Coronavirus (COVID-19)

Update and Thorough Guidance

Compiled by Julie McMurry, MPH

Updated Mar 15, 2020 1:19 AM (UTC)

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You can share this as widely as you like using the URL: www.flattenthecurve.com, via facebook, or via twitter. Just note that it is evolving. Speed is key, so a good plan now is better than a perfect one later. If you’d like to help with a language translation please reach out via the contact page. New efforts for Italian, French, German and Spanish underway.

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Hyperlinks are provided to the original sources both for attribution and for referencing.

Yes; this is bad

Don’t panic but do not brush off the public health warnings of Coronavirus. Emerging consensus is that containment might have been possible a few weeks ago, but is no longer realistic. Although China bought us all time, we wasted it. We are entering the pandemic phase which will be followed by seasonal recurrence of the disease unless and until we have a vaccine (which may still be 18-24 months away, if we are lucky).

This is not normal flu

Not even in the best case

The World Health Organization estimate of 3.5% is an average across age groups, and they have provided large surveillance data as evidence against high numbers of asymptomatic cases. There is very strong consensus that those aged 60+ and those with underlying conditions are the most impacted.

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Earlier in the epidemic, there was hope that 3.5 percent was grossly overestimated, however as evidence continues to emerge, there is dwindling support for that hope. The numbers out of South Korea are so far the most optimistic in the world (0.7% cases were fatal); however, a) the South Korean population is younger on average and b) South Korea (in contrast to the USA) have been doing everything right from the earliest stages of the outbreak: they have done massive roll out of testing coupled with radical transparency, public support and brilliant drive-through testing! If this strain of Coronavirus is like other viruses, aggressive measures that reduce transmission, may also lower the average ‘dose’ of viral particles that cause any given case; this might reduce the average severity of disease and decrease overall death rates. Time will tell.

Moreover, even IF the true Covid-19 mortality rate is as low as 1% (as it is so far with the Diamond Princess), that would already be ten times higher than a typical seasonal flu.

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For most people, infection results in a mild but still transmissible illness; that is how it spreads. Those that get severe illness are hit really hard. Mortality is not the full picture: Italy reports that 10% of cases need not just hospitalization but also ICU care – and they need that care over a period of 3-6 weeks. This is unsustainable.

Keep the main thing the main thing

#FlattenTheCurve

A lot of ink has been spilled on speculation about the “true” rate; however we are still in the early phase of the pandemic and it could take years to precisely determine the rate. BUT we know that it is somewhere between .5% and 4 percent mortality; this range is more than adequate evidence to warrant decisive, immediate, large-scale preventive action. Far and away, the most important thing to do is flatten the curve of the epidemic so that our health systems can cope and to give time for the scientists to research vaccines and treatments.

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It is here

Assume that the virus is already in your city / town / workplace / church / etc. It almost certainly is “here” and is simply not yet detected due to the shortage of tests. Moreover there are 6 states that still don’t have a single lab ready to carry out the test even if they had one in their hands. Estimates from Italy are that in the early outbreak, the number of actual infections was four times the number of cases than it was possible to confirm at the time. Cryptic transmission in the community was happening for weeks before it was detected in Seattle. Seattle and Stanford are doing an amazing job of getting up to speed with their own testing kits; about 5-7% of tests in Seattle are positive and anyone (with a doctor’s indication) can be tested.

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(For the sake of public health, University of Washington are publishing these results). So far only UW and Stanford have been moving ahead with their own (non-CDC) testing; both of these institutions have mandated that in-person classes be moved to distance learning alternatives. That speaks for itself; more universities should follow suit. That said, professors need the technology and support to make this switch.

Education communities that are resource-poor (without laptops or internet) would have the hardest time doing this switch. So let’s start with those universities (and disciplines) for whom this switch is not such a major hardship. There is no one-size-fits-all intervention, but speed is key. Professors, please don’t wait for your university administration to make the decision campus wide. Move to a distance-based option of your own accord. Check out these tips for teaching online in a pinch.

Healthcare system

The US healthcare system is not well enough prepared. No one is

In the USA, our health care capacity is under 1 million staffed beds; this is not adequate to accommodate the number of hospitalizations we are expected to see (4-8 million). Johns Hopkins University did a 3-year global survey of pandemic preparedness. Although the USA ranked at the top of the countries, even the US only scored a 42 out of 100. We simply don’t have the equipment, training, or messaging in place and we need to ramp up fast. No one does. That is why your choices today matter so much.

