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COVID-19 Summary by Cumbria GP Arabella Onslow

Introduction

After a couple of weeks of lockdown it is clear we are in extraordinary times as a result of the SARS-COV-2 virus causing Covid-19.


Now the virus is global, we are all aware how widespread it is and are behaving as if we could encounter it anywhere. That has resulted in dramatic alterations to lifestyle and normal practice.


In addition, there is a tsunami of information that washes over us day by day in our attempts to explain and understand.

There is, reassuringly, a great breadth of similarity of approach across nations, with some notable differences however and these need understanding a little more so we can take the best of the advice and ensure we optimise our own behaviours without compromising wider society or having an unsustainable approach to this ultra marathon we are experiencing and sharing with billions of other people.


Characteristics of pandemics that differ from more local outbreaks


None of us has experienced a global pandemic of this type before. Anyone alive in the last pandemic would have to be at least 102 and is unlikely therefore to remember much about it.


Any behaviours and memories that we learnt in order to manage the last one, including dealing with the aftermath, have been long forgotten and the world we live in is very different a century later, however, many basic principles are unchanged.


Firstly, human need for community and connection remains the same even if the way in which we achieve it differs. The range of human emotion is also unchanged and our important needs, wants and feelings are essentially the same.


We are designed to be social, safe and have an appropriate response to threat and it is important to remember that, in our highly technological world, still our biology is our greatest asset.


Viruses and humans have fought a dance of supremacy for millennia and, on balance, we’re doing pretty well, but having perhaps become a little complacent in our technologically advanced lives, we need to re-engage our skills to ensure we can restore a safe and socially-engaged world.


How do viruses work?


Viruses are packets of genetic instruction that depend on a host and a vector to propagate.


A host is an organism whose biological machinery can be hijacked by the virus to make viral protein so they are able to reconstruct the viral packet and replicate itself and a vector is a form of transportation the virus can use to pass between host to host.


Virions (a single viral unit) do not have any life supporting processes themselves, they can exist, but they can’t reproduce or replicate without a living organism.


There are viruses all around us, each with a unique requirement for replication. SARS-COV-2 specifically attaches itself to a protein found on the surface of cells in the moist membranes of the upper and lower airways of humans.


This allows the virus to gain entry to the cell machinery to help them print off more of their proteins and reconstruct more viruses.


The cell full of newly made viruses dies because its normal function has been taken over and with the breakdown of the cell the viruses are shed into the surrounding area. In the case of SARS-COV-2, these new viruses can attach to nearby cells and infect them.


The virus also has methods that enable it to be transmitted to new hosts. In Covid-19, this is through fluid we expel when we speak, sneeze, cough, sing, breathe and drool (for those of us who do drool).


There are debates about how far these droplets and aerosolized particles containing viruses can be spread. On balance the risk drops off significantly after 2 metres however, there is some evidence that it may be able to spread beyond that distance.


There is also evidence that it is present in small amounts in stool especially diarrhoea and there were some early theories in urine, although that has not been found since.


This virus can remain viable for several days outside of its host depending on the surface it lands on. If that surface is touched and transported to near or on the appropriate mucous membrane then it has found a new host and the process starts all over again.


Innate versus adaptive immunity


Our immune system is a complex and dynamic biological warfare system against perceived threats consisting of a “mercenary” innate immune response that aggressively destroys anything it doesn’t recognise and a highly skilled “SAS” adaptive immune response that recognises and targets previously encountered infectious agents using memory molecules (antibodies) to prevent re-infection.


A new virus, as in covid-19, therefore relies on the innate immune response triggered by cell death caused by the virus releasing distress chemicals.

Usually, if only a few viruses enter the host, then the immune response is small and contained, sometimes invisible, which might account for asymptomatic infections.


If the infectious “dose” is significantly larger, the immune system is stronger, making us feel more unwell or even be overwhelmed and in some rare cases, becomes in itself destructive.


The balance of power between immunity and virus is therefore both influenced by the state of the host’s immune system, which in turn depends on both genetic and acquired factors including lifestyle, other diseases, medications for example, as well as the amount of virus to invade in the first place.


Once we have successfully mounted an immune response, we will then, over a few weeks develop antibodies to prevent re-infection.


Typical immune response to covid-19


The spectrum of the disease is highly variable and people have reported a wide variety of symptoms, but the most common are a high temperature (over 37.8) and a dry cough.


