Life: Interim Guidance for Management for SARS-CoV2 Infection (COVID-19) in Adults

Let's say you are having mild fever, dullness, dry cough, and unpleasant feeling in your chest, for 3 days.

You have convinced yourself that it's the Corona.

Is it time to panic and run to hospital nearby?

No. Please read on.


On Tuesday (3/24/20) our Department of Medicine chair was circulating "Interim Guidance for Management for SARS-CoV2 Infection (COVID-19) in Adults, Adapted from the University of Washington Treatment Guidelines " for the use of University of Oklahoma physicians.

It is "Interim Guidance" (a provisional manual) for clinicians regarding how to manage COVID19.  As COVID19 treatment options are rapidly evolving, the Interim Guideline is subjected to amendments. Some local factors (like test availability and capacity of facility) will influence adherence to the Guideline.


In the Guideline, diagnosis is made by  

(a) Positive nasopharyngeal swab for SARS-CoV2, or 

(b) if results are pending, a presumptive case would be defined as respiratory tract infection [fever, sore throat, shortness of breath, cough] with oxygen requirements and with chest X- ray or chest ultrasound findings suggestive of COVID-19 

Then they'll move on to evaluate oxygen requirement (followed by rapid pregnancy test for women with childhood potential).

 (1) no oxygen requirement, no risk factors -> treat symptomatically

 (2) no oxygen requirement, any risk factor ->(virologic test)->Hydroxychloroquine plus azithromycin
 (3) oxygen requirement ->(chest imaging) ->Hydroxychloroquine plus azithromycin (Evaluate eligibility for cytokine blockade)

Hydroxychloroquine is anti-malaria med, being repurposed for the Coronavirus treatment based on early reports from China and France. It's experimental, but choices are limited at this moment.

Azithromycin is antibiotics for bacterial pneumonia. Viral pneumonia is often complicated by secondary bacterial infection and bacterial pneumonia.

The Guideline further describes risk factors, baseline evaluation, suggestions and other treatment considerations.

Such as

 Avoid systemic steroids

 Use of NSAID (e.g., ibuprofen, aspirin) is controversial. Consider Acetaminophen (Tylenol) for fever management


(Apparently, some of inflammation pathways may be being used to resist the virus, so that some anti-inflammatories may be counterproductive. Researchers will figure out the details later.)

In short, priority is placed on patients with oxygen requirement (failing lung) with viral test-positive and/or visual pathology with imaging.

If your suspected case is mild, stay put and don't panic. That is what you can read from the guideline. After all, a majority (80% or so, or probably more considering asymptomatic infection may be widespread) do not get to the point of oxygen requirement.

If mild case patients flood clinics and demand resources (manpower, equipment, facility), that will take away the resources from severe-case patients with real need, eventually leading to more deaths.

Besides, hospitals are already a high-risk place for the contagious disease. Do you really want to go there, with only mild case of yours, risking getting and giving the virus? 

They are even discussing that X-ray is preferred to CT scan, because CT scanner is much harder to clean/disinfect between uses. Practical concerns.


"Take it seriously" does not mean to run at hospital at the first sign of possible infection, but to make informed and sensible decision.

Hope this helps.

PS1

If your case is turning severe, don't hesitate. Contact your doctor, go to hospital and get help. SARS (Severe Acute Respiratory Syndrome), caused by the virus, is no joke.


PS2
You can find this kind of professional manuals, or its "consumer version" online. It is a good source for your research.

An example is one from Johns Hopkins.

https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540747/all/Coronavirus_COVID_19__SARS_CoV_2_

These "interim guidance" are not quite well-established yet and will be amended often. It really is like building airplane while flying. 

Life: 8 reasons why we need to take COVID19 seriously and stay put for now

Well, as we all now know, two weeks can make such big differences. In my workplace, I see only "healthy, mission-critical" people around. Certainly this whole COVID19 affair is disruptive.


Here I attempt to summarize reasons why we need to take this COVID19 seriously and stay put, for now at least.