And those of us with Italian colleagues in the north (hit hardest) know they have exceptional physicians, infectious disease docs and immunologists. And effectively universal care. This is not a developing-world tale that is irrelevant for the US situation.

Policies

Relative to other countries, US labor and healthcare policies are a perfect storm for pandemics

• Zero universal guaranteed paid sick leave
• Even among those *with* paid sick leave, the covered time frame is often on the order of days, not the weeks adequate to account for prolonged illness.
• Zero guaranteed paid family leave to care for sick members
• Zero guaranteed financial or operational support for people who should self-quarantine. People are therefore ignoring quarantine because they need to eat.
• Many people are uninsured. Given where things are right now (cryptic transmission and no available vaccine), the insurance companies have a moral obligation but have no financial incentive to improve testing and ensure access to care.
• In the USA insurance is tied to their employment, so when they get sick they are also vulnerable to bankruptcy. In a pandemic year this is devastating for an economy.

The fact that these safety nets have not previously existed in the US complicates the behaviors required to #flattenthecurve compared to most other countries affected so far. However, legislation passed Friday by the US House of Representatives aims to address some of these critical issues. Namely, the bill will provide enhanced unemployment benefits, free virus testing, and additional funds for food assistance and Medicaid. The bill is reported in the New York Times, CNNand by other news organizations. Read the text of the bill here.

Global tracking and communication

Doctors worldwide are getting pummeled on the frontlines of this crisis, the lack of protective equipment is causing them to get infected, and themselves unable to get the care they need. For a personal lens on this, have a look here, but this is by no means unique; the accounts are flooding in.

Globally speaking, authoritarianism can limit pandemic control since it can limit the expertise and transparency required for good decisionmaking, to make the best use of resources, and to communicate status to the regional and global citizens. Examples of this have been seen in China (earliest in the epidemic), and in Iran, Turkey and Russia, which until recently had reported the statistically unrealistic scenario of no cases. Country-specific US Embassy pages now are now reporting cases, for example Russian Embassy. A number of effective data visualizations and world-wide case tracking are now available, for example at the Johns Hopkins Coronavirus Resource Center and the New York Times Coronavirus Case Maps

There is hope.

You’re it. That’s the work

You can help by following as much as possible of the following guidance. The earlier the precautions are taken, the more precautions are taken, the more lives are saved. It is that simple. Expect yesterday’s under responders to be today’s over-responders. Resist the urge to ricochet or give up hope. The key is to stay calm and do the steady work of infection control and urge others to follow suit.

From a dear friend in Beijing “Steer as far away from the fear and hysteria that might be hitting your towns. Use wisdom but don’t allow it to become an empty excuse for not loving your fellow humans. Choose generosity instead of hoarding. And on those really hard days (or maybe after watching too many news reports) turn up the music and dance! Celebrate the goodness! It’s there, it will remain and you can be a catalyst for it!”

Here’s how.

Do

Wash your hands

>20 seconds with soap and warm water. Here are great options of songs to sing to help you pass the time. Unlike some really stubborn viruses (like polio), viruses in the coronavirus family typically don’t survive longer than a few hours on most surfaces hard surfaces; though it can be up to days. Bleach or ethanol are more effective at decontaminating surfaces than they are disinfecting humanskin. So don’t hoard the hand sanitizer, that should be used only when you do not have any access to a soap and water sink. At a restaurant? Wash your hands. At school? Wash your hands. Vigorous handwashing with soap really is vital to reduce transmission; the awesome science of why is here. If you do nothing else at all, do wash your hands.

Stay connected

but avoid crowds

It is best to stand at a distance from people. 6 feet or more is safest from infectious droplet spread. The higher your underlying risk factors (age, recent major surgery, cancer, immunocompromised, asthma, diabetes, etc), the more you should avoid crowds.

