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⫸STICKY⫷ What to do if you contract coronavirus

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mr peabody

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Battle to contain the virus is lost, health officials say

by Carolyn Johnson and Lena Sun | Washington Post | 21 Mar 2020

Health officials in New York, California and other hard-hit parts of the country are restricting coronavirus testing to health care workers and people who are hospitalized, saying the battle to contain the virus is lost, and the country is moving into a new phase of the pandemic response.

In hard-hit areas, testing restricted to health care workers, hospital patients As cases spike, health officials are saying the battle to contain the virus is lost and are hunkering down for an onslaught, directing scarce resources where they are needed most to save lives.

As cases spike sharply in those places, they are hunkering down for an onslaught, and directing scarce resources where they are needed most to save people’s lives. Instead of encouraging broad testing of the public, they’re focused on conserving masks, ventilators, intensive care beds — and on getting still-limited tests to health care workers and the most vulnerable. The shift is further evidence that rising levels of infection and illness have begun to overwhelm the health care system.

Health officials are struggling with a complicated message — more people can get tested, but those with mild symptoms should stay home and practice social distancing. Some go so far as to warn that widespread testing at this point could threaten the U.S. response by burning through precious supplies just as a tidal wave of sick people descend on the system

“In a universe where masks and gowns are starting to become scarce, every time we test someone who doesn’t need one, we’re taking that mask and gown away from someone in the intensive care unit,” said Demetre Daskalakis, deputy commissioner for the Division of Disease Control of the New York City Department of Health and Mental Hygiene.




Jeff Engel, executive director of the Council of State and Territorial Epidemiologists and former health director for North Carolina said it was time for a “pivot” in the testing strategy.

“If you have mild illness and can stay at home … don’t get tested,” Engel said. “You’re not only putting others at risk if you go out and about with symptoms, you’re wasting all these valuable resources we really need to conserve for society.”

Other county and state health officials are sounding similar alarms — just as drive-through testing sites are finally opening and weeks after federal officials announced 1.1 million tests had been shipped out and another 4 million more were coming.

Los Angeles County health officials advised doctors in a letter Thursday to give up on testing patients as a strategy to contain the outbreak, instructing them to test patients only if a positive result could change how they would be treated, the Los Angeles Times reported. The department “is shifting from a strategy of case containment to slowing disease transmission and averting excess morbidity and mortality,” according to the letter.

That same day, Sacramento county officials ordered residents to stay home except for essential activities, part of the city’s evolving strategy away from efforts to contain the virus by identifying and isolating each case and tracing that person’s contacts — a laborious process that becomes all but impossible once cases mount. The health order said the intent is to protect the most vulnerable, slow the virus’ spread, and preserve the ability of front-line workers to care for severely ill patients.

In Washington state, where hospital workers have been fashioning makeshift protective medical gear using parts purchased from Home Depot and craft stores, officials are restricting testing to high-risk populations, including health care workers and people with more severe symptoms.

“We’ve asked the public to understand we can’t test everyone, especially if they have mild symptoms or are asymptomatic,” said Jeff Duchin, health officer for Seattle and King County, a hard-hit part of the country.




How social distancing buys the U.S. valuable time against coronavirus

The shift represents a change in both messaging and strategy after weeks of efforts to expand access to testing after the federal government’s botched rollout of testing kits, which hampered states’ ability to know whether the virus was already circulating and to take steps to try to get ahead of it. Now, the repeated reassurances from various federal officials that testing is plentiful and free have sown confusion. Every day, White House coronavirus task force officials have promised Americans they’re ramping up widespread drive-through testing.

On Saturday, however, they laid out explicit guidelines for who should get tested, stressing that top priority should be given to those who are hospitalized, health care workers and residents of long-term care facilities who have symptoms, as well as people over 65 with symptoms, especially those with health problems like heart and lung disease that place them at higher risk.

“Not every single person in the U.S. needs to get tested,” said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. “When you go in and get tested, you are consuming personal protective equipment, masks and gowns — those are high priority for the health care workers who are taking care of people who have coronavirus disease. … We want to make sure that the people who are taking care of people with coronavirus disease do not endanger themselves because they do not have the protective personal equipment.”