1. COVID19 is highly contagious

CDC says (as of 3/20/20) the virus itself can survive in air for 3 hours, and on surface, 3 days or even longer. It is tougher than many other virus. Also, it can infect others through particles or inhalation. Incubation time is 3-14 days. Even if the patient number itself look small compared with seasonal flu, this potential for infection explosion should not be underestimated. 

We have seen cases of cluster infection in church (Korea), cruise ship (Japan), and in hospitals. Cases of community infection with unknown source are increasing. Limiting gathering is not a bad idea.


2. COVID19 is a little more deadly than originally thought.

This "a little more" can make a big impact on the numbers. And current death rates for COVID19 are higher than those for seasonal flu.

Among "infected" people, 80% show mild symptoms (Mild means you do not land in hospital bed. It can be hard enough). The remaining 20% find themselves in hospital. 14% is categorized moderate, and 6% severe, mainly with pneumonia. 


3. Your age affects the outcome. Some are more vulnerable.

Being young can give you more resistance. But the infection can still be damaging to lung, and there is still a chance of death. Being old and/or having preexisting conditions (diabetes, heart disease, etc) shoots up your chance of death.


4. People with mild (or no) symptoms can walk around and infect others.

Combined with 3, "you are okay but your mom or grandpa may not" situation can occur. You might be literally killing others by being careless/carefree.


5. Too many patients at once can overwhelm hospitals.

Here comes the notion of "flatten the curve". Left unmanaged, number of the patients can increase exponentially, and some of them will end up in ICU or emergency room, while their capacity is limited (both manpower and equipment). In such a case, they'll have to triage patients. It is war zone-like emergency situation and you may be left there, under-treated.

By imposing quarantine, the government is trying to reduce the number of patients showing up in hospitals at once, so that doctors and nurses can still do their job.


6. Therapies are being tested. You'd be the test subject.

COVID19 is a new member of coronavirus family that caused SARS. No vaccine is available, capacity for the test is still small, and therapeutics are still being tested. These drugs in hopeful news (including anti-malaria drugs, flu medicine, and anti-HIV drugs) are tested under assumption of anti-SARS or other antiviral medications may work.

On high demand, FDA  quickly approved is reviewing the use of anti-malaria drug with drug repurposing route. Yet, this is an emergency procedure and these drugs are not well-tested for the virus yet. You get COVID19 now, and you may be a part of ongoing clinical trials.

Even if you are eventually going to get COVID19, you might want to receive a tried-and-tested, established treatment. 

Then, you need to buy yourself some time with hand washing and isolation. Don't catch it now.


7. Money. Current treatment can be expensive.

As Doctors do not have established therapeutics, current treatment is mostly for symptomatic relief, or for assisting failing organs for severe cases. And this infection can drag on for weeks. You may stay in hospital for a long time.

How insurance companies handle COVID19 infection is not established yet. In America, with for-profit healthcare and tricky insurance system, you might end up with filing medical bankruptcy.

You would want to wait until they find a "cure" and sort system out before getting this virus. 



Reasons 5-7 together say that our system is not in place. We aren't exactly ready for this pandemic yet. 


8. We don't know enough about this virus and its long term effects.

COVID19 is a new virus, and we know little about what it can do to your body in long term.

Fascinating facts in virology include that some virus can possibly cause (a) cancer (e.g., RSV, HTLV, HVB, HVC), (b) dementia (e.g., HSV1), (c) make you infertile (e.g., mumps), and (d) destroy your immune system (e.g., HIV). 

Investigating on possible long-term effects of COVID19 infection is upcoming researchers' job.

We don't have to be pessimistic, but dealing with an Unknown is unpredictable and can be scary. Error on the side of caution if you can. Be careful.


With high contagiousness, this virus may even spread among a majority of people, like Merkel said. The projection may not be outlandish, as 60-70% of us are positive for HSV1 (the "cold sore" virus).

In coming years, we may eventually learn to live with this virus or even learn to ignore deaths as a part of life, much like we do to seasonal flu.

But for now, it would be wise to try not to catch it. Delay the spread.