CDC has recommended that older adults ‘stay at home as much as possible’. But keep in mind that over the longer term, this isolation could have negative impacts on many people’s mental health. Cultivating meaningful relationships is a well established but under-appreciated determinant for all health outcomes. So DO see the people you love, but consider doing so via lower-risk activities. For instance, go for a walk outside with a smaller group of people rather than attending an event indoors. Go to the beach. Ride bikes. Golf. Picnic more. This is not going away in one week, so pace yourself.

Lower your overall risk

with everyday choices

Taken together, making safer every-day choices on average — not just this week but for the next several months — can flatten the curve. Continue to support your local economy, but go off peak; staggering by even 15 minutes can reduce crowding. Everything from restaurants to art museums to public transport will be less risky (and more pleasant!) off peak.

• Non-contact sports are better than contact ones. E.g., Tennis is better than (>) rugby
• Takeout > eat on restaurant patio > eat in restaurant
• Video streaming options > movie theatre
• Outside events > inside events (small events also are better than large ones)
• Delivery/curbside pickup > going in person
• Remote observance > religious service attendance
• Birthday cupcakes > birthday cake (if candle blowing is involved)
• Drink your coffee/beer/cocktail at a table instead > drink your coffee/beer/cocktail at the bar
• Live performers are going to be hard hit economically. Consider supporting their work on Patreon, directly via PayPal, or attend only the smaller shows. Promote them on social media. Buy their work directly.

Get your flu shot

(and if you’re 60+, pneumonia vaccine)

Better late than never. The flu vaccine won’t protect you at all against Coronavirus. However it DOES reduce your likelihood of contracting flu. And therefore your likelihood of needing to be hospitalized, which also reduces your chances of contracting Coronavirus while you are there. If you’re 60+ get your pneumonia vaccine as well for the same reason.

Medic visits

Cancel all non-essential face-to-face medic

Hospitals are hot spots for transmission; get your vaccinations at a pharmacy rather than at the doctor. Find ways to do your physical therapy at home if possible.

Telemedicine professionals, this is your time to save the day, for everyone’s benefit but especially those in rural areas who are hard hit and without easy access to medical care. https://doxy.me and https://vsee.com/clinic/ provide free HIPAA compliant video platforms for telehealth.

JHU is developing resources here for hospital staff and administrators; more info here.

Travel

Cancel all non-essential travel anywhere

This illness can start slow and accelerate suddenly. If you are away from home when it does, you’re away from the systems that could keep you fed and cared for even if you turn out not to have a bad case. Even if you remain healthy, you could end up being quarantined. It is atbest boring, at worst terrible conditions, not to mention potentially really expensive. You could risk getting infected even if you are careful. Travel history is increasingly irrelevant to risk, especially because we are flying a bit blind with the lack of testing, but the available data of confirmed infections is available here from Johns Hopkins University. Strain genetics information is available here.

Stock up

on food and essentials - Early, gradually, and responsibly

Thread:

“If the virus is everywhere, what’s the point of preparedness?”

On neither why continuing about your day as usual OR buying every can in the shop are helpful responses to #COVID19 #SARSCoV2 #Coronavirus#SARSCoV19 :\ (1/n)

— Dr Emma Hodcroft (\@firefoxx66) February 29, 2020

“Experts aren’t telling you to stock up on essentials because they think you’re going to run out of food & society is going to collapse. It’s because a few days of panic buying & high demands cause more panic & stress systems unnecessarily. Also, being in line with hundreds of people isn’t wise. Go off peak. Buy a little more than what you need. Preparedness isn’t about doing nothing, but also about not overreacting. It’s about doing your part to put the *slack in our systems* so that short disruptions are smooth as possible, can absorb extra load, & resources remain available for those most in need.

Don’t bother buying bottled water; tap water is very unlikely to be impacted and anyway, boiling would be adequate if it turned out it were needed for unforeseen reasons. Intestinal symptoms of coronavirus are very rare; there’s no reason to expect that supplies of toilet paper will dry up. Get what you need. Leave the rest for others.

Work from home

If you can work from home, do so as much

Not everyone can work from home (WFH) 100% of the time; that is ok. Part time WFH is better than none. Don’t wait for your employer to mandate WFH for everyone. Ask your manager if it would be permissible for you personally. Encourage your colleagues.

If you can WFH, do it precisely because your barber, your kid’s teacher, your local restaurant staff, your barista, and your doctors etc. can not.