But some state health officials worry that earlier suggestions that everyone who wants a test could get one has sent the wrong message.

“I’m just scared there’s going to be mass confusion when people find out there is a testing site, are worried about their covid status, and they’re going to mob the testing site,” said Michael Fraser, executive director of the association that represents state health directors, ASTHO. “It’s confusing to people to hear that testing is being made available in a much more convenient way, and they think, ‘Hey this is great, let’s get tested.’”

New York City’s Daskalakis said that a recent spike in pneumonia-related hospital admissions, just as other respiratory diseases are receding, is almost certainly attributable to covid19 — and people with a manageable fever and cough who aren’t at high risk should assume they have it and not seek testing.

Doing so exposes health care workers administering tests to people with mild illness and uses up limited protective gear, even though nothing would change for those individuals based on their test results, he said.

What went wrong with the coronavirus tests in the U.S.

As the disease has become widespread, a “negative” test could also provide false reassurance. When one of his patients with symptoms — who sought a covid19 test against his medical advice — tested negative, Daskalakis told the person to presume he had the disease anyway and to isolate himself.

As the flu season recedes, people with cough and fever will increasingly just have to presume they have covid-19.

At New York’s Mount Sinai Hospital, which treated the state’s first coronavirus case, "only a minority of the hundred-plus patients with respiratory symptoms who come to the emergency department each day get tested for the coronavirus," said Jolion McGreevy, the emergency department medical director.

“The default assumption is yes — anyone who comes in with any kind of fever, cough, respiratory symptom, flu-like illness, we’re making the assumption that they have this,” he said, based on the prevalence of community transmission in New York. “It’s very likely you have it. There’s no benefit for you to test.”

It’s a trade-off between individual and societal good that the United States, with its wealth and technologically-advanced health care system, is not used to making. A test result may be reassuring to individuals who feel unwell, but the mask and health care worker to test someone with mild symptoms are resources that could be used to save someone’s life.



“Because there’s a shortage, you have to think the way the rest of the world thinks. In developing countries, we only recommend testing if it changes how you manage the care of an individual person,” said a government public health official who has worked in the U.S. and Africa who requested anonymity because he was not authorized to speak. “I know it would make you feel better to know what you really have, but it doesn’t change your individual care.”

In an ideal world, public health officials say they should have done wide scale surveillance testing of people with respiratory symptoms much earlier. But city-by-city and state-by-state, officials say they are nearing — or in some cases have already crossed — the line when they must make a hard trade-off:

“In the 2009 influenza pandemic, we stopped testing for H1N1 once the level of illness in the community was so high that it just made more sense to treat based on clinical symptoms,” said Jennifer Nuzzo, an epidemiologist with the Johns Hopkins Bloomberg School of Public Health’s Center for Health Security.

In the coronavirus health crisis, there are no specific treatments.

“Our only defense is to tell people to stay home and to hope that sick people isolate themselves,” she said. While it’s essential for testing capacity to increase, the general public needs to understand what health officials are up against given the shortages.

“We have to target our resources and reserve testing for those who need it most: severely ill and those in high risk professions, such as health care workers,” she said. “We’d cause more harms by encouraging the general public to run out and get tested if they are well or experiencing mild illness.”

 
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mr peabody

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Potential harms of chloroquine, hydroxychloroquine and azithromycin for treating COVID-19

Canadian Medical Association Journal | Neuroscience News | 8 April 2020

Summary: Study warns of the potentially serious adverse effects of prescribing hydroxychloroquine and azithromycin for the treatment of COVID-19. Some of the potential side effects include cardiac arrhythmias, hypoglycemia, and neuropsychiatric effects.

Chloroquine, hydroxychloroquine and azithromycin are being used to treat and prevent COVID-19 despite weak evidence for effectiveness, and physicians and patients should be aware of the drugs’ potentially serious adverse events, states a review in CMAJ (Canadian Medical Association Journal).

“Physicians and patients should be aware of several rare but potentially life-threatening adverse effects of chloroquine and hydroxychloroquine,” says Dr. David Juurlink, Division of Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre, and a senior scientist at ICES.

