reported their first two days with no new cases after eight weeks of strict quarantine enforced by their government. After lifting strict quarantine, China is again reporting clusters of cases. In our society, it’s going to be difficult to accomplish eradication that quickly.

https://fortune.com/2020/03/19/coronavirus-hubei-province-no-new-cases/

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports

One thing in our favor is that this virus is mutating very slowly, That makes creating a vaccine much easier.

https://hub.jhu.edu/2020/06/10/sars-cov-2-dna-suggests-single-vaccine-will-be-effective/

On January 10th, researchers at Moderna applied existing mRNA vaccine development techniques to the newly sequenced coronovirus genome. Initial tests in a few volunteers indicate the vaccine is safe and produces an immune response to the virus which causes Covid-19. Moderna hopes to produce a million doses each month by the end of 2020.

https://www.wired.com/story/moderna-covid-19-vaccine-trials/

https://investors.modernatx.com/news-releases/news-release-details/moderna-announces-positive-interim-phase-1-data-its-mrna-vaccine\

A team from Oxford University which produced a vaccine for the MERS coronavirus has another leading candidate.

https://www.raps.org/news-and-articles/news-articles/2020/3/covid-19-vaccine-tracker

This site maintains a list of treatment and vaccine developments:

https://www.statnews.com/feature/coronavirus/drugs-vaccines-tracker/

If you are wondering why it is taking so long to develop tests, treatments, and vaccines, I recommend this journal article: https://www.nejm.org/doi/full/10.1056/NEJMp2002125.

 

10. What should we do and what should we avoid?

Wash your hands often for at least 20 seconds. If you must visit a public restroom, use a paper towel to dry your hands, turn off the faucet, and open the door before throwing it away. If using hand sanitizer, use one with at least 60% alcohol.
Cover your cough or sneeze with a tissue, then throw the tissue in the trash. Do not reuse it.
Clean and disinfect frequently touched objects. You can use 70% alcohol if necessary.
Stay home when you are sick.
Contact a health worker if you have symptoms.
DO seek emergency care if you have been sick and develop difficulty breathing or shortness of breath, persistent pain or pressure in the chest, new confusion or inability to arouse, and bluish lips or face.
DON’T touch your face. The virus can enter through your eyes, nose, or mouth.
DON’T travel if you have a fever and cough or other symptoms.
DO wear a face covering in public places to protect others in case you are infected without having symptoms but DO NOT trust that it will work.
DO let people know if you are coughing from an allergy or something else that won’t kill them.                                                                    • DO have a plan in place in case someone in your household develops symptoms and needs to be quarantined at home away from others.

• DO slowly resume high-risk activities like church services slowly, with a science-based stepwise plan. This one is excellent:

https://www.christianitytoday.com/ct/2020/may-web-only/when-churches-reopen-phase-coronavirus-covid-19-guidelines.html?utm_source=ctweekly-html&utm_medium=Newsletter&utm_term=15727149&utm_content=711240621&utm_campaign=email

“If it looks like you’re overreacting, you’re probably doing the right thing” (Anthony Fauci).

I love the analogy of playing football. You want to place the ball where the other player is going to be, not where he or she is now. Public health works the same way. We anticipate what will happen in the future and act accordingly.

https://thehill.com/homenews/sunday-talk-shows/487639-fauci-if-it-looks-like-youre-overreacting-youre-probably-doing-the

In general, these are sources you can trust:

1) Anthony Faucihttps://www.niaid.nih.gov/about/director

2) US Center for Disease Controlhttps://www.cdc.gov/coronavirus/2019-ncov/index.html

3) World Health Organization Situation Reports – These tend to be one day behind. Some nations are not keeping their information up-to-date, so do be aware of that: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports

4) Johns Hopkins Universityhttps://coronavirus.jhu.edu/

5) Florida’s Community Coronavirus Dashboardhttps://experience.arcgis.com/experience/7572b118dc3c48d885d1c643c195314e/

11. A reflection by Kelly Ladd Bishop, an alumna of Gordon-Conwell Theological Seminary

Schools and gatherings are closing left and right around us. Life will be disrupted for a bit. People will be sick. Hopefully people will also get well! We pray to God for this! God is good.

We cancel gatherings and we stay home, NOT to preserve our own health (although that may be a happy side effect), and NOT because we are afraid, but because we care about those who are vulnerable, who are elderly, who may not have access to health care, and because we don’t want our hospitals overrun, and our doctors unable to help those who need help. This is simple math and science. Fewer vectors, fewer sick people.

What affects “the least of these” affects all of us. Maybe it takes a pandemic to make us realize that we are all on this rock together – doctors, epidemiologists, teachers, students, bus drivers, pastors, babies, homeless people, politicians, weak, strong, all of us.
In my city there is a percentage of the population that experiences food insecurity. Many students receive free meals at school twice a day. When the community closed schools, people began to talk about how to help. A local restaurant gave away free meals today, no questions asked. A group of residents put together a Facebook page offering to pick up groceries or supplies for anyone quarantined (MANY families in our community are currently under quarantine). People have started asking, “how can we help?”

Sometimes life stinks. But when it does, the heart of God can often be seen in those who desire to care for “the least of these,” the vulnerable, the sick, the poor, the scared. Take heart friends, God is always moving. God is moving in our communities. God is drawing us together despite these challenges. God is good, and this will end. And when it does, I pray that we don’t forget the importance of caring for “the least of these,” and that we don’t forget that we’re all in this together.

“‘Then the righteous will answer him, ‘Lord when did we see you hungry and feed you, or thirsty and give you something to drink? When did we see you a stranger and invite you in, or needing clothes and clothe you? When did we see you sick or in prison and go to visit you?’ The King will reply, ‘Truly I assure you that when you have done it for one of the least of these brothers and sisters of mine, you have done it for me.’” (Matthew 25:37–40).

Image via Wikimedia Commons