Great software now makes distance collaboration easier than ever. My personal favorites are below. The choice of collaboration tools isn’t important: use whatever works for you and your team.

• Google drive (collaborative documents) is free
• Zoom.us (video conferencing) is free up to 40 mins,
• Slack/Gitter (free instant messaging).
• Skype is also free and works pretty well for videoconferencing with 2 people at a time.

Do a dry run. See what is missing so that you’re ready for when it is not optional. Some resources here for people with ADHD working from home for the first time.

Flu buddy

Get a flu buddy (aka ‘pandemic pal’) and make back-up plans for care of children, pets, and those in need of special assistance

Especially if you live by yourself. In the event of local transmission call each other daily. If anyone is sick, call them twice daily and have an agreed-upon contactless plan for delivering food, pain relief, and prescribed medications as well as for back up care of dependents.

Those who are already struggling with pre-existing demanding medical conditions may have useful experience to share about preparedness and about how to navigate the kinds of operational challenges the rest of us may be just coming to grips with. Ask them what they need from you, then provide it.

It is a good opportunity to think about longer term versions of these care contingency plans (if for some reason the patient were to pass away).

Social interactions

Pick your battles; reduce non-essential social interactions

On a lighter note, go ahead and use the pandemic excuse to beg out of any in-person meeting / party / wedding you would attend only out of some vague sense of duty. If you’re not really certain to enjoy it yourself or to bring joy to someone you really love then just. skip. it. Attend remotely if you can. Or show your face for a few mins and head back out. Send a gift instead.

If you are planning a wedding and wondering what to do, a mini-thread here with some options.

Your home

Keep your home clean and develop routines for coming back

I’m developing guidance on this right now and others are welcome to weigh in, but a few things off the top of my head: If you have the ability to do so, consider a ‘staging’ area for clean entry into your home. Remove shoes, outerwear. If you work in a high risk environment like a hospital, nursing home, etc, wash your clothes immediately and then dry them at high heat or at least dry in the sunshine. Wash hands right away. Isolate your mail, packages and purchases (including food) before bringing them into the house and leave them isolated a few hours at a minimum. If you are in an especially high risk group, you might want to consider leaving goods isolated a longer time (a few days) and avoid eating raw produce, and also decontaminating products that come into your house. The latest research shows that the virus can survive up to 4 hours on copper surfaces, up to 3 days on plastic and stainless steel, and up to 24 hours on cardboard. [guidance needed as to how best to do this; what potency of bleach solution/duration etc?].

Look beyond yourself

At all times, be kind to each other and be mindful of other people’s worries. You may be in a low risk group and feel this is nothing to fret about, but your 80-year old neighbor or your friend with recent heart surgery may feel quite differently.Every person matters; no one is “expendable.”

With all the cancellations this is one of the first times I’ve seen normalization of an “it’s everybody’s problem approach.” Yes, your one cancelled event might not save lives but the fact that everyone is doing this will. Same mentality is needed for climate change. Because travel is a big source of the spread, use the occasion to buy locally grown produce. This will reduce coronavirus transmission, support your local economy, and also have a net carbon savings.

Hot zone

Prepare a hot zone in your home just in case someone falls ill

Prepare your home for the possibility you’ll need to isolate and care for an infected member of your household. Stock the room in advance with food that the infected person can consume with zero preparation and without face-to-face interaction with others. If you have a dedicated bathroom for the infected person, that is best. Realistically, given shortages you won’t have access to a mask, but if you do have one, prioritize its use on the infected person rather than caretakers.

Spread the word

and lobby your reps for vital research

If it is any indication, the link tracking for this very guidance document (stats can be viewed at bit.ly/corona-guidance+) shows that the word is getting out on twitter, where scientists have a larger usership; however it is lagging on facebook and on direct shares where the general public need it most. Call a friend. Call your family. You will have the most influence on people you personally know. While there are certainly reasons not to panic, most people should be more concerned than they are. Raise the floor of awareness, not the ceiling; this will be much more effective in the long run.

“One aspect of that policymakers desperately need more information on is how readily children can transmit the virus. We know children experience milder disease than adults but do they transmit to others?” There’s been some seemingly contradictory evidence on this front so far.