The review provides an overview of potential harms associated with these drugs as well as their management based on the best available evidence.

Potential adverse effects include:

- Cardiac arrhythmias
- Hypoglycemia
- Neuropsychiatric effects, such as agitation, confusion, hallucinations and paranoia
- Interactions with other drugs
- Metabolic variability (some people metabolize chloroquine and hydroxychloroquine poorly and a small percentage metabolize them rapidly, which affects the response to treatment)
- Overdose (chloroquine and hydroxychloroquine are highly toxic in overdose and can cause seizures, coma and cardiac arrest)

The review summarizes the poor quality of evidence suggesting that these treatments might be beneficial in patients with COVID-19 and cautions that it is possible that these treatments could worsen the disease.

The review provides an overview of potential harms associated with these drugs as well as their management based on the best available evidence.

“Despite optimism (in some, even enthusiasm) for the potential of chloroquine or hydroxychloroquine in the treatment of COVID-19, little consideration has been given to the possibility that the drugs might negatively influence the course of disease,” says Dr. Juurlink. “This is why we need a better evidence base before routinely using these drugs to treat patients with COVID-19.”

 
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mr peabody

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Rest as soon as you notice any symptoms.


What to do if you contract coronavirus

by Emine Saner @eminesaner | The Guardian | 8 April 2020

There is a lot of confusion about how to protect yourself from illness – and what to do if you contract coronavirus. Here is the expert advice,

You will already be regularly washing your hands and social distancing, but many of us are still likely to become infected with coronavirus. Doing what you can now to improve your health and boost your immune system will help your body cope. Thankfully, the majority of cases are mild and you should recover within a week, though if your symptoms are persistent it is vital to seek medical advice from NHS 111 rather than try to continue to manage at home. With that in mind, here’s what you can do to put yourself in the best position to help your recovery.

Protect your lungs

Tom Wingfield, a physician and clinical lecturer in infectious diseases at the Liverpool School of Tropical Medicine, says you should avoid anything that damages your lungs – stop smoking, and don’t expose others to secondhand smoke. “Open fires are not great, and if you have allergies that irritate your lungs, avoid what you can.” One upside of the lockdown is that air pollution has decreased. "And," says Wingfield, “general aerobic exercise will help your lungs.”

Boost your immune system

There is no magic supplement. The advice is as it’s always been: reduce your alcohol consumption, exercise, sleep well and reduce stress. A varied, balanced diet, with lots of vegetables and fruit, is important, but there is little evidence for most vitamin and mineral supplements.

"Getting out in the sun each day can also be beneficial," says the GP Amir Khan. “The majority of people have low vitamin D because we don’t have enough sunlight in the UK, and we are coming out of winter. Vitamin D levels will be depleted, so there’s no harm in taking a vitamin D tablet.”

Rest as soon as you start to notice symptoms

Many people who are suspected of having had the virus report at least one day of fatigue. Now is not the time to try to tough things out. “Your body is using all its energy to fight a virus that is infecting cell after cell,” says Khan. “Even with mild symptoms, you’ll have some days when you feel fine and other days when you are tired and achey. You can potter around the house and make food if you need to, but you shouldn’t be doing any more than that and, where possible, you should be on the sofa or in bed.”

"Once you develop a fever,"
he says, “your body is starting to use energy to raise your core body temperature to make it an unfavourable environment for the virus to reproduce. You shouldn’t wait until you feel tired [to rest], because by then you’ve expended too much energy already.”

Keep drinking fluids

Khan says: “Everybody should be sticking to two to three litres of fluid a day” – as normal. "When you have a fever," says Saira Ghafur, an honorary respiratory consultant at St Mary’s hospital in London, “you can become dehydrated, so you need to make sure that even if you don’t feel like it, you’re drinking as much as possible. If you feel you’re not peeing very much, that’s another sign you’re very dehydrated and should seek medical advice.”

How to manage a fever

Take paracetamol, rather than ibuprofen. There has been concern that ibuprofen, an anti-inflammatory, could reduce immune function and make coronavirus symptoms worse, but there is not enough evidence to confirm this. Still, the advice is to take paracetamol for fever and muscle pain instead. “If you have been prescribed ibuprofen then discuss that with your medical practitioner,” says Wingfield.