Due to the variability it is worth considering you might have it if you experience any general malaise, especially one that differs from your normal response to viral illness.


If you are unwell, then follow the government’s guidelines on self isolating. If you are suspicious you might have it, but do not fit in with the current inclusion criteria you might want to consider voluntarily quarantining yourself anyway.


Your immune system, if activated and giving you symptoms, needs energy to fight it, so conserve your energy by resting fully, ensuring you are well hydrated and contacting 111 or your GP if concerned.


GPs are still open for telephone advice and will be able to help. The course of the illness can be prolonged, lasting 2-3 weeks or more and severe illness tends to develop in the second week of symptoms so if your condition is worsening seek medical urgently. Do not use anti-inflammatories for symptom relief.


What we can do to break the chain.


As explained above, the virus is useless without a host. It can hang around for several days hoping to hitch a ride not only to a host, but to the right place on the host, but it is the behaviours of both the host and the vectors that determine how widespread the virus becomes. We know much about this virus increases our power in this pandemic.


Destroying the virus

  • Soap: the virus has an oily membrane holding all its component parts together. Using a good lathering soap and hot running water will dismantle the virus and wash the parts away. Soap is the best way of destroying the virus. It will work for hands and objects as long as it is sufficiently foamy and well distributed.

  • Alcohol: The virus is also deactivated by solutions of >60% alcohol (gin and vodka are not effective enough) which can be used as a hand sanitiser between washing with soap and water or to clean surfaces such as handles, door plates, table surfaces, keyboards, keypads, phones etc

  • Bleach: dilute solutions of household bleach are also effective at killing the virus, however repeated use of bleach can perish rubber and other surfaces, so it is best to reserve this for usual household cleaning

  • Heat Freezing does not deactivate the virus and it is stable from freezing point to at least body temperature (37 degrees). This accounts for its ability to live on surfaces at room temperature and seemingly in most climates. It starts to become unstable above 56o C after 15m exposure.

Preventing becoming infected

  • Hand washing: We touch surfaces, our faces and rub our hands all the time and that distributes the virus to all the surfaces of the hands and on to the mucus membrane. The reason washing hands needs to be for 20 seconds or more each time is to ensure that all parts of the hand are cleaned thoroughly, palms, backs, thumbs, finger webs, finger tips, backs of fingers. Steps for effective hand washing

  • Wet hands

  • Apply soap (liquid or bar is the same)

  • Rub hands together to generate a foamy lather

  • Wash hands for 20 seconds at least covering all the areas above

  • Rinse

  • Dry hands with paper towel

  • Turn off tap with paper towel & discard


  • Social Distancing: The main direct transmission is within 2m of two hosts, via droplet and aerosolized particles, which is why the rules around social distancing have been advised and enforced.


However, direct transmission may be across wider distances than that which means that it is possible the droplets or particles may linger longer in the air space than immediately drop to the floor.


Reducing transmission

  • Social distancing as above also reduces transmission

  • Masks: This is a highly controversial subject. The initial recommendation from WHO that they were not helpful unless in healthcare setting caring for people with confirmed infection. This was likely based on a real concern that because the entire world’s health system needs medical masks if the general public used them, they would become scarce for the most high risk situations.


However, covering your mouth and nose does have a role to play in the reduction of transmission and several countries, including the US and the WHO have altered their stance to reflect that. The UK has not.

We now know that there are many people who will be completely unaware they are infectious, as the virus can be shed both prior to, or without, symptoms.


Studies have demonstrated that even using a homemade cotton mask reduces the droplet projection from the mouth by around 50%.


This means fewer droplets in the air and on surfaces. So if everybody wore a face covering when outside, direct and indirect transmission is reduced.


This might have significance for our communities and provide a strategy that would allow a safer downgrading of our current lockdown situation prior to a vaccine development.


Best practice: We should not feel falsely reassured by covering our mouth and nose, we are protecting others but only if we are also practising frequent hand-washing and social distancing. It does however remind us not to touch our faces and others to continue safe practices in public spaces. We ourselves are not protected well by it nor are people we are caring for at close quarters unless we are using a medical grade mask


Take these simple safety precautions if using any face covering or mask.

  • Choose a material which is safe to breathe through ie that has no chemicals infused in it eg avoid materials that might have fire retardant properties.

