COVID-19 or the novel coronavirus disease continues to spread in our country. At the time of this article, we had a total of 63 cases of which four have died, representing a case fatality rate of 6.3 per cent.
The Government has been taking increasingly assertive measures to try to prevent further infections and worsening of the crisis in Jamaica. These measures have included travel bans, curfews, and using masks. These measures have caused a degree of hardship for the society as a whole and it is important that our people understand the reasons for what can seem to be excessive measures. At the same time, conflicting messages are emerging from multiple channels touting various treatments and potential cures. Not surprisingly, the public is anxious about all these developments. Our intention with this article is to shed some light on these topical issues to allay the anxiety and encourage citizens to play their role in combating this devastating pandemic. We shall attempt to present what is known regarding these various issues.
How is coronavirus spread? Why social distancing?
The important thing to remember is that coronavirus is spread in primarily two ways. The virus is present in large amounts in secretions from the respiratory tract. The virus can spread directly from person to person. In this case, when an infected person coughs or sneezes, ‘macro-droplets’ and ‘micro-droplets’ containing virus particles are sent into the air around them. People immediately around them can breathe these in and may become infected. Of some concern is the recent finding that virus particles, particularly the micro-droplets, can stay in the air for a few hours after the infected person coughs or sneezes. There is also concern that this may also occur with shouting and singing, hence the need for social distancing. It has been speculated by experts that keeping at least six feet (three metres) away from individuals would be a reasonably safe distance from exposure to virus droplets especially in the event of a cough or sneeze. This recommendation is particularly important for individuals considered to be more vulnerable to infection or adverse outcome, including individuals older than 60 years; smokers; patients with hypertension, diabetes, heart disease, underlying respiratory illness, or other chronic health conditions.
The second way of spread involves the virus getting on surfaces in the environment. This may be from coughing or sneezing, or an infected person may have virus particles on their hands which they use to open doors or push buttons, etc. Uninfected persons may touch these surfaces and then their faces, which allows the virus to get into the body and cause infection. All methods of spread, however, are tied to an infected person, who is the source.
Stopping the spread of the coronavirus virus basically involves keeping infected people and their bodily fluids away from those who are not yet infected. The simple truth is that if we had a way of keeping everybody in the country away from each other for three weeks, we could stop the spread of the disease totally.
Methods for stopping the spread are very important as many people who are infected have no or minimal symptoms. Trying to quarantine people who show signs of infection or who are known to have been exposed to the virus cannot be the sole method of disease control.
Should I wear a mask?
It is generally understood that health care workers must wear protective masks, like the N95 masks, and be properly fitted with personal protective equipment (PPE) to protect them against coronavirus infection while they take care of the sick. On the other hand, the use of masks during the coronavirus outbreak by the general population was controversial initially. However, recently, most countries have begun recommending the use of masks by the general population as a measure to contain and mitigate the community spread of the virus. It is now suggested that, when travelling outside your home, you use a cloth mask. Similar advice has come from our chief medical officer. Some people have wondered why the change. The simple answer is that we know that cloth masks do not stop virus-sized particles and thus the virus should have no difficulty getting through. It has, however, become clear that cloth masks can stop droplet-sized particles that come from coughing or sneezing. The use of a cloth mask will therefore protect against virus particles that are present in these droplets. The whole idea of universal use of cloth mask is that everyone in the community is protected from each other as some members of the community may be carrying the virus without symptoms and may inadvertently infect others when they cough or sneeze and discharge virus-filled droplets into the air. It has also come to light that countries in which a high proportion of their citizens wear masks have shown significantly lower rates of the virus spreading in the community.
Why shouldn’t I wear a surgical mask or N95 mask?
It is well known that one of the best masks to wear is the so-called N95 respirator mask which is very effective in preventing the entry of virus-size particles. Surgical masks, while not as effective as the N95 masks, do offer increased protection when compared to cloth masks. The reason for not recommending these types of masks for the general population is practical. All over the world there are not enough surgical and N95 masks for medical use. The people at highest risk for catching coronavirus disease are nurses, who must spend hours at the bedsides of these patients, and the physicians who must sometimes perform procedures that result in exposure to a large amount of virus particles, for example, when putting the patient on a breathing machine. It is very important that our health care workers remain healthy to care for patients afflicted with COVID-19. High-grade protective masks like the N95 should ideally be reserved for the use by these front line health care workers. If doctors or nurses get sick with COVID-19, they are unable to take care of patients until they are better, worsening the current manpower shortage in our clinics and hospitals. The risk of the general population outside of health care facilities is low particularly if practising to keep three metres away from other people so therefore cloth masks are recommended. The use of masks offers additional protection in that people who are wearing masks seem to touch their faces less.
Why a travel ban?
It is important to remember that except for China where the disease started, all other countries with COVID-19 have had the disease brought to their shores by people who have travelled. For this reason, most countries in the world have instituted some degree of restriction of movement. This can be somewhat selective, restricting movements from high-risk regions only or a total ban, as is the case in Jamaica and Thailand. The purpose of a travel ban is to try to avoid bringing new cases into the island and allow the concentration of health care resources on people who are already infected. This can be very successful in countries or regions in which there is no significant community spread, ie almost all cases can be traced back to people who have come from abroad. It is important to recognise that this does impose some degree of hardship on a population, for example families kept apart, and the inability to travel for business, routine medical care or pleasure, but this is unfortunately a worldwide reality.
Travel bans, however, are most effective when coupled with aggressive contact tracing, testing, and quarantine of suspected or proven cases. Recently, there have been news reports of several individuals who entered Jamaica but have not made themselves available to the authorities for proper evaluation. The danger is that if any of those individuals came in from a zone with a high infection rate, they may introduce the virus to their contacts in Jamaica who can initiate another round of community spread, making containment difficult. The transmission efficiency of viruses is quantified using what is called a reproduction number (R0-pronounced R-naught). The R0 indicates the number of new infections that can originate from one infected person. The R0 for the coronavirus is thought to be between 2.5 and six, suggesting that one infected person may infect as many as 2.5 to six persons. This could quickly create a crisis. This is why it is important to restrict movement to contain the spread of the virus.
Is this curfew really needed?
The curfew can be thought of as being used to encourage people to stay apart. It is the same logic that leads to the closure of schools and places of worship, and suspension of social gatherings and events. Some countries have very strict curfews in which people are unable to leave their homes without a permission slip. Most of the necessary activities of daily living can be accomplished in the daylight hours. A night-time curfew is an attempt to prevent people from congregating at bars, restaurants etc. It is important to note that if the coronavirus continues to spread, it may be necessary to take more extreme distancing measures or impose greater periods of curfew.
It is important to recognise that the numbers of COVID-19 patients in our population appear to be relatively low, and that we should continue to do all that we can to prevent the spread of the disease to our family, friends, and fellow citizens.
Is chloroquine a cure for COVID-19?
There is no known cure yet for COVID-19. Hydroxychloroquine or Plaquenil has got a lot of publicity as a potential cure for COVID-19, thanks to the hype of the medication by President Trump of the USA. While there is no randomised, controlled clinical trial of the efficacy of hydroxychloroquine, there are anecdotal reports from physicians in France and other locations suggesting an improvement in recovery of patients when treated with chloroquine, and more so when