Part 48--COVID-19 is a Lower Respiratory Tract Infection-Importance of Hand Washing and Social Distancing in Disease Prevention (Part 2)

Technically, the COVID-19 virus is not a free-living organism. Viruses require a host, animals or humans, to survive and multiply. It contains genetic material and protein molecules that are wrapped up by a protective, lipid-protein (lipoprotein) cover. With its genetic-mutation recently, COVID-19 acquired the ability to infect humans, entering through any of the mucous membranes [i.e., eyes, nose, mouth (buccal mucosa), and the genito-anal region]. It enters into human cells using its S-protein tails in the outer membrane. In the presence of the adverse conditions, viruses decay and ceased to exist. 

Ways to get rid of COVID-19 from hands:

COVID-19 virus cannot penetrate the intact skin. The COVID-19 is covered with a protective thin lipid layer around it; thus, it sticks to surfaces, including hands and fingers. Washing hands with water with any detergent or soap (preferably in warm water) will damage the viral outer lipid layer; so it destabilizes the virus. Therefore, washing hands with soap in running water for 20 seconds must become a routine process for everyone. This should be done, each time one is returned home or to the office, after shopping, using toilets, etc. Touching any mucous membrane in the body with contaminated fingers, without washing properly, would allow COVID-19 to enter into the body.

The frequent use of soap and water does two things: the virus will not stick to hand or clothes and it will fragment viral genetic/protein molecules. The dissolution of the lipid layer also occurs when the virus encounters stronger alcohol that has in excess of 65% concentration or bleach (hypochlorite) solution. Since commercially available alcoholic drinks contain less than 42% alcohol it will not harm the virus nor the use of vinegar. The use of hand moisturizes and keeping the finger-nails short would help.

Flu season that coincided with the COVID-19 pandemic:

November through April is the flu season in the Northern hemisphere. Millions of people get common colds or flu/influenza; the two most common respiratory viral-mediated infections. However, these viral illnesses primarily affect the upper respiratory tract, lungs are affected only if secondary pneumonia is developed. 

None of the bactericidal preparations able to do this efficiently nor ANY antibiotic is capable of terminating the virus. In addition, COVID-19 can survive in very cold weather for a period, so as in any air-conditioning setups, and thrives in a humid atmosphere. Dehumidification and exposure to sunlight would be helpful.

COVID-19 causes “lower” respiratory tract infection:

Many fake-videos that are circulating claim that COVID-19 causes upper respiratory tract infection; this is incorrect. It is predominantly a lower respiratory tract disease, predominantly infecting lung, heart and renal cells. While high fever occurs in about 80% of the affected, it is not an essential criterion for making the diagnosis. Other than COVID-19, there are many other illnesses causing fever and feeling of unwell.

A perspective: Each year, during the winter months, more than 80,000 people in the United States and 20,000 in the United Kingdom die of “cold and influenza,” virus-related illnesses, such as pneumonia and acute respiratory distress syndrome (ARDS), despite having effective vaccine against influenza. This is one of the commonest cause of death in the elderly in industrialized countries. However, the public, politicians, and healthcare administrators alike, have taken these preventable deaths for granted.

Unlike COVID-19, cold and flu-related viral diseases predominantly affect the upper respiratory tract, so milder temperature, runny nose, headaches, and sneezing are common. These symptoms can, however, be mistaken for COVID-19. In contrast, COVID-19 predominantly causes a lower respiratory tract infection--primarily the lung and heart cells are affected. Fewer than 15% of those affected with COVID-19 have associated runny nose, flu, or allergy-like symptoms. However, this too could be due to coexisting flu with COVID-19 infection. If one has these signs and symptoms, in the absence of high temperature, the probability of having COVID-19 is less.

Having COVID-19 vs. common cold/influenza:

The care for patients with severe COVID-19 in hospitals and in the ICU units is similar to that provided to those with other viral pneumonia and ARDS illnesses. However, because of the increasing peaks incidences of COVID-19 infections, the number of patients requiring critical care facilities is increasing. Most such patients are older than 70 years and more than half of them have comorbid conditions. They have the highest risk of dying.