  • The optimal material for a reusable face covering is one with a tight weave that can safely be washed at high temperatures, 60 degrees or above ie 70-100% cotton prewashed to avoid shrinkage. Adding a non-woven bonded layer might improve the quality of the filtration and could be added as a disposable layer.

  • Put it on clean with clean hands and tie or fix tightly across the face.

  • As you breathe through it, it becomes moist and there will be virus on the surface front & back. If you touch the front of it, you must wash or sanitise your hands immediately. If it needs adjusting, do it by the straps where necessary.

  • Once you have finished using it, remove it without moving it around, do not put it down on any shared surfaces but straight in a place where it cannot contaminate anything but be disposed safely if single use, or cleaned properly if reusable.

  • Immediately wash your hands before touching anything else.


Reducing the viral load

Using all of the above measures together, rigorously and consistently will not prevent you ever getting infected, however, it will both reduce your chances and also reduce the amount of infection you encounter if any virus slips through the net, and that means that you are reducing the severity of your infection and your infectiousness.


Each of us must do our very best to practice all of the measures all of the time, but don’t blame yourself if you still get infected because in the dance of supremacy, invisibility of the enemy means it is very hard to completely elude.

Impact

The reality is that this is such a significant global event that it will have a lasting impact on how we live our lives.


There will be short-term consequences, but we also need to think about the longer term effects as well. Thinking about the future, will help us plan and cope with some of the changes we will have to manage.


One important consideration is to take time to prioritise what really matters to us and find ways of preserving those aspects of our lives and learning to let go of some of some of the perhaps less important parts.


Feeling under threat

At the moment, there are many things which feel threatening. In addition to the health threats posed to ourselves or loved ones by the virus, both directly and indirectly as a result of the pressures on the health system, there may also be financial dangers, risks of increased violence, threat to security, disruptions to mental well-being, separation and loss, loneliness reduced support and many other possibilities.


It is important to understand that we are wired to recognise and respond to threat to try and keep ourselves safe, however, how we respond individually will depend on our previous learned experiences of perceiving and managing danger.


Most threat responses will revolve around fight, flight or freeze, but there are a multitude of ways these can be expressed and we are likely to experience variations in all of those at some time.


It is so important to be compassionate of our own emotional state. We may be experiencing depths and durations of emotions we are not familiar with and which feel scary in themselves.


When we are in a heightened emotional state, our behaviours become more reactive and automatic. Do not criticise yourself for this, understand your response is a biological imperative and not a failing or sign of weakness.


Instead, practice recognising what affects the height or length of the emotional intensity and find ways to influence those for the better. And practice also being compassionate with yourself.


Coping strategies

Over our lives we have all learned coping strategies, some of which are more helpful than others but also some of which may not be accessible in the same way as before ie connecting with loved ones or exercise.

Coping strategies are ways in which we either try to reduce the intensity of our feelings or reduce the sense of the threat. This difference is important because, sometimes the feelings are appropriate and coping strategies aimed at reducing them may be unhelpful if they increase the threat.



However, for some, experiencing those intense emotions may be more intolerable. Try to take this into account when thinking about how you are feeling.


Most of our emotions are felt physically, not in our head, which is why so many coping strategies are physical.


We manage the range of emotions we experience through co-regulation with others and self-regulation. It might be helpful to explain how these work.

  • Co-regulation: We are social creatures and our physiology is optimised when we are socially connected which is therefore an especial challenge currently. Find as many ways of remaining regularly connected with others despite the distance limitations. Plan for it and incorporate it into the new daily rhythms.

  • Self-regulation: is the means by which we ourselves optimise our mental and physical health and ensure that we are able to function in the best way possible. It depends primarily on maintaining the important daily biological rhythms of sleep, rest, eating, drinking and activity. We then have a variety of self-soothing techniques (coping strategies) which we feel help us further, but can sometimes be unhelpful.

Arabella Onslow, Cumbria GP

Hopefully it is helpful to explain biological responses to stress, especially as this is a marathon and not a sprint and many lives will be changed permanently over the months to come.


We are coming into the peak of the spread of the disease and the illness can, in the most serious cases, peak a couple of weeks after infection, so there are a few difficult weeks ahead of us yet, before we feel the weight of the pandemic ebbing.



Please remember, as stated at the beginning, this is a natural phenomenon for which we have uniquely evolved.


The costs seem high, but we have many skills, tools and resources we can utilise to increase our resilience and reduce the burden on ourselves, our loved ones and our community, especially if we work together and share our experience.

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