Published on: March 26, 2020
Last updated: May 22, 2020
I thought I’d take a minute of your time to explain some things about COVID-19. If you’re in the healthcare industry, you’ve seen it by now, and I know you’re scared. My intention with this post is not to create more fear, my intention is to get everybody on a level playing field because there are people out there who still do not understand the gravity of this situation.
This post is darker than most of the ones you’ll find here, and I would apologize for that, but this is a dark time, and we need a reality check right now about what we’re facing together. I really believe the only way we’re going to get through this is together, and to do that, we need to all be on the same page.
What is COVID-19?
The virus itself
COVID-19 is the disease caused by the virus, SARS-CoV-2.
This particular virus belongs to the coronavirus family, and along with SARS-CoV (2003) and MERS-CoV (2012) is one of three betacoronaviruses, a genus within the coronavirus family, that has caused disease in mankind (at least in recordable history). The coding for each of these viruses is single-stranded RNA, and SARS-CoV-2, the virus responsible for the disease COVID-19, is 30,000 base pairs long (Reference 6). By comparison, the DNA of the human genome is made up of about 3 billion base pairs (Reference 12).
Scientists have modeled how this novel coronavirus infects human cells. And, if you’re interested in that, you can visit the Wikipedia page here (Reference 7).
One of the most troublesome things with COVID-19 is that it doesn’t create the same symptoms in everybody. It seems young people typically (and I say typically here because there are always exceptions) have milder symptoms, and about 80% of those who contract SARS-CoV-2 wind up with a mild case of COVID-19, more like Greta Thunberg who says she’s had worse colds (but who is SUCH a dear and quarantined herself before and after symptoms appeared).
Why are 80% of the cases mild? Most of the time in mild cases, the virus doesn’t infect the lower respiratory tract, it infects the upper respiratory tract (nose, throat, sinuses) and feels more like a head cold.
But, in the other 20% of cases, this little virus causes serious symptoms. Here are just a few of the few ways this diminutive devil can wreak havoc.
Inflammation of the Airway
The virus can move deeper into the airway – into the bronchus leading to each of our lungs, and into the bronchioles, the path leading to our alveoli, the tiny air sacs in our lungs where gas exchange happens and oxygen from the air passes the alveoli lining to oxygenate our blood and carbon dioxide from our blood passes into the alveoli (air sacs) for us to exhale out through our bronchioles (the dirt roads and paved lanes of our airway) that join up with our bronchus (the freeway), which connects with our throat (the Autobahn) and then our nose for exhalation. Don’t worry, if you didn’t follow my metaphor, I’ve got an illustration below 😊.
When the novel coronavirus infects our bronchioles, the body responds by sending immune cells into the airways to fight the infection. This causes inflammation of the airway (bronchioles) making adequate air intake difficult. This inflammation causes acute respiratory distress in about 20% of novel coronavirus (SARS-CoV-2) cases (Reference 18).
Instead of making us susceptible to secondary infections like pneumonia (typically how the influenza virus works – it’s usually not the influenza virus itself that causes pneumonia infection, it’s typically the influenza virus itself that makes us susceptible to other viruses or bacteria that cause pneumonia), SARS-CoV-2 actually causes pneumonia because of migration into our lower respiratory tract. This type of pneumonia is known as primary pneumonia because it’s caused by the same infection that made us sick to begin with (References 13 and 15).
What is pneumonia? Inflammation of our airways causes an immune response that fills the little air sacs (alveoli) in the lungs with fluid so that gas exchange (exchange of oxygen from the air with carbon dioxide exhaust from our bodies) is not as efficient as normal because each air sac has less surface area available for gas exchange (since it's partially fluid filled). This fluid build-up within the air sacs is known as pneumonia.
Pneumonia is easily seen on a chest x-ray as white (fluid filled) instead of dark (air filled) tissue of the lungs… of course, other diseases can cause this same look on a chest x-ray, but we’re talking infectious diseases here.
And, yes, the normal flu can lead to pneumonia as well, and a diagnosis of pneumonia doesn't necessarily translate into a trip to the ER. It's also possible to develop pneumonia in just one lung or in both lungs. With more severe cases of COVID-19, pneumonia rapidly develops and frequently progresses to both lungs.
