One fact that stands out about this novel coronavirus is how little we really know even after we hit new daily world highs of cases. Currently, over 2 million cases exist and deaths stand at almost 150,000 worldwide. After a smoldering start in China, the virus has exploded on the world stage, infecting every country and continent except for Antarctica. Our efforts to contain, control and treat it are met with limited success.
It is also true that the virus comes at a time when our country, in particular, is divided. People are responding to true science with skepticism and accepting rumors and conspiracy theory without question. It gets harder and harder to know which is which and as healthcare providers, we can find it challenging to distinguish and promote facts over fiction.
Here are some of the questions we consider daily, trying to pin down easier answers:
1. What is the death rate?
Because the illness extends over a period of days to weeks, measuring death rates from COVID-19 has been difficult. Best-guess estimates are currently somewhere between 1-3% with Italy reporting 12% and Germany 1%. Estimates vary so widely because the age of the persons contracting the virus can push that number up significantly. It is helpful to compare these to the known flu death rate which is 0.1% As time goes on, this number will become more accurate. For now, it is still largely in flux. Nurses need to recognize the difference between case mortality and infection mortality. The above numbers are case mortality, but infection mortality is largely unknown since we don’t test asymptomatic people at this time.
2. What are the symptoms?
When we all first learned about COVID-19 we were told to watch for basically four symptoms: cough, fever, fatigue and shortness of breath. Coupled with recent travel, those symptoms were the ticket for getting one of the precious few tests. Time has altered our understanding of the presentation of the virus. Yes, the top four symptoms are still the gold standard, but the virus can vary its presentation by starting as a sore throat for a few days, maybe with a runny nose, then turn into fever and cough. A significant number present with gastrointestinal symptoms instead. Other symptoms include: headaches, body aches, severe fatigue, general malaise, chills, new onset loss of taste or smell. It is also disheartening that some people can have the virus and have zero symptoms. For the general public, learning and re-learning the symptoms—expanded as our knowledge expands—has been challenging. While they may be able to recite the first four, they may not be as versed on later accepted descriptions of possible onset. This makes it hard for an average person to consider they may have it when “all they have” is gastrointestinal discomfort and severe fatigue.
3. How is it transmitted?
Because the virus is basically transmitted via droplets, coughing is the #1 mode of transmission. The novel coronavirus can survive on surfaces for variable amounts of time. It can also aerosolize which has made it particularly communicable in health care settings where breathing treatments, ventilators, Bi-pap and other pulmonary interventions tend to set the virus free in the air surrounding the infected person. The unpredictability of transmission has set many on edge because the virus is the great unknown. Where is it? How long does it survive on a shipping box, on a grocery store bag, on the countertop? All of these questions lead some to throw up their hands and give up trying, while others become excessively paranoid and struggle to continue with activities of daily living.
4. Viral load
For most viruses, the amount of virus present at infection correlates with the illness severity. At this point, we do not know if COVID-19 follows the usual pattern of many other viruses. If that were the case, it would seem that people would get sicker when encountering more of the virus and less sick if subjected to a smaller viral load. At this point, scientists are still studying the behavior of this virus, which continues to be atypical in many ways.
5. Ventilator use
COVID-19 has sparked intense discussion among medical professionals about the use of ventilators to treat the devastation inflicted by the virus on the lung tissue. The “standard” parameters for intubation do not seem to apply across the board, making what were once protocol-based decisions, much less reflexive. At this point, care teams are beginning to wonder if positional changes and other interventions are an important direction to focus on. Again, this virus is perplexing and far from predictable, making standard treatment options much less helpful. It is safe to say that over the next few weeks, care teams will continue to ask questions, explore answers and try new interventions. With time of the essence, we see medical providers taking bold steps to discover best treatment protocols.
6. Masks in public
We are accustomed to seeing Asians wearing masks in public, even before COVID-19. Living in ultra-crowded conditions, they are forced to seek ways to protect themselves and others from potential illness due to infectious organisms as well as pollution. In the West, where masks have been less plentiful, we are now learning that they may be one of the keys to helping us slow the spread of COVID-19. As the saying goes, “My mask protects you. Your mask protects me.” As a kindness to others, and out of consideration for the possible protection that it may offer, we will all most likely need to wear masks for a period of time, especially as we try to re-introduce more “normal” life activities. As nurses, we help others by setting an example and instructing them to remember that the goal is not to eliminate all the germs but to lower the infectivity rate low enough so that the pandemic cannot sustain itself.
7. Physical distancing, washing hands, staying home
While many questions remain, we do know that physical distancing is necessary for now and for the longer term. We will have to continue to practice obsessive hand hygiene and stay home a lot more. This requires that the entire society participate, otherwise it will not be effective.
A friend said to me, “The real evil of this virus is that it has made every other person an enemy.” Her shocking statement rings true, as we all try to adapt and change our behavior. Just two short months ago, few people, not even the most erudite pandemic specialist could have predicted the extent of the disaster we find ourselves in: staying home with the economy at a standstill, airports empty, businesses shuttered. While the leadership and timelines are subject to argument and opinion, it is undeniable that nurses play an important role in combating and eventually dominating this foe.