Considering that this pandemic has occurred during the peak winter months in the Northern hemisphere, it is difficult to rule out other respiratory viral infections, such as influenza alone or in coexistence with COVID-19. Outcomes are however worse if patients are infected with more than one type of virus.

Cough-associated droplets carry infectious virus particles that spread the disease to those who are nearby. When an infected individual travel via public transportation, a shared ride in a vehicle, or airplane, those people sitting/staying nearby are at high risk for contracting the disease. Because of the potential for widespread infectious particles, it is virtually impossible to isolate all undiagnosed people with such viruses in an ordinary set-up.

Incubation periods of COVID-19 and other recent viral outbreaks:

The incubation period for the stated common viral diseases (flu-like infections), such as the cold and influenza are between 2 and 6 days. In contrast, COVID-19 has an estimated incubation period--the time from getting an infection to the manifestation of signs and symptoms of the virus--is between 2 and 14 days, depending on the viral load, comorbidities, and the status of immunity of the exposed person. 

In addition to high fever, persons with COVID-19 is presented with a dry cough that can gradually change into a productive cough as the disease progress. As the lung cells die and the ability to transfer oxygen to blood across its membrane decrease (i.e, the physiologic capacity of the lung), shortness of breath (dyspnoea) developed. A proportionate decline of the health status occurs with the reduction of the oxygenation capacity of the lungs. In addition to direct invasion of cardiac myositis (i.e., infection of heart muscle cells) reduction of blood oxygen concertation worsen the ischemia of heart and other muscles, leading to the accumulation of metabolic waste products, causing weakness and body aches. 

COVID-19 infection markedly reduces intracellular energy production (respiration) exacerbating organ failures. The insufficient energy and oxygenation, worsen the cardiac (heart) failure and ischemic heart disease (i.e., increasing the risks of heart attacks), especially in the elderly. In persons exposed to one with the disease, although they may not have obvious signs and symptoms, they can spread the virus during the incubation period prior to manifestation of the disease.

Social distancing:

One key reason to maintain social distance is to flatten the peaks of outbreaks in an epidemic like in COVID-19. Such would allow the reduction of the number of infected persons to a manageable number of patients needing critical care facilities. So, that hospital can efficiently handle the reduced case-load and patients will get benefitted. As a part of this strategy, individuals are encouraged or imposed mandatorily staying at home and working from home, the closure of schools and universities, banning larger gatherings of all kinds, and mandating businesses to alter their operation times and practices to minimize larger-scale social contact.

Issuing voluntary guidance for people to stay home as much as possible is a good option in conjunction with taking stringent personal hygiene measures. In these situations, there are several allowable exceptions, including taking care of sick and vulnerable persons, access to essential services including visiting medical providers and pharmacies and picking up food. As a part of this process, rather than closing businesses, employees should be allowed to carry out essential work from home in individual setups rather than working in groups.

Imposing social distancing, including closing schools and universities, modifying business operations, prohibiting large gatherings, are acceptable actions in the current circumstance. However, imposing a continuous curfew, locking down large cities and provinces for days at a time can be counter-productive. In fact, there are better and less harsh ways to achieve the same or better clinical outcomes with significantly less inconvenience to the population.

After several days of 24-hour curfew, allowing thousands of desperate people to gather (scrum) to purchase food is irrational and unhelpful. This will be discussed in Part 2 of this series (tomorrow), providing safer and practical alternative options minimizing hardships the population.

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Professor Sunil J. Wimalawansa, MD, Ph.D., MBA, DSc, is a physician-scientist, educator, social entrepreneur, and process consultant. He is a philanthropist with experience in long-term strategic planning and cost-effective investment and interventions globally for preventing non-communicable diseases [recent charitable work]. The author has no conflicts of interest and received no funding for this work.