Dance/Life: One week after mini-milonga marathon in Dallas

I went to mini-milonga marathon event on 3/7-8/2020 in Dallas. There were good turnouts on both Sat and Sun. 

Dallas has a much bigger Tango community than Oklahoma City. That means, there are more good or fun dancers as well. Visiting there once in a while and dance with friends and new people,...it was fun time. Thank you for the dances.

One week later, I have no cold or flu-like symptom. Average Coronavirus incubation time being said to be 5 days, I survived the milongas with zero-distance contacts with multiple people in a confined place. No problem.


Speaking of the Coronavirus, the Friday before the Sat/Sun, we had a milonga in Oklahoma City. At the time we were joking like "We got to go to Dallas tomorrow before they start cancelling these events".

Sadly it is no longer a joke.


This past week, we had stock market sell off, price gouging on masks and hand sanitizers, and shortage of toilet papers due to panic buying, followed by travel banning from Europe and declaration of national emergency.

In this past a few days, we have seen a storm of event cancellations on Facebook. A swing dance event on April I was planning to go has been cancelled, too.


For the Coronavirus itself, I am not worrying about it too much. My alert level is not so different from handling with seasonal flu. Even if I got the Coronavirus, probably I'll survive, just like with the flu.

I did have the flu about a month ago. Some stock for food and medicine in home helped then. After I recovered, I restocked some canned/frozen food and medicine, but not to hoarding amount. In the drawer there are a few large rolls of toilet paper that should last for a month or two. I should be fine for another flu/cold-like disease.



This Corona panic is more revealing issues in society, or how many people are prone to anxiety and panic. 

In many cases, damage is self-inflicted. While being mindful at changing environment, we got to think for ourselves on how we deal with it. There will be people who want to "sell" something with this panic.

There are people who want to change others first, and people who reflect on themselves and try to change themselves first. I like the latter.


Anyways, eventually this will pass, too.

Dance: New/updated First Sunday milonga in Tulsa

Tango dancers in Tulsa have had monthly milongas at Casa Tango or other venues. But past 5-6 month I did not hear their milonga announcement, and wondering what happened.

I heard the host at Casa Tango was sick for a while.

Then, they announced new/updated monthly milonga at All Star Dance Company, 6038 S Sheridan Rd, Tulsa. First Sunday of every month, 5pm-7pm. $10.

The Ballroom Dance studio was much bigger than Casa Tango. I was there before, several years back, once or twice. How nostalgic.

About 20-22 people showed up. Quite decent turnout for the community.

In a bigger place, we have choices in dance styles. You can use milonguero style with tight hug and small steps, usually no wider than shoulder width. The lead needs to have and manage axes of both dancers. Leading has to be precise to keep balance and mobility. Subtle pivot is very important for the tight-hug style.

A tango practice video that I found helpful for the style is this. By Nany Peralta. Recommended.

NANY PERALTA / EJERCICIOS TANGO EN UNA BALDOSA



Or you can use more showy and dynamic style (stage tango style) with stretchy connection, with big boleos and back sacadas. If you have a partner who allows you to dance the style, it is quite fun. A good exercise, too.

For practicing more stage-ish style, for example, I bought this video "One Step Further" by Diego Di Falco and Carolina Zokalski, like 15 years ago and liked it then. To check out the contents I watched it again, and still like it. 

(not sure if they still sell it though. Please contact them directly in case you are interested.)



Next month (April) they are planning to have a class from 4pm (on the cheap, +$5) then dance 5-7pm. $10.

Next one should be 4/5 (Sun). Check it out.

PS
Feb 2020 was busy. Cancer Center symposium 2/7. A few sessions of mice necropsy and sample collection with and without collaborator. Down with the flu for 3 days. Writing, etc.

Come to think of the flu, the Coronavirus turned out to be much more contagious and possibly deadly than originally reported. Thanks to the Government response, if I travel to Japan now, I'll have to go through telephone health interviews and 14 days of self-quarantine before I come back to work in the University. How troublesome. No family emergency or anything that would force me to travel, please.