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Original Articles By Dr. Lavin Featuring Expert Advice & Information about Pediatric Health Issues that you Care the Most About

COVID-19 Update: April 7, 2020 Symptoms of the Infection – More have Less, and More have More

By Dr. Arthur Lavin

Glossary

  • Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses, and on it goes.
  • Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
  • SARS-CoV-2– the specific name of the new coronavirus
  • COVID-2019– the name of the illness that the new coronavirus is causing
  • Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
  • Epidemic– a sudden burst of an illness that comes and goes over a limited time
  • Pandemic– an epidemic that bursts across the world not just one region
  • Spreadability– how contagious is the disease, how many people will end up infected
  • Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
  • Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
  • Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
  • Personal Protective Equipment (PPE)- PPE are any item that covers any part of the body with the design and intent of keeping viruses in the environment from infecting the wearer of the PPE. PPE’s include all masks (which includes respirators), face shields, eye shields, gloves, gowns.
  • Ventilator- a ventilator is a machine that can force a person unable to breathe to inhale and exhale and control both effectively.  They are sometimes called respirators, but during this pandemic the word respirator is now reserved for reference to a tightly fit mask.

 

SPREADABILITY

The SARS-CoV-2 virus continues to spread across the globe.

The United States Continues to Do Worse than any other Developed Country in Numbers of Cases and Deaths

The United States currently has more known cases than any other country, more deaths from COVID-19 than any other country, and continues to have rates of rise of numbers that are some of the fastest in the world.  Dr. Tony Fauci stated publicly yesterday what everyone already suspects, or should: this pandemic is not under control in the United States.

Some Rough Estimates of How Likely a Test will Be Positive in various US Regions

As of a few days ago, the CDC shared incidence of testing positivity across parts of the US.  That is, take all the tests for COVID-19 done in a region of the US and find out, what percent were positive?

Here is what they found:

  • NY and NJ- 35%
  • LA- 26%
  • MI/CN/IN/GA/IL- 15%
  • CO/DC/RI/MA-13%
  • All other states- <10%.  (The Cleveland Clinic reported its testing rate recently at 11% positive)

Warning: These rates are very rough.  Much depends on how many people are tested.  Not enough people are tested in the US to get a real sense of such numbers, so these are very rough indicators.

SEVERITY

Readers of Real Answers may recall that in many, many posts on COVID-19, we emphasize that the virus SARS-CoV-2 is new.  And it still is.  It jumped into humans only about 5 months ago.   Other coronaviruses that cause many mild colds have been in humans for 8,000 years!  So this is indeed still new.

Which means how sick the virus makes us will change for two very, very big reasons:

  1. We are still studying infected people to learn what their illnesses look like.
  2. The virus can change, and likely will, changing what it does to us.

Which is why we are writing so many updates, we will be learning more, what we learn will be changing what we know, and so yesterday’s understandings will very likely change.

Here are two changes learned today:

More Have Less- The Rise of the Asymptomatic

Since this disease first invaded humanity we have been deeply eager to know, if you are infected, what’s the chance you will not have any symptoms?

That’s important because to stop the virus from spreading, we need to know who is infected and keep them from spreading it.  The more have no symptoms, the more we will have infected people not known, and so more people able to spread it.

This is one the key rationales for staying at home. If EVERYONE stays home ALL the time, then even asymptomatic infected people will have limited spread of the virus.

So, what is the percentage of people infected with SARS-CoV-2 that have no symptoms?

Initial reports suggested that that number was quite small.  The infection began in China, so that is where the first data came from, and it suggested, as you may recall, that most people infected had symptoms, that very few people infected had no symptoms.

Since then reports from various groups of infected people have been found to be without any symptoms at all.

The best data now available are from Iceland, which has embarked on testing everyone in Iceland, including doing full RNA, genetic, analysis of every SARS-CoV-2 virus found in every infected case.  Initial data from Iceland were a bit confusing, but now the nation has tested as many as 5% of the entire nation.  With 17,000 people tested, with the strategy being to test everyone, symptoms or not, a truly random choice of who gets tested, Iceland now reports that 50% of those with the COVID-19 have no symptoms and develop no symptoms.

This is big news, at this point, we now need to assume that a good chunk of infected people will have no symptoms, but still are contagious, and that chunk is likely about 50%.

As noted in earlier posts, it is not unusual to be infected, contagious, but feel perfectly well.  The most common example is strep throat, we now for sure that about 33% of people with a true infection of their throat with strep have no symptoms.

This is bad news for knowing who is infected without a test.   Now we must greatly raise the chance that someone exposed directly (less than 6 feet away) from someone who has proven COVID-19, may have the infection, even if completely well.  Now if you are a direct contact, you must wait 14 days to know you are not contagious, you cannot rely on not having a symptom to know you are not infected, and therefore, contagious.

One last point here, if 50% of people with COVID-19 infection have no symptoms, that does not mean 50% of people who feel fine have COVID-19!

Let’s see why:

One stat asks, take everyone in a nation that somehow someone knows is infected with COVID-19, and asks how many have no symptoms.  Our current understanding is that the answer is about 50%.

So if a million Americans have the COVID-19 infection, about 500,000 have no symptoms.

Remember, we do not know the total number of infected Americans, not enough have been tested to know.

