COVID-19: Are you ready for the next normal?

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COVID-19 Beyond Basics FAQ

Image provided by CDC

Hung Cheung, MD, MPH, FACOEM – Environmental Epidemiology, Toxicology, Public Health

Thomas Taylor III. MD, MBA – Occupational & Environmental Medicine

Paul Rockswold, MD, MPH, FAAFP – Medical Epidemiology, Biostatistician, Outbreak Investigations

Ben Kollmeyer, MPH, CIH, Chief Science Officer, Forensic Analytical Consulting Services (FACS)

 

The COVID-19 pandemic is in full swing, and even with the rapid escalation of emergency public health measures at many state and local jurisdictions to reduce the spread of the virus, it is expected to be at epidemic levels for an extended period of time. The epidemiologists, environmental health, medical, and public health experts at Cogency and FACS are continuously reviewing the latest data, providing guidance to clients to develop infection prevention plans to address the immediate challenges of this pandemic and to prepare for various scenarios that could play out in the coming weeks and months. Due to the novel features and changing appearance (e.g., mutations) of this Coronavirus, the research or science, that informs our public health and workplace recommendations, is still at infancy stages, and must be constantly updated. While there are many basic guidelines and recommendations published by various agencies and on the internet, below is an update on the current science, what we call “FAQ 201”, for the next level of understanding. It is this science that will inform and update our public health recommendations:

1. What is the mode of transmission for COVID-19 and how long can it linger in the air?

  • Understanding of the transmission risk is incomplete. At the beginning of the outbreak in China, investigations identified an initial association between a seafood market, that sold live animals, and the earliest patients. These patients had worked at or visited the market before it was closed for disinfection. However, the virus rapidly mutated and after the shut-down of the seafood markets, person-to-person spread became the main mode of transmission. The person-to-person transmission routes included direct transmission, such as cough, sneeze, droplet/ inhalation transmission, and contact transmission, such as contact with oral, nasal, and eye, mucous membranes. COVID-19 can also be transmitted through saliva, via micro-sprays during conversations. Fecal–oral may also be a potential person-to-person transmission route. Fomite (inanimate objects) transmission can occur as a result of a person touching an infected surface or infected object and then touching eyes, nose, or mouth, etc.
  • Infected aerosols or droplets typically do not travel more than six feet (about two meters) and typically do not linger in the air. However, under experimental conditions, the virus is viable in aerosols for at least three hours. Given the current uncertainty regarding transmission mechanisms, airborne precautions are routinely recommended, especially when performing certain high-risk procedures which can generate aerosols.
  • Individuals with suspected COVID-19 infections should be advised to wear a mask to limit possible transmission by respiratory secretions or aerosols from sneezing/ coughing. In a small study in China, an estimated 43% of the cases acquired their infection from a healthcare setting.

2. I own a mass mailing company. How long can the virus survive on paper products and other various surfaces? USPS had irradiated the mail for us during the Anthrax crisis; however, USPS is not doing this for COVID-19. Can I bake them?

  • Our knowledge regarding the length of time this virus can survive on various surfaces is incomplete. According to a February 2020 Journal of Hospital Infection article, information from SARS (another Corona virus) 2003 outbreak and other Coronavirus strains, it can remain infectious from 2 hours to up to nine days. The SARS data showed that the virus may survive on inanimate surfaces for up to six to nine days. For paper, specifically, the SARS data showed viral persistence anywhere from 24 hours to 5 days. In general, virus survival also appears to depend on the viral load (inoculum) and whether it was protected, e.g., within biofilm or soil, etc., from the external harsh environment.
  • Based on data about the SARS Coronavirus, a 2003 study found that the viruses remained stable at 4 degrees C (39 degrees F), at room temperature (20 degrees C or 68 degrees F) and at 37 degrees C (98.6 degrees F) for at least 2 hours without remarkable change in the infectious ability in cells, but were converted to be non-infectious after 90-, 60- and 30-min exposure at 56 degrees C (133 degrees F), at 67 degrees C (153 degrees F) and at 75 degrees C (167 degrees F), respectively. Irradiation the virus with UV light for 60 minutes in culture medium resulted in the destruction of viral infectivity to an undetectable level. The author’s conclusion was that the survival ability of SARS Coronavirus in human specimens and in environments seems to be relatively strong. Heating and UV irradiation can efficiently eliminate the viral infectivity.

Note: Practically speaking, UV irradiation outside of the laboratory setting is often inconsistent in such situations. The ability of UV to come in contact with all the surfaces of the many envelopes is highly unlikely and therefore, not likely to be completely effective.

3. Any updates on spectrum of disease and asymptomatic cases?

  • The spectrum of symptomatic infection ranges from mild to critical; most infections are not severe. Data from China reveals mild disease in approximately 81% of cases. Another 14% developed severe disease with symptoms such as shortness of breath, poor oxygenation, and/or disease involvement of over 50% of the lung. An additional 5% of cases experienced critical disease with shock, breathing failures, and/ or  multi-organ failure. Overall case fatality rate was 2.3%, with no deaths from the non-critical cases.
  • Asymptomatic cases do occur but their frequency is still unknown due to lack of widespread testing and/ or lack of random studies on asymptomatic individuals. In a recent cruise ship outbreak, 17% of the population on board tested positive for COVID-19. Approximately 300, or over 50%, of the confirmed COVID-19 cases were asymptomatic at the time of diagnosis.
  • In a very small study of 24 asymptomatic COVID-19 confirmed cases, 70% of these asymptomatic individuals had typical COVID-19 characteristics on chest imaging (ground glass or patchy), or atypical lung abnormalities.

4. What are the updates on clinical manifestations and can we use temperature checks for infection control or as a screen for the infection?

  • There are no specific clinical features that can yet reliably distinguish COVID-19 from other viral respiratory infections. Pneumonia appears to be the most frequent serious manifestation of infection. Other associated symptoms include:
    • In over 50% of symptomatic cases – Fever, fatigue, dry cough
    • In less than 50% of symptomatic cases – anorexia (loss of appetite), myalgia (muscle pain), dyspnea (shortness of breath), sputum production
    • Less common symptoms – headaches, sore throat, rhinorrhea (runny nose), nausea and diarrhea
  • While many clients or municipalities may demand or request a temperature check prior to entry into a building or workplace for purposes of infection control, fever might not be a universal finding. In various studies, anywhere from 20% to 40% of individuals may not present with fever. Furthermore, it appears individuals with COVID-19 infection can be contagious prior to manifestation of symptoms. A much more robust risk assessment is important to a well-planned infection control program.

5. Any information on this amazing drug that the White House has been touting?

  • Both chloroquine and hydroxychloroquine have been found to inhibit SARS-CoV-2 in vitro (cell studies), although hydroxychloroquine appears to have more potent antiviral activity. Both drugs are in a class of medications that were first used to prevent and treat malaria. Today, it is also used to treat rheumatoid arthritis and some symptoms of lupus, etc. A number of clinical (human) trials are underway in China to evaluate the use of chloroquine or hydroxychloroquine for COVID-19. The FDA has not approved these drugs as treatment for COVID-19. It must still be assessed in rigorous clinical trials before being declared safe and effective treatment for COVID-19.

There are significant gaps in our knowledge of this Novel Corona virus as this is a new and evolving world-wide outbreak. Cogency and FACS will strive to stay on top of this situation to keep you informed. For more information about this Corona virus outbreak and how to characterize your risk and reduce risk to those you are charged to protect, contact the experts at Cogency at solutions@cogencyteam.com

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