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-19-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
• Symptoms- the experience of being ill, for example- fever, cough, headaches, loss of smell etc.
  • Asymptomatic– literally means “without symptoms”.  For COVID-19 it refers a person infected with the virus but has no and will have not symptoms
  • Presymptomatic– This is a person who was infected with SARS-CoV-2, and will feel sick, but hasn’t yet
• 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.
• Live Virus Swab– this is the swab which attempts to swipe live virus from one’s nose or throat to see if you are currently infected.
• Antibody Test- (aka serology test) this is the blood test which looks for antibody to the SARS-CoV-2 virus to see if you have been infected in the past.

Spreadability

Yesterday the World Health Organization discussed the situation of someone infected with the SARS-CoV-2 virus but who has very few or no symptoms of being ill at all, and won’t during the course of their infection.   This category is called asymptomatic, which literally means without symptoms.

What does this announcement really mean?  To understand who spreads this virus in relation to symptoms let’s look at symptoms and spreading.

A Symptom

A symptom is an experience and can only be experienced by the person having that experience.  Technically speaking, if a doctor finds a problem on her or his exam, that is a sign.  A symptom can only be discovered by the person having that experience.   A good example is headache.  For most situations, I cannot know if someone else has a headache, I can only learn that if the person tells me they do.  So a headache is always a symptom.

Fever can be a symptom and a sign.  Someone can feel very hot, they are feeling a fever, and so that is a symptom.   But someone could be asleep, have no feeling of fever, and someone else can take their temperature and find they have a fever, and so that would be a sign.

A blood test finding that has no experience attached to it, for example a high cholesterol, would then be a sign and never a symptom.  Someone else finds the problem, the person with the problem has no experience of it.

So, without getting too technical, a symptom really is, very simply, an experience.

We all have thousands of experiences and feelings every day, which are symptoms?  The ones we say are bothering us.  Again, at the heart of symptoms is subjectivity, a sense, a perspective.

Infections and Symptoms

We just discussed what is a symptom, so now we ask what is an infection?   An infection is a situation in which a germ, some form of life not our own, has invaded our body and is doing damage to it.

Not all infections cause symptoms.  About 10%, or 30 million Americans are walking around today with pinworms in their gut, and nearly all 30 million of us with pinworm infections have no idea that they are there, we say they have no symptoms.    If you were able to magically identify everyone in the United States right now with a strep throat infection, about 1/3 would have no idea they were infected, they have no symptoms.   About 75% of all adults are infected with the virus, HPV, the #1 cause of sexually transmitted infections, and nearly all of those infected have no idea they are infected, they have no symptoms.  And on it goes.  Having an infection and not having any symptoms happens all the time.

But is there a connection between having symptoms and being contagious?  Sometimes.

For pinworms, strep throat, and HPV, you can be just as contagious if infected with or without symptoms.   But other infections are not so contagious if you have no symptoms, and are far more contagious if you do.

Contagion

As these posts have emphasized two of the most important aspects of any infection are how well they spread and once infected, how sick do they make you.   There are many words to talk about how well an infection spreads:  contagion, contagiousness, infectivity, spreadability, catchy.  But they all mean the same thing.   Of course, if you are a germ and you cannot spread, you don’t have much of a future, so from the germ’s point of view, spreadability or contagion is most essential.   Making us sick is not.  Which is why so many germs, as just noted, spread without causing symptoms.

For us humans, contagion or spreadability is so important when it comes to infections because in the absence of a modern medical miracle like a curative drug or immunization, germs have their way with us unless somehow we figure out how to stop them from spreading.

To put it another way, the more contagious a germ is, the harder it is for us to stop it from spreading.

One set of infections we have found ways to stop spreading are the sexually transmitted infections or STI’s or STD’s.   For many, not all of these germs, a condom will stop the spread.   This is dramatically the case for HIV or AIDS, where universal condom use would end the spread, perhaps entirely.

Contagion and Symptoms and Stopping the Infection

There are few infections that we have snuffed out purely by blocking contagion.  The only one that we have actually eliminated by blocking contagion was the first SARS epidemic, from SARS-CoV-1 virus causing SARS.   Erupting in 2003, this infection spread rapidly across the world, coming as close as Toronto to us here in Cleveland, but it never went past 8,000 or so cases total, worldwide.  In contrast, our current COVID-19 outbreak just passed 7 million cases worldwide.  Why was the first SARS stoppable and not this one?

The answer lies in the connection between contagion and symptoms for the two viruses.  For the first SARS virus, people really did not spread it very well until they had symptoms.   This is a big deal.  It meant if we isolated everyone with symptoms, we could stop the spread.  That is precisely what was done and the disease went extinct in humanity.   In general, if whenever a germ infects a person, if it generates symptoms rapidly, controlling the spread is so much easier.

