Jason Gallagher, PharmD, FCCP, FIDP, FIDSA, BCPS
You may or may not be aware that I am a pharmacist and a professor at Temple University who is specialized in infectious diseases.
As part of my job, I roundtable with a group of physicians who are specialized in infectious diseases and I advise them on how to best treat patients with infections. I am admittedly not an expert on COVID-19, the name for the infection caused by the novel coronavirus called SARS-CoV 2. I’m generally cautious about giving advice about things in which I can’t consider myself an expert, but I’ve decided that since 1) there are almost no experts on this 3-month-old virus and 2) I hear a lot of misinformation going around, that I should serve as an informed conduit for some of the information that’s out there. I’ll keep this to facts and informed opinion and try to keep politics out of it.
First, I don’t think we need to panic, but we need to be aware of the impact that bad news and changes related to mitigation will have on people. We haven’t seen anything like these interventions in our lifetimes and it is going to be scary, but we’ll be ok.
As of today (3/8/20), there has been a major lack of testing available for this virus. That is a major problem and the US is significantly behind other countries in this regard. There is evidence that transmission is going on in our communities that has no link to recent travelers, which means that the virus is spreading around us. Once more widespread testing becomes available, the number of cases is going to skyrocket. That may lead to panicked behavior even though it is do to discovering the problem that we already have, not just an increase in cases. It is likely that the government response will change from containment to mitigation. Containment is a strategy to identify and isolate cases and their contacts individually. It is hard and expensive to do, and is relevant when diseases are not yet circulating in the community. Mitigation is a strategy to slow down the spreading of a disease and involves more draconian measures, like we’ve seen in China and more recently Italy. If (or when) this happens in the US, it will be disruptive, consisting of events like school closures, canceling of large gatherings, and possibly travel disruption. The point of these measures is to slow the spread of disease, not to stop it, and the reason is to prevent the health care system from being overwhelmed before it is prepared to respond. In the graph below, the ‘non-mitigated’ curve on the left overwhelms our hospitals (which run at near capacity most of the time); the shorter one does not.
What we know about COVID-19 is increasing daily. Data from China have shown both good and bad news. The good news is that children have been remarkably spared from clinical infection. If they are not spreaders of the virus, then closing schools won’t be useful. There’s some information suggesting this but it’s not solid yet. Also, most identified cases have mild infection – roughly 80%. That is of the identified cases, which doesn’t include all of the people who have infections so mild that they seek out care. We don’t have a test yet to identify that someone was infected already, which would reveal how many people were once infected and either didn’t have symptoms or had them so mild that they didn’t think anything of it. So the 2-3% mortality rate is likely an overestimate. We also know that age and other chronic diseases are significant risks for death when infection does occur. That can be a little misleading, since age and chronic disease obviously go hand-in-hand. It’s possible, even likely, that older people who are healthy are better equipped to do well than younger people who aren’t. We also know that it seems to be able to spread before people demonstrate symptoms, though the greatest spread seems to be while patients have those symptoms. This point will make the virus difficult to control and is what separates it from SARS, which is much more lethal, but was controllable. Speaking of symptoms, the two most common ones are dry cough and fever. If you’re wondering why we’re being told that face masks don’t help, it is because people touch their faces when they put them on and off, and N95 masks are so difficult to wear than people take them on and off, touching their faces more than they might without them! People are also hoarding masks and causing shortages in hospitals already.
Most importantly for cyclists, we know that the virus is spread primarily through 2 ways – droplets and touching infected surfaces. Droplets are spread when people cough or sneeze and are transmitted only a finite distance. In this way, it is like the flu, not measles. Measles is spread as an aerosol, which does hang around in air and is why it spreads so effectively. That’s very important for us because it means that we won’t be biking through “contaminated air” or anything like that, unless one of us fires a snot rocket or coughs and the trailing cyclists inhale that loveliness. It also seems that touching infected surfaces (like another person) and then touching one’s face is the most likely way that most cases occur. Handwashing is truly key!! Hopefully it goes without saying that if you may be sick, stay home – period. This needs to be done even if you think it’s “just a cold” until it passes.
As cyclists, I think we have a few things we need to consider. First, social distancing is going to become a term that we hear a lot and will need to think about. It is a way of decreasing each person’s likelihood of infection by limiting the number of people they are in close contact with daily. Large gatherings will be discouraged or canceled (possibly including organized rides). On a smaller scale, it means we should keep our distance a bit when we congregate. Small groups are better than large ones, even when we are meeting before a ride. Fist bumps are better than handshakes (there’s actually a study on this!). Second, people are going to be distracted and on-edge, and that includes motorists. We need to look out for each other more than ever as possibly panicked people take to the roads to over-purchase toilet paper or whatever. Third, let’s keep our bodily secretions to ourselves. Swallow that mucous if you can, and if you can’t, be sure you pull away from everyone before you fire a snot rocket or spit. Finally, if you are a member of Team Evesham who bikes a lot, then you are likely a pretty healthy person. But if you aren’t, I suggest reconsidering activities that involve large groups.
Nobody knows what the months ahead will bring. There is already a vaccine in development, which is pretty amazingly fast BUT a year away. There are some investigations into repurposing a few already-available drugs that may be active against SARS-CoV 2, but those studies are ongoing and nobody knows what they’ll show. I hope that this virus spreads less effectively in warm weather (like flu) and we can keep cases from getting out of hand before the weather changes, but truthfully there isn’t evidence of that yet, and it could come back in the fall. For now, let’s hope for the best, prepare for disruption, and look out for each other.
If you are wondering about my own feelings on COVID-19, I can tell you that I am concerned about it, but I’m not afraid. I also intend to keep riding until I become sick myself and even purchased a new bike to ride while I’m stuck at home, since my employer’s contingency plan is to move classes online. I am happy that my kids are the least likely of us to be affected, but am concerned about my patients and the few friends that I have who are immunosuppressed.
Be well, and I’ll see you out there.