In the meantime, do your best to demonstrate, teach, and reinforce good hand hygiene for kids, but be realistic too. In the absence of a clear signal on the degree to which kids are vectors, keep your kids’ fingernails (and yours) as short as is (safely) possible so that virus has fewer crannies in which to hide. I’ve stopped wearing rings for that same reason; I don’t know that there’s been a formal study on this ring idea.

Only if you are in a financial and operational position to do so, consider temporarily tutoring or home schooling, or even just keeping kids home from after-school activities or for part of the school day.Don’t compromise your kids’ education, but every little bit of distancing helps. Do what you can and don’t sweat the rest. You should not feel personally responsible for everyone.

Do not

Do not just wait

to see how this plays out. Speed is the key

See above and #FlattenTheCurve now. There is no advantage to being late to adopt policies. We are not yet in the peak and already many people are being turned away.

Do not touch your face

That is the most common way the virus enters the body. It is really hard to avoid; this is also why we advise staying home and avoiding crowds. It is also why top-down measures (event cancellation and imposed quarantine etc) work. The average person, even ones with baseline good hygiene, touch their faces constantly already without thinking about it. Especially with allergy season coming up, please keep this in mind.

Be on guard

against false hope of “remedies”

Be good to your body. Expect companies to capitalize on your fear. Don’t buy products that claim to protect or heal you at this point. Currently available products like ibuprofen and paracetamol can be useful to lessen some symptoms; however so far, nothing has been proven to do above random noise. Don’t believe individuals who say that crystals, essential oils, etc. have helped them; the folks sharing these products may have the best intentions, or they may be predatory. But the idea is the same: many patients spontaneously do get better on their own because most cases are mild and resolve without pharmaceutical intervention. Instead of worrying about remedies, eat good food. Exercise. Meditate. Rest. Don’t neglect your mental health and don’t use your anxiety as an excuse for poor behavior towards others.

Public gatherings

Do not attend non-essential public gatherings

There is overwhelming historical evidence for cancellation as an effective public health measure. I’ve retweeted some good resources here, you can use that thread alone to help convince decisionmakers to cancel events. Here’s the money shot:

Don’t wait to cancel until things are demonstrably really bad; this leaves available only the most socially disruptive interventions (like closing schools). Measures as extreme as closing schools tend to burden vulnerable populations the most. (E.g., because the poorest kids only eat at school). If you’re in a position to help kids in these scenarios, try to give money directly; the case for this is well established. When elementary schools close, it also makes it harder for health workers, teachers, city officials, etc. to get to work and keep things on track. Kids may have nowhere to go when parents are at work. Aggressive social distancing measures are never too late, but they are most effective at flattening the curve if undertaken before 1-2% of the population is infected [ I read this somewhere but lost the citation, please DM if you can help]. It isn’t just large events to avoid, even small meetings can have consequences.

I’ve put out the call for tooling that would help event planners model go/no-go decisions more appropriately. If you are a scientist interested in collaborating on this, let me know. In meantime, here is this:

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Do not hoard masks

Healthcare workers desperately need them to care for you and your loved ones. If healthcare workers are at risk, we are all at risk. Masks are NOT the most useful thing you can do to protect yourself: they’re hard to wear properly, especially for long periods of time, and their effectiveness against viral particles stops as the filter gets moist with your breathing (about 30 minutes). Also for some people, wearing a mask makes it more likely that they will touch their face.

Do not shake hands.

get creative with zero-contact greetings

Some fun alternatives are:

• hand over heart
• wakanda forever
• bow
• curtsey
• live long and prosper
• finger wag,
• princess wave

…are best.

One awesome side benefit is that contactless greetings don’t even need to be agreed-upon in advance. Unlike handshakes, hugs, kisses, etc, there is no need to have an understood protocol. Do what works for you.

Do not touch public surfaces

with your fingers; get creative

Where possible, use knuckles rather than finger tips (e.g., for elevator buttons, light switches, etc.). Open doors with your hips rather than your hands. You may use your elbows to open door handles, if it’s an option. Use a sleeve to open a doorknob if needed.

If you are sick

Do not go to work if you are in any way sick

A good idea — even if it is not coronavirus. Health systems need every available capacity. Don’t cause unnecessary panic. Don’t assume it is just a common cold. Definitely stay home if you have a fever or cough.