Disrupting Hemoglobin’s Oxygen Carrying Capacity
Hemoglobin is a chelating molecule, much like EDTA, but I digress. In plain English, hemoglobin is a cyclic ring, and its shape allows it to bind iron, which enables it to transport oxygen and carbon dioxide around in our body. SARS-CoV-2 disrupts hemoglobin’s ability to transport oxygen (Reference 17).
Combine hemoglobin's decreased ability to transport oxygen with the reduced ability of the alveoli (air sacs) to transfer oxygen into the blood because they’re mostly fluid-filled due to pneumonia, and the body is even more starved of oxygen. That’s why it’s so important to have ventilators on hand… and why it’s so important not to overburden our healthcare systems.
The result of extensive infection of COVID-19 is something worse looking than pneumonia... ground-glass opacities on x-ray. If you’re in the medical field, chances are, you’ve seen this over the past few weeks.
Two months into the declared pandemic, more and more evidence points to a cytokine storm in patients with a severe response to SARS-CoV-2.
A cytokine storm occurs when the immune system overreacts to an infection.
It's believed that the Spanish Flu of 1918-1920 was so deadly among young adults because it induced a cytokine storm. Growing evidence now suggests SARS-CoV-2 does the same thing.
This could explain why healthy younger people are succumbing to COVID-19. And, this poses an increased risk for those of us with autoimmune conditions who already have an overactive immune system.
Let’s talk about how this virus spreads.
What is viral shedding?
Specifically, this is the period of time when a person infected with a disease is contagious, actively shedding virus into the environment. Viral shedding is of course dependent on a number of factors including the severity of illness in the sick person, how long she’s been sick (Reference 1), and what type of virus she’s unwillingly harboring (yes, different viruses have different infection windows).
More interesting, viral shedding of SARS-CoV (Severe Acute Respiratory Syndrome-Coronavirus – keep in mind, this is not COVID-19, but the virus identified back in 2003 that was limited to 30 countries (Reference 2 and 3)) was also dependent on gender and age – guys and older folks shed that virus at higher levels than other individuals (Reference 4), and the mortality rate from that virus correlated well with viral shedding).
How exactly is viral shedding measured? Well, by measuring the number of virus copies (viral replicates) in swabs of the nose and throat (nasopharyngeal swabs), and for SARS-CoV, the viral load (number of copies) were found to be as high as 108 virus particles per mL of swabbed mucus.
In real numbers, forget the science jargon, that’s 100,000,000 (100 million copies of the virus per mL of material collected).
Why social distancing is important
Long Contagious Window
A person with COVID-19 can spread the virus during the “shedding phase” because copies of the virus are present in respiratory droplets (coughs and sneezes).
Technically, the range of a respiratory droplet expelled by a cough or sneeze is 6 feet 7 inches as reported by Wiki (Reference 5), so tack another foot onto that 6 feet recommendation to be on the safe side (I personally have been carrying around a 10 foot pole when I have to go to the grocery store for perishables like almond milk).
There’s some hot debate right now about whether people can infect others before they’re exhibiting signs of infection themselves, and there are plenty of articles suggesting people may be contagious even if they're asymptomatic (Reference 20).
This is why sheltering in place and social distancing is so important to limit the spread of the virus.
Regardless of where the science lands on contagion by asymptomatic folks, what's definitive is that people infected with the coronavirus can start to shed the virus (this is that contagious part of the disease I talked about above) early on during infection when they’re just starting to exhibit symptoms, and people remain infectious for up to 8 days after onset of symptoms in mild cases and for three days longer in more severe cases (Reference 21).
This contagious window is substantially longer than what’s been documented with influenza virus.
That’s what’s so difficult about this virus – 80% of the time, the infection is mild, and when’s the last time you took 8 days off work for a mild head cold?
I’m betting, never, not once, ever.
That huge contagion window alone is potentially deadly… not to any of us who wind up with a mild case of novel coronavirus, one where our immune system responds early, swiftly, and effectively eliminates the virus but to the people we infect during our contagion window, and the people they infect during their contagion window, and the people they infect during their contagion window...
That is why social distancing and shelter in place are SO important regardless of how you’re feeling and regardless of whether or not the virus can be shed by asymptomatic folks. And, I know isolation is hard, I’m there with you.
Fear of Mutation
One of the reasons the Spanish flu was so deadly is because it mutated and went around the world a second time.
The novel coronavirus, SARS-CoV-2, is mutating at a rate of about one to two mutations per month (Reference 6). According to molecular evolutionary biologist, Andrew Rambaut, the rate of mutation is about two to four times slower than the flu. This slower rate of mutation is a potential blessing. It gives time for vaccines and treatments to be developed against this virus.
Mutations can work for or against us as we try to rid ourselves of COVID-19. Mutation may result in a less virulent strain of the virus, and this is exactly what happened with SARS-CoV (Reference 6). SARS-CoV lost 29 base pairs during a mutation, which likely resulted in less widespread transmission of that virus during 2003.
Mutation might also make the virus more virulent, which might render the vaccines and treatments currently in development powerless against a new strain. Mutation towards a more sinister strain is exactly what happened with the Spanish flu or at the very least believed to be why the second wave, which started in the fall of 1918, was so deadly (Reference 8 and 9).
If you’re curious about how bad the Spanish flu was, well you’ve seen it if you’ve watched Season 4 of The Walking Dead. And, if you want to see what it might look like if we proceed with life as normal right now, then I’ve got a case study straight from history for you.
Philadelphia held the Liberty Loan parade on September 28, 1918 despite the Spanish flu raging among soldiers and citizens. It’s estimated 200,000 people attended that parade, and at least 12,000 in the city died of influenza following the parade – the entire city was quarantined. The number of the dead in Philly overwhelmed the morgues, and mass graves were dug to hold them all (Reference 10).
That’s why major gatherings have been canceled, why shelter in place ordinances are being put in place, and why self-quarantine is so important right now.
I’m so scared about the future
Let’s talk (if you get this reference, please, drop me a comment below).
I feel so much like Frodo here lately. When he cries to Gandalf “I wish it need not have happened in my time.”
And, Gandalf gives his reassuring smile and empathetic eyes and responds
“So do I, and so do all who live to see such times. But that is not for them to decide. All we have to decide is what to do with the time that is given to us.”
None of us EVER know what the future holds. We live in this wonderful world where time is hidden from us, the future is always uncertain, and in normal times that is exhilarating – the future is a blank slate, ours to create, so why should we fear the future more now than we ever have before?
The thought that a tiny virus can cause civilization to screech to a halt and cause many of us to lose our minds in fear-stricken panic is terrifying, let alone the new financial uncertainty many of us are facing as we woke up to work closures and layoffs when the shelter in place ordinances went into effect.
I don’t have answers for the uncertainty you are facing, but I want to invite you to mentally check out of this insanity.
What would it look like if you watched the news less these days, took up meditation, started a new self-care routine (how about dry brushing?), begin a new exercise regimen (yoga or Pilates perchance?), or maybe let yourself see the world through somebody else’s perspective?
If you’re looking for a few good books to cross into an alternate reality, I’ve got a list – a couple light-hearted reads to help you find some humor and a couple intense tomes to help you explore the depths of all of the feelings you’ve experienced over the past few weeks.
It’s an open invitation, so whenever you’re ready to escape from the COVID overwhelm, check back in, these resources will be waiting.
If you can’t imagine letting go of reality because things are just too real right now, then I have some words for you to think about: dreams come to life in the darkness.
The darkness isn’t a time to mourn about what you’ve lost, it’s a time to dream how great life could be, to plan your next hiking trips, to try some new recipes you haven't had time to make, to reconnect with all the ones you haven't had time to call in a hot minute, to journal and explore what you're feeling right now and to process some feelings you haven't had time to deal with until now.
And, I know the unknown is swirling about like dark clouds right now, and you’re worried about very real things like staying healthy during this epidemic, but dare to dream – dawn is closer than it seems.
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