The other stat asks, take all 320 million Americans, and imagine thinking about all of those who feel fine and have no symptoms, and asks, how many are infected?  As noted, we don’t know how many Americans are infected, symptoms or not.  Iceland found that when testing nationwide, regardless of symptoms, that about 1% of Iceland is infected.  If that would translate into 3.2 million Americans infected, about 10x more than we know about today.   But let’s say it’s a fair guess.  If so, then 1.6 million of Americans are infected and feel fine.  Now, overall how many Americans feel fine?  Let’s say about 80% feel fine, that would be about 250 million Americans are feeling fine.  Now we can do the math and answer, if you feel fine, what’s your chance of being a person infected with COVID-19 and asymptomatic, that would be, in this example, 1.6/250 or 0.64%.  This means if you feel fine, your chance of NOT being infected with COVID-19, is over 99%.  Of course, this chance goes way up if you have a known direct contact with an infected person.

More Have More- The Virus is Causing Damage in More than the Lung

For the first 4-5 months of this infection, it has been dramatic at how focused on the lung this virus has been.  Nearly every death described has come through how the virus, and our own bodies, sparks enough swelling and inflammation in the lung to cause it to fail.

More recently, doctors caring for people with no other health problems except COVID-19 are reporting that two new problems have been arising, problems medical experts are concluding this virus now should be known to cause.

Heart

Reports from NYC and now in Cleveland establish that otherwise healthy people who get infected with COVID-19 can experience what appears to be direct viral infection of the heart.  Other viruses are known to cause heart infections, and when they do, the heart does what any tissue infected with a virus does, it gets swollen and inflamed.  But when the heart gets infected, swollen, and inflamed, it doesn’t pump blood as well, causing one to experience heart failure which includes serious symptoms such as profound weakness, and chest pain.

Some elderly patients prone to heart attacks have had heart attacks when their lung disease gets bad enough with COVID-19, but this direct infection of the heart is different, it can happen with no prior history of heart disease and can happen in young adults as well as the elderly.  Technically such situations are called viral cardiomyopathies, which means a virus has hurt (-pathy, as in pathological) the heart (cardio-).

COVID-19 viral cardiomyopathy is a very unfortunate possibility for this very dangerous virus.  It is too early to know how many people will or will not recover from this form of the infection, or how their hearts will work once recovered.

Blood Clotting

Another highly disturbing development is the occurrence of clotting that appears to be due to the SARS-CoV-2 virus able to turn the blood into a more clotting state.  Blood is a unique fluid. It must always remain a fluid, flowing freely, except at any moment, in any part of the body, when some hole in a blood vessel happens, for example with a cut, when this fluid must suddenly turn solid, and only at the hole.

So everyone’s blood balances between being too ready to clot and being too unready to clot.  Usually the body strikes just the right balance.

Now we learn that this virus, SARS-CoV-2, can make our blood clot more easily.  And once this balance tilts, people are developing very dangerous clots in their legs (DVT’s), lungs (pulmomary embolism), and brain (stroke), each of which can be life-threatening.

Reports of young, healthy adults with no medical problems but COVID-19 infection presenting with strokes, leg clots, and/or lung clots are appearing in NYC.  An older adult had a lung clot in a hospital on the West side of Cleveland this week.

TESTING FOR ANTIBODY

We have all longed for our nation to expand the ability to test for whether the virus of COVID-19 is present.  This is the now famous naso-pharygeal swab, swiping a sample and seeing if the virus is there.  This test tells us if we are infected at that moment in time.

Another test takes a sample of blood and looks for antibodies to SARS-CoV-2, which would tell us if we have ever had COVID-19.  How useful that would be!  People testing positive for antibody and negative on swab would know they had the infection and recovered and are safe.

But testing of recent series of people tested for antibody to the SARS-CoV-2 virus have all reported a major disappointment.   As noted above, the  SARS-CoV-2 is a new coronavirus, but old ones go way back, and those old ones cause about 25% of all the common colds we have ever had!

The antibody tests are detecting antibody to the old coronaviruses, and almost everyone has antibodies to those, rendering this technique to find who has had COVID-19 useless.

But work is continuing to refine such a test, stay tuned.

BOTTOM LINES

  1. As we all know this virus is spreading rapidly, and is dangerous.  Our country, the United States, has not controlled the spread of the virus yet, and in fact is experiencing more cases and deaths from COVID-19 than any nation in the world as of now.
  2. The number of the total of people infected with COVID-19 who will have no symptoms is greater than we had expected, and the current best estimate is as many as 50%.   Right now in the US, though, if you feel fine, you have an over 99% chance of not having the infection.  That low risk, however, rises if you have been in contact with an infected person.  The higher rate of asymptomatic cases means if you are exposed to someone, within 6 feet, who is infected, you really do have to assume you may be infected and contagious for a full 14 days if you develop no symptoms.
  3.  This virus is now known to infect the heart, causing a weaker heart pump, a condition called cardiomyopathy.
  4.  This virus is now known to cause our blood to clot more readily, leading to clots in the legs (DVTs), in the lungs (pulmonary embolism), and in the brain (strokes).
  5.  Overall, these developments are creating more and more stories of someone coming along fine with their COVID-19 infection suddenly getting so seriously ill, a point highly dramatized by the Prime Minister of Britain, Boris Johnson who was coming along fine and now suddenly deteriorated on Day 10-11 and is in the ICU.
  6.  Current technology to test for antibody to prove someone has had COVID-19 already detects all coronavirus antibodies, which almost everyone has, so we don’t have this test yet, but stay tuned.

Our best hope remains not coming into contact with other people.  So stay home, stay safe.

Advanced Pediatrics will remain available to provide medical care by phone, by AP Televisit, and as need be by appointment in the office.

We hope we all come through this terrible pandemic safe and well,
Dr. Lavin

 

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