Call ahead

Do not go to the doctor without calling ahead

Do NOT go directly to the hospital. More guidance from CDC here.

Call centers are understandably overwhelmed right now with the “worried well” so please try to leave those lines open for the people who really need them.

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Do not spread misinformation

I can’t stop people from repurposing this document and mixing in guidance that is not backed by science. However, if you do so, do not attribute me. There are no treatments yet.

Do not be careless

Don’t be that person. It might not be about you but it is everyone’s problem. Don’t be careless in the hopes you get sick when you can “avoid the rush.” There is zero benefit to individuals or the population to getting sick early in the pandemic. You would be putting the lives of others at risk. It is not just that people are dying, but how they are dying. To say nothing of the physical trauma, emotionally speaking this is the opposite of a “good death”. People are dying alone, quarantined from those they love.

Early reports are that people who recover develop antibodies that provide immunity if they are infected with the same strain again. However, this is great news for vaccine development, so flatten the curve and wait it out.

This can get very serious; one person described the pain as feeling like her lungs were being put through a pasta maker. 10% of cases require ICU care and mechanical ventilation. Even if autopsy reports from China have beenmisrepresented or overstated, there is a possibility of long term or permanent lung damage if you do get sick and recover. There are lot of gaps in the information about lung damage, mostly because everyone qualified to let the public know exactly what is going on is already very busy saving lives and putting their own at risk.

Do not be racist

Don’t use “concern” as a smoke screen for racism. The virus is here now. It could have started anywhere. Use the same empathy as if the source city were your own. Next time it might be.

Be present, do not binge the news

Once you’ve done everything you can, step back. Way back. Watch something funny. Read a good book. Learn an instrument. Garden. Hug your kid. Call your mom. Hug your mom. Call your kid. Be present. Take this moment to be grateful that you are alive on this amazing planet. We are in this together; look after each other.

About the author

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I have a masters degree in public health from the University of London School of Hygiene and Tropical Medicine as well as a background in infectious diseases and vaccine development. The impact of this pandemic will be needlessly amplified by misinformation, so be careful. I’ve endeavored to be as accurate as possible without causing panic. I have not been paid to write this post, but given my training I do feel like it is my responsibility. This is a volunteer effort that qualified people are welcome to help contribute to. Frankly the only reason it is not anonymous is because it would be less likely to be taken seriously, and we need all of the gravitas we can get right now.

Full disclosure, I worked in the TB and HIV vaccine field from 2000-2010 but have since switched gears into rare disease genetics. I’m currently an assistant professor (senior research) at Oregon State University in the College of Public Health; to learn more about our group’s work in computer models for rare genetic disease feel free to have a look at tislab.org.

Affiliations

Please note, I’m not speaking on behalf of any institution. I’m just applying what I know and listening to the evidence as it rapidly emerges. It isn’t perfect. Please let me know if there are issues with the veracity or currency of this summary; if you are a virologist / public health professional, etc., and wish to contribute to it, please se the contact page to get in touch.

Thank you to Moni Munoz Torres for copy edits and for translating into Spanish (a work in progress). I’m working on a translation into Italian tomorrow March 9, 2020.

Consider this content licensed as public domain CC-0 to the extent that the content here is original. The license doesn’t (can not) cover the sources referenced herein. Do not mix this guidance with pseudoscience.

Who to follow

if you’re interested in the science of pandemics

The real heroes are those at the frontlines and those whose work is referenced above.  Here are a few I’m following for various reasons. My citing them doesn’t imply that they’ve read or endorsed this full guidance. A non-comprehensive list of their twitter profiles is here. I follow a lot of other (non outbreak related) people too, but you can browse here: https://twitter.com/figgyjam/following

How to help and contribute

First of all, thank you! A lot of unpaid work is going into this site to try and make it one of the best and most helpful resources in this uncertain time of COVID19. There are, however, some hard costs associated with that, like the cost of hosting, or potentially hiring someone to help manage the work as the site grows.

If you’d like to contribute financially, we’re very grateful for any amount, and you can do that here.

For contributing with content, reviews and translations please go here

Don’t feel obligated to contribute–this information is free to access and share.

Please be assured that all money collected will go back toward running, building, and maintaining this site.

Thanks again! And wash your hands.