Sadly, this is not the case for COVID-19.   We didn’t know how catchy it was or when it got catchy, but it is now known without a doubt that this virus spreads in infected people with no symptoms.   This means that if we tested everyone with symptoms and isolated them, and only them, the virus would spread.  And it has.

COVID-19 and Symptoms

So now we come to the question of who with COVID-19 is contagious, and how contagious, and when?

Here is what we know:

• People who have no infection with the SARS-CoV-2 virus are of course not contagious for COVID-19
• For people infected with the SARS-CoV-2 virus, you can be in one of several situations when it comes to having any symptoms:
  • You can be in the first days of your infection and about to come down with symptoms, but haven’t yet- you are presymptomatic and in particular, on the day or two before your symptoms begin, you are highly contagious.
  • You can be at any day of your infection, but you will never develop symptoms of any significance- you are asymptomaticand can be contagious, but perhaps not very contagious.
  • You can be several days into your infection and sick, but do not need oxygen or admission to a hospital- you are mildly symptomatic and contagious.  The earlier in the days of your symptoms, the more contagious you are.  People with mild COVID-19 may no longer be contagious by Day 10 of their symptoms.
  • You can be several days into your infection and severely ill- you are severely symptomatic and highly contagious.  People with severe COVID-19 can be contagious for many more days than the mildly ill, and tend to be more contagious as well.
• Children
  • We know that children are less likely to catch COVID-19 than adults.  In most research studies, children make up a very small percentage of the infected.  This may reflect the fact they tend to be truly asymptomatic, but it also appears they do not catch the illness as readily as adults.
  • When it comes to children giving it to adults, the picture is less clear.  This is because there are so few known cases of COVID-19 in children, so we don’t know much about how they give it to adults.

The World Health Organization announcement yesterday seemed to suggest that if you feel fine, you are not contagious.  This is not what they meant to imply, and this is not true.

Here is the problem with knowing if you are contagious.   I feel fine today.  But like everyone else, I have limited powers to predict the future.  I simply do not know how I will feel this afternoon, tomorrow, next week, no one does.  Never mind COVID-19, none of us know what our health will be in the future.

So, if I am  fine now, I could be in the category of any of the first three bullets above, namely:  not infected and not contagious, infected and about to have symptoms tomorrow and so highly contagious, or infected and not fated to have any symptoms so perhaps not too contagious.

Notice that for all  of us who feel perfectly well today, one of the three categories we could be in is the infected person about to come down with symptoms, and that is a highly contagious category.

This means that as long as COVID-19 is spreading actively, which it still is in the US (we remain at 20,000 new cases a day!), one has to assume that everyone else might be contagious.  

What to do?

The two key facts of life in America and COVID-19 today are these:

1. The virus is spreading.  As noted, at a clip of 20,000 new cases a day.  At this rate the estimate is that we will hit 200,000 dead by September.
2. People who feel fine do not know, cannot know, if they are contagious.  And so if you are out of your “safe house” you should take precautions to avoid catching COVID-19:
   • Wear a mask, as noted the evidence they help is gathering and convincing
   • Stay 6 feet away from others- very, very effective
   • Consider wearing safety glasses, or goggles if you don’t wear glasses.

The WHO announcement is interesting, maybe infected people who will never develop symptoms are not so contagious, but that fact does not help anyone who cannot know if they will have symptoms tomorrow, which is all of us well people.

Severity

Laurie Garrett, an award-winning science journalist, and one of the best sources on COVID-19, reported yesterday that scientists recently released an estimate of how many people COVID-19 would have killed had the world ignored the pandemic entirely, not isolated anyone.

The number is staggering, really shocking- 500 million!

This means that had this very virus, SARS-CoV-2, had been the virus of the Pandemic of 1918, it would have been even more deadly than the deadly influenza virus that did spread that year.

The point here:  this virus does have two faces, many infected will not get sick, but many will, and it can cause very dangerous illness.

BOTTOM LINES

1. COVID-19 is spreading vigorously in the US right now.  Fourteen states have had their worst week of the pandemic so far.
2. Recent reports from the WHO might make some think if they feel fine they are not contagious.  Not true.  In fact, the most contagious people tend to be those about to have symptoms who feel perfectly well.  As well, of course, as the severely COVID-19  The situation for children is less clear.   It appears they are less likely than adults to catch it, but unsure how easily they spread it.
3. This disease is very, very serious.  If left to spread unchecked, it is now estimated that instead of 400,000 dead around the world, that 500 million would be dead.
4. Therefore, if one is leaving the safety of an isolated home:  Wear a Mask, Stay 6 Feet Away from Everyone, Wash Hands Frequently.

To your health,
Dr. Arthur Lavin