Working in the Virus’ Shadow: SARS-CoV-2 28 March, 2020, 1132 Hrs

This should have been the first post on this topic, under this heading, that I made. With so many high quality sites available, why put together another to attempt to explain the Pandemic that is upon us?

I think for at least two reasons:

1. As a front-line intensivist who, having worked and taught in and out of the US – Nicaragua, Nigeria, Sudan, Germany, Turkey, Greece, Japan – I have an internationalist’s view of what we could be based upon these experiences.

I am in the South, not New York but, unlike European newspapers of 230 years ago who wrote progressively more favorable accounts of Napoleon and his Army as they came closer to their cities, this will not be the case here. This disease knows no border, class, race, or gender. Even the observation that the young may not be seriously affected may have been in error (more on that later).

In my decades of work – as the Division Chief of Emergency Medicine, of Critical Care Medicine, Medical Director of a City and County EMS Service, Associate Director of a Burn Center, and Chair of a Department – I have observed the way administrative leadership can make or break an institution in tumultuous times. And these times are, at least, tumultuous.

2. In the context of “tumultuous times, we are left to fend for ourselves. Trump and his band of Merry Men and Women – look up  the old English definition of this word – have and continue to grossly mismanage this disaster. While this fact is no surprise – what do we expect to happen when we hand the reins of power to an ignorant, thin-skinned, vindictive, corrupt, racist and misogynist who is a know-nothing? I hope I have made my position on Trump and enablers crystal clear – it is disturbing that some 50% of my fellow citizens think he is doing an acceptable job related to the pandemic, when in reality  we are “in parlous state”. The real leaders of the United States today are the Governors of NY,  California, and Michigan; Senators Sanders and Warren, and former VP Biden, as well as any number of academics and former Department of Justice Officials who recoil in horror at the state of our World and Country.

So let’s start with a couple of issues related to the virus – SARS-CoV-2 (Severe Acute Respiratory Syndrome – Corona Virus Type 2) – the disease (CoViD19 – Corona Viral Disease 2019), and peripherally related topics:

How is this virus transmitted (1):

There are really three ways to transmit a virus:

Body fluids/secretions/products – this is a minor mode of transmission of SARS-CoV-2. Viral particles have been found in the stool of some infected children. I have not seen a major observational study detailing how common this is, in general. One will come, for sure. But this mode of transmission, fecal-oral (yes, it is what it sounds like!) is one of the many reasons we need to wash our hands always: before going out of the house; after coming back into the house, before and after touching your face. I say this especially to men.

I have conducted non-scientific experiments while driving long-distances. In the men’s bathrooms at Rest Stops from PA to FL, I have noted that about quarter to a third of men leave the bathroom without washing their hands. It doesn’t seem to matter whether they are coming from stalls or urinals. I don’t know the data from women’s bathrooms  for, well, obvious reasons. I welcome one of you (women) to do the observation.

Droplets – when we cough or speak, we expel various sized water particles from our mouths. The larger of these, droplets (2), generally are 20 microns or larger in size, and they tend to behave in a ballistic fashion, meaning they rapidly fall from the air. These will not follow airflow streams so, unless you are REALLY CLOSE to the person who coughs or speaks, you are not going to inhale these or get them in your mouth or eyes. Rather, large droplets will fall via gravity to the floor, onto tables, books. This is why we must clean surfaces before using them – who knows if the person who was at the table before you sneezed and contaminated it? – and wash hands. The best data we have suggests that SARS-CoV-2 particles can stay active (infectious) on plastic and stainless steel for up to 72 hrs and on copper and cardboard for 4 hrs and 24 hours, respectively (3). Droplets are the major means of transmission of SARS-CoV-2 at this time. As far as masks go, regular surgical masks will protect against particles of this size but, at this time, are not really needed unles you are closer than 3-6 feet from another person who is speaking/coughing.

Aerosols – But still…….the difference between droplets and aerosols are relative. It is generally accepted that small particles of < 5–10 μm aerodynamic diameter will follow airflow streamlines and are capable of short and long range transmission. Particles of < 5 μm will readily penetrate the airways all the way down to the alveolar space, and those < 10 μm readily penetrates below the glottis. For particle of 5-10 μm N95 masks are needed. The difficulty is that there are ‘intermediate particles’ of diameters 10–20 μm which will act as similarly to both small and large droplets.

SARS-CoV-2 has been shown to remain viable in aerosols for as long as 3 hrs, with a median estimated half-life of approximately 1.1 to 1.2 hours. These relatively new data suggest that there is, for some short time, the possibility of aerosol transmission of the virus, although, as with fecal-oral transmission, it is at this time considered a relatively minor mode of transmission.

This may change in the future, but as of now, these are the best data on transmission.

So, What Should You Be Doing?

First, look at these:

The graph on the left shows new cases in several countries  – including the US – plotted against days AFTER the first 100 cases were noted. You can see that in the US cases are increasing dramatically; there is no plateau. That red line is warning us that we are in serious trouble and it is shooting straight up.

The graph on the right shows cases in Florida, which are increasing in an exponential manner very rapidly. Yet the leadership here cannot decide what to do likely , I suspect, because they are tightly tied to the Trump School of denial.

Agree or disagree with me on that last point, but it is clear that the things we need to do are as follows:

  1. Right now and for the next 10-14 days we should be sheltering in place if at all possible. This includes students, some of whom have behaved as if this were a prolonged Spring Break. Critical industries such as health care, grocery stores, pharmacies and so forth will continue to operate, but the rest of us should stay home. It appears that the Federal Government will finance those who have list paychecks.
  2. When going out, keep 4-6 feet between people, this minimizes droplet transmission.
  3. Wash your hands often and well – 20 seconds each time. Use hand sanitizer (at least 60% alcohol) when you can’t wash with soap and water.
  4. The “shall I wear a mask” issue remains unclear at this writing. But for sure don’t hoard masks because those of us in the ED and ICU trying to take care of you and your loved ones do not have adequate Personal Protective Equipment (PPE). If you hoard these you put us – nurses, physicians, respiratory therapists, pharmacists – at risk. If we go down, who will care for you? This should be a time of solidarity, not toxic individualism. I would repeat this 10 times.
  5. Have enough food for an extra couple of weeks, so that if anything really goes wrong, you are protected; the same for your medications. If possible – I recognize, given the income inequality (AKA: oppression of working people) that exists, this may not be possible.
  6. Commit spontaneous acts of kindness, We are all in this together, whether or not all quite get it.

More later. We need to talk about treatments and what to do if you feel sick.

About AJ Layon

AJ Layon was, for 28 years, at the University of Florida College of Medicine, in the Division of Critical Care Medicine, in Gainesville, FL. For the approximately 10 years until September 2011, he was Professor and Chief of Critical Care Medicine at UF; In September of 2011 he became System Director and Co-Chairman of Critical Care Medicine in PA; this ended in 2017. He served as a Physician in the Surgical Group with Médecins sans Frontières (MSF, Doctors without Borders) through 2018 and is presently an intensivist in Florida, struggling through the SARS-CoV-2 crisis. While his interests are primarily related to health care, health care reform, and ethical issues, as a citizen of our United States and our world, he will occasionally opine on issues of our "time and destiny". Follow on Twitter @ajlayon
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