• Dennis Lipton, MD

COVID-19 in the Vail Valley: Isolate Now!

When my daughter texted me unexpectedly from school on January 21, “have you heard of coronavirus?” I didn’t think much of it. I had diagnosed coronavirus numerous times the past few years and knew it as a source of common cold upper respiratory symptoms, just like rhinovirus, adenovirus, and others. Why would she be asking me this out of the blue? I typed ‘coronavirus’ into google and saw the headlines for the first time. One week ago I would not have imagined that I would be staying at home in self-imposed isolation due to COVID-19 (the disease caused by SARS-CoV-2 virus). On top of that, my kids’ schools are closed, and I’m seeing patients this coming week via telehealth only (as far as I know!). We are all being told to socially isolate. What changed?

Until the past 3-4 days, I was paying only peripheral attention to all this, not really thinking it would impact me much. I’m embarrassed to say that the past several weeks as patients would ask me about COVID-19 I didn’t really have much to say, other than to be careful, stay healthy and follow typical guidelines (ie wash hands, don’t touch your face, etc).

What’s the big deal? Why are schools closing when kids don’t even get the disease? How is it different than the flu? I’ve spent the past few days reviewing recent medical literature, and I now more fully understand the scope of the problem. My own questions are answered, though unfortunately we still don’t really have all the answers with this new disease.

I was originally telling people that the flu kills more people than COVID so there was not much to worry about. WRONG. First of all, it’s more contagious than the flu, about 2-4X more contagious. It is still only about 1/3 to ¼ as contagious as measles or chickenpox would be in an unimmunized naïve population. (Those disease particles can stay airborne for many hours). It is also about twice as contagious than the most similar virus we’ve seen in the past, SARS-1, back in 2002. Fortunately, it is also less deadly. SARS 1 had a mortality rate of about 10%. Another coronavirus causes a disease that has been confined to the Middle East, called MERS which has a mortality rate of about 35%. We don’t really know for sure the mortality rate of this current outbreak, but it’s estimated to be anywhere from 0.5% to 15% depending on the population.

The current SARS-CoV-2 virus as noted is more contagious than viruses we’re used to seeing and it does not have a vaccine. Reasons are as follows:

The virus can live on surfaces for DAYS. It may stay in the air for HOURS. This means that an infected person could have touched a doorknob or toilet handle yesterday, and you can touch it today and become infected unless you practice impeccable hygiene. Even more worrisome, a person with the virus could have been in a room an hour ago and coughed or sneezed, or just talked or sang, and you can walk through that room and become infected, if the virus finds a good place to land like the mucosa lining your eyes, nose, or mouth. To make matters worse, current thought is that people are most contagious at the peak of symptoms, but that they can be shedding virus (ie contagious) for 3 or more days before symptom onset. The virus has an incubation period typically 3-5 days but up to 14 days.

It’s called ‘novel’ simply because we don’t know this virus as well as we know others. It was just identified in the 1960s. The flu has been around for centuries and we know what to expect from it and how it moves through populations. We’re still learning about this one.

This virus attaches to and infects cells lining your lungs called type 2 pneumocytes. These cells secrete surfactant, which is a substance which allows you to exchange oxygen, which is necessary for life. When these cells are infected, you cannot oxygenate. It takes out a big part of your lungs. Most people have lots of excess lung capacity. In fact, people can have a lobe of lung or even a whole lung removed, and survive. People who get in trouble are those with decreased lung capacity, such as the elderly, those with COPD or other lung diseases. When they get sick and are no longer able to oxygenate by breathing on their own, they need respiratory support to get through the illness. This means ICU care with oxygen or mechanical ventilation.

We don’t have a lot of excess capacity of ICU beds or respirators. If a lot of people suddenly need this type of support for a few days to get over this illness, we will run out fast. This means that someone who would otherwise potentially have another 20-30 years of life ahead of them could die of this disease. We’ve seen what happens in this scenario from what’s happening in Italy.

Why no vaccine? A promising coronavirus vaccine was being worked on to SARS-1 by Dr Peter Hotez in Texas (look it up!). It was never funded for formal testing because interest waned. We are many months away from a safe and effective vaccine.

To re-iterate, the best way to prevent transmission of this disease is social distancing, social isolation. Stay home. Yes, this is counter to the advice I typically give which is to stay socially engaged. I know this is hard. Don’t go to social events, avoid unnecessary trips anywhere that you will be in close proximity to people. The Vail ski mountain was open today, but it was the last day for a while. The Vail Valley is now full of visitors from all over, with nothing to do. This is a huge loss for everyone, and it’s really hard, but it must be done.

If you are a basically healthy person with a cough and runny nose and fever, current advice is to stay home, just like you would if you had a cold. You don’t need to be tested. Presume that you have the virus, and that you are very contagious. Don’t go out.

Our current advice is to only seek medical attention if you are at high risk, ie have heart disease, lung disease, or other condition that puts you at high risk of death. If you don’t know your risk, you need to talk to your primary care physician who knows your medical history.

I’ll be staying on top of this situation and posting at least once a day. Please send me any questions or concerns, or any topic you would like covered.

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