The recent worldwide appearance of the “severe acute respiratory syndrome coronavirus-2” (SARS-CoV-2) resulting in the spread of coronavirus disease-19 (COVID-19) has spawned a great deal of confusion, misinformation and understandably questions. The World Health Organization (WHO), whom the world has relied on to provide accurate information regarding such pandemics, has been accused of a lack of transparency if not spreading misinformation in the early stages of the Pandemic. Ironically, the WHO has recently coined the name “Infodemic”, referring to the daily barrage of information that we are bombarded with on a daily basis.

Clearly, much of this information has been confusing, conflicting and dynamic on a daily basis if not controversial or flat out false in some cases. Some of this is likely due to the sense of urgency that we all feel when trying to learn more about the impact of this disease as well as how to control the spread, eliminate it permanently or at least reduce the seemingly skyrocketing mortality rate. Some would say that the “infodemic” is also exacerbated by the rapid spread of global information via the worldwide web.

The world’s attention has definitely been focused on this pandemic and it motivates each individual to contemplate different new subjects and thoughts in respect to the world as well as their own personal lives. My personal thoughts were driven to what can I add to the conversation. One of the burning questions is what does one do and where can one go if they are concerned that they may have been infected and are getting sick? I will get to that in a moment, but first I wanted to make some comments regarding my observations of COVID-19 in general perhaps for those that have not been researching it on a daily basis as pathologically as I have.

Is COVID-19 Serious or just another Influenza?

While it is true that annual influenza cases typically result in complications and deaths for thousands of people each year in the U.S. alone, COVID-19 does have some distinctions that separate it from the flu. Some of the differences are based on the accuracy of statistics that we previously mentioned which may not be currently accurate and which suffice it to say, would alter those assumptions. However, there are a number of assumed factors such as contagious power, incubation periods, virus transmission and possibly a higher severe to very severe infection rate of the neo-coronavirus versus influenza. I think it is fair to say that the COVID-19 should be taken seriously.

In the world of Healthcare, we often utilize the philosophy of “risk v. benefit ratio” and often part of this process includes looking at retrospective statistics. However, when looking at statistics we need accurate numbers and it seems due to the rapid escalation of COVID-19 as well as many other factors, including lack of adequate testing in many areas, the ever-changing dynamic nature of obtaining these numbers make accuracy even more difficult. How many infected, severity of morbidity, mortality rates as well as asymptomatic infected individuals. Additionally, due to the apparent rate of spread of the disease, numbers that are 12 hours old may significantly differ from current.

So why are some exposed individuals asymptomatic, some have very mild symptoms, some with moderate non-life-threatening illness easily recover while others are hospitalized and too many do not survive, typically from end organ failure. Sometimes it seems the best approach is to attempt to compartmentalize and prioritize key information such as Risk Factors for potential severity and COVID-19 death, such as age, race, and sex as well as comorbidities such as hypertension, coronary heart disease, diabetes, immunocompromised and obesity to name a few.

Spread of the Disease and Preparedness

As we attempt to learn more about this pathogen and resulting COVID-19 disease, we are quickly learning that in the US as well as abroad, we were not as prepared for this pandemic as we would have liked to be. Our hospital systems and especially intensive care units in many areas have exceeded capacity, putting even more patients at serious risk of mortality. While it’s easy to point fingers, at our lack of preparation or “Pandemic Game Plan” such as having adequate inventories of Personal Protective Equipment (PPE), adequate critical care facilities, equipment and staffing for an unprecedented pandemic. However, one thing I have witnessed is the selfless dedication that so many healthcare teams have shown by working extended tireless shifts and often putting their lives at risk to help those in need. To avoid continued overload of healthcare facilities and equipment or “flatten the curve” of this disease while we learn more, we are being asked to “shelter in place” or stay at home unless essential needs dictate leaving in addition to self-quarantining for 14 days if you have been exposed. Also, as always, enhanced hygiene, including washing hands with soap and water (x 20 seconds) as we as wearing personal protective gear, such as masks and gloves could decrease the number and severity of the cases.

What can Individuals do to prevent serious illness or mortality?

While social distancing procedures and “sheltering in place” most likely has and will continue to slow the transmission of infection, but since comprehensive diagnostic testing may still be forthcoming for a while, what can individuals do if they suspect exposure or infection?