Definitely don’t rely on supplements or ‘miracle’ cures

Khan has seen advice online about taking vitamin C to treat coronavirus – but that doesn’t mean you should be trying this at home. “It has been used intravenously in very, very high doses in hospitals in China. That’s a big difference to what you get in a tablet. The jury is still very much out in terms of using intravenous vitamin C for coronavirus.”

"Taking a vitamin C tablet from the chemist or supermarket won’t stop you getting an infection and it won’t help treat the infection,”
says Khan. "And certainly don’t try to take very high doses."

Don’t pin your hopes on “superfoods” or the social media posts about “alkaline” foods (a virus doesn’t have a pH level, and you can’t change the body’s pH level through diet). What about garlic? “It may help reduce the length of things like a cold, but won’t prevent it,” says Khan. "And there’s no evidence it has any effect on coronavirus."

Can breathing exercises help?

It’s far from clear. On Monday, the author JK Rowling shared a video of Sarfaraz Munshi, the head of urgent care at Queen’s hospital in Romford, London, demonstrating breathing techniques that he said could relieve symptoms and prevent someone developing a secondary pneumonia infection. "People with asthma and those recovering from pneumonia are often helped by respiratory physiotherapists," says Wingfield, “who can help support your breathing with exercises. The main thing you are trying to do is make patients’ lungs open as much as they can and try and get rid of some of the fluid and inflammatory material.”

"Coronavirus,"
says Khan, “causes inflammation around the alveoli, the air sacs at the peripheries of the lungs, and it can damage them. It reduces your lung capacity. If you are safely managing your condition at home [on advice from a doctor or the NHS 111 service], then breathing exercises might help."


“What you’re really doing there is forcing air into the alveoli by taking big breaths in and holding the alveoli open, and that will help clear any excess mucus, pathogens, as well as stop them from becoming hardened, which can happen. This is with the caveat that you are safe to stay at home and you don’t need to be in hospital. If there’s any chance of pneumonia, you should be in hospital.”

However, Laura Breach, a spokeswoman for the Association of Chartered Physiotherapists in Respiratory Care (ACPRC), says "while the exercises should be harmless for healthy individuals, she would not advise them, adding that they could make symptoms worse in someone suffering breathlessness." Although Munshi’s video was well-intentioned, the ACPRC says the techniques are not correct (it is preparing its own video). "If you did try the exercise, you only need to take three or four breaths so as not to hyperventilate and become dizzy, and if you have coronavirus symptoms, there is no need to make yourself cough as part of the exercise. We would always encourage nose-breathing rather than mouth-breathing, because your nose is really important in humidifying the air that you breathe in and catching any particles in the air,” says Breach.

There is no evidence these exercises will help healthy people prepare for the illness, she says. “There are patients with longer-term respiratory conditions and we do teach them techniques to give them a better starting point. If it’s something you should be doing then your healthcare professional will have already advised that.” Instead, the ACPRC says: “Propping yourself up with pillows, or leaning forward onto the back of a chair, can be beneficial to breathlessness."

Wingfield also questions whether the exercises can aid recovery from coronavirus – “it’s a slightly evidence-free zone” – and says "if you are having trouble breathing, you should seek medical help rather than simply try to follow breathing exercises at home. But they can keep your lungs moving, and some people might find these exercises meditative and stress-relieving,” says Wingfield. Ghafur agrees: “None of this is evidence-based.”

But try lying on your front

"One of the big things in intensive care that we’re seeing with a lot of patients," says Ghafur, “is you have to put them on a ventilator in what we call a prone position, which basically means you’re lying on your front. It’s not in any recommended guidance for patients who are not in intensive care, but if you’re able to lie on your front for a while that can help breathing. There’s no harm in trying it," she says, "but only if you’re generally fit and healthy. Do not try to lie on your front if you are older, infirm, have mobility problems or are pregnant."

Lying continuously on your back is not ideal. “If you can sit and take deep breaths in and out, that will help any respiratory condition – you’re taking in a bigger lungful of air and that will help remove any mucus. However," she adds, "there is no evidence that this will improve your recovery."

 
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