Risk Factors

First, those most concerned should be those with concomitant comorbidities. Those at high risk for serious complications include, the aged population, or those over 65, those with obesity, asthma, hypertension, diabetes, heart disease, etc. should be most diligent.

Early Chinese data suggested that severe and fatal illness occurs mostly in the elderly, but in the U.S. (and especially in the South), many middle-aged adults have been hospitalized, perhaps because they are more likely to have other chronic illnesses. The virus might vary little around the world, but the disease caused by the virus varies a lot.

This explains why some of the most important stats about the coronavirus have been hard to pin down. Estimates of its case-fatality rate (CFR)—the proportion of diagnosed people who die—have ranged from 0.1 to 15 percent. It’s frustrating to not have a firm number, but also unrealistic to expect one. “Folks are talking about CFR as this unchangeable quantity, and that is not how it works,” says Maia Majumder, an epidemiologist at Harvard Medical School and Boston Children’s Hospital.

The CFR’s denominator = total cases; depends on how thoroughly a country tests its population. Its numerator = total deaths; depends on the spread of ages within that population, the prevalence of preexisting illnesses, how far people live from hospitals, and how well staffed or well-equipped those hospitals are. These factors vary among countries, states, and cities, and the CFR will, too. (Majumder and her colleagues are now building tools for predicting regional CFRs, so local leaders can determine which regions are most vulnerable.)

Testing Statistics

How many coronavirus cases have been reported in each U.S. state?

Using data from the COVID Tracking Project, we’re following how each state in the U.S. is responding to Covid 19.

The best estimate as of May 1, 2020 is the following:
6,551,810 tests given | 1,095,681 positive | 59,059 deaths

State Breakdown figure 1.o

https://www.politico.com/interactives/2020/coronavirus-testing-by-state-chart-of-new-cases/

The United States’ ability to detect Covid-19 is crucial to understanding how the coronavirus — now confirmed in nearly every state and territory — is spreading. While the Trump administration has promised a mass rollout of tests, supply in the U.S has lagged behind that in other countries, making the scope of the disease harder to track.

With the help of The COVID Tracking Project — a volunteer-run accounting of every coronavirus test conducted in America — we’re monitoring how many Americans have been tested in all 50 states. We will update our numbers as new results come in.

The data isn’t perfect. Since the Centers for Disease Control (CDC) hasn’t begun publicly releasing the number of people who have been tested, The COVID Tracking Project is pulling data from state health departments, which can vary in the way they report tests and infections.

What symptoms should I be looking for?
Due to inadequate supply and distribution capabilities for testing, different states are screening people using different criteria. However, it may take some time before all 350 + million Americans can all be tested. Consequently, people are encouraged to become familiar with symptoms that are associated with COVID-19. Unfortunately, people with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness and many of these symptoms are also associated with common colds and seasonal allergies. Symptoms may appear 2-14 days after exposure to the virus.

As a disease, COVID-19 shows considerable symptomatic variation. Individuals may present with no symptoms at all, while some may have a mild cough and fever, and an unlucky few may experience severe pneumonia and respiratory failure [1]. To complicate matters, COVID-19’s most common symptoms strongly overlap with those presented by other co-circulating respiratory illnesses:

Because of this, diagnosing COVID-19 on the basis of clinical symptoms alone is highly inaccurate and must be confirmed by the use of highly specific  diagnostic tests. Fortunately, thanks to rapid sequencing and publication of the SARS-CoV-2 genome in early January [2], RT-PCR primers and open access protocols were made quickly available, and are now being used by medical facilities worldwide to diagnose patients.

People with these symptoms or combinations of symptoms may have COVID-19:
Cough
Shortness of breath or difficulty breathing

Or at least two of these symptoms:
Fever
Chills
Repeated shaking with chills
Muscle pain
Headache
Rhinitis
Nasal Drainage
Sore throat
New loss of taste or smell
Itchy Eyes and/or Eye infections (pink eye)

Also, concomitant pathologies such as Asthma, COPD, Diabetes, Hypertension, coronary Heart disease as well as a history of respiratory illnesses or pneumonia put people at higher risk of more serious illness if infected by the (SARS-CoV-2) virus,

Additional updates regarding COVID-19 and symptoms can be found on the CDC Website.
https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html

Where Should One Go? The Need for Primary Care Physicians

Rising demand for emergency and urgent care services is well documented, as are the consequences, for example, emergency department (ED) crowding, increased costs, pressure on services, and waiting times. Especially, during the COVID-19 Pandemic, hospital ED s are probably not the ideal place to go to determine if your symptoms may be COVID-19. The excessive load that these non-essential visits place on an already over-taxed system in addition to subjecting oneself to others who are infected does not seem ideal.

A number of studies have been published researching the rationale for the increase in ED usage. Multiple factors have been suggested to explain why demand is increasing, including an aging population, rising number of people with multiple chronic conditions, and behavioral changes relating to how people choose to access health services. One of the notable reasons listed is the lack of a designated Primary Care Physician (PCP).

Declining numbers of Americans have a primary care provider
According to a recent study by Reuters Health – In a little over a decade, the number of patients in the U.S. with primary care providers dropped by 2%, a new study finds and fewer Americans of all ages, except for those in their 80s, had a primary care provider, researchers report in JAMA Internal Medicine. While 2% may not seem like a big drop off, “that’s millions and millions of people who no longer have a primary care provider,” said the study’s lead author Dr. David Levine, an associate physician at Brigham and Women’s Hospital in Boston, and an instructor in medicine at Harvard Medical School. In fact, “it’s essentially about the population of New Jersey.” “It’s a particularly stark decrease among younger folks, particularly those who are healthy,” Levine said, adding that the decline was also dramatic – at nearly 10% – among those who were in their 60s and healthy.

The study team found that, overall, the proportion of U.S. adults with a primary care physician fell from 77% in 2002 to 75% in 2015. Among 30-year-olds, the proportion dropped from 71% to 64% in the same period. People with three or more chronic health conditions were an exception, and the proportion with a primary care doctor remained relatively stable, the authors note.

For Levine, primary care isn’t about healthy people getting an annual physical, it’s about having a relationship with a particular primary care provider, so that when you do get sick that doctor knows something about you. “I tell my 20- and 30-year-old patients, ‘I don’t need to see you until you need to see me,’” Levine said. “It makes a big difference having a relationship with a physician even if you’ve met only once. Then the physician has some history on you, and maybe some baseline labs.”

Additionally, having a relationship with a PCP ensures that they have all of your records and can better assist you with health issues or diagnosis. The past 40 years in particular have seen major leaps in medical discoveries and treatments which is a wonderful thing. We are now able to treat many fatal diseases that would have been a death sentence in the past. Keeping up with these often complicated and highly specific detailed medical achievements has resulted in many new, granular niche therapeutic areas of medical practice requiring more and more specialists who can focus on complicated, specific pathologies. However, the PCP ideally is the first line of defense and as a generalist, they often can better identify multiple, diverse pathologies, and refer patients appropriately to specialists when necessary.

So Again, WHERE SHOULD ONE GO?

Due to the myriad of symptoms that could be associated with COVID-19 or common colds, the flu or seasonal allergies (directly in the middle of allergy season in most areas of the country) getting help sorting out whether or not your symptoms may be related to COVID-19 or something else is challenging for most people to do on their own. My recommendation is to go to your Primary Care Physician (PCP). If you don’t have a relationship with one already, get one plan ahead and do not wait for when you may desperately need one.

  1. Lowthian JA, Curtis AJ, Jolley DJ, Stoelwinder JU, McNeil JJ, Cameron PA. Demand at the emergency department front door: 10-year trends in presentations. Med J Aust 2012;196:128–32 [PubMed] [Google Scholar]
  2. Booker MJ, Simmonds RL, Purdy S. Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process. Emerg Med J;31:448–52 3.
  3. Derlet R, Richardson J, Kravitz R. Frequent overcrowding in U.S. emergency departments. Acad Emerg Med 2001;8:151–5.
  4. https://thenativeantigencompany.com/why-we-need-antigen-and-antibody-tests-for-covid-19/

Other Sources of COVID-19 Information
https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html https://www.allergyasthmanetwork.org/
https://www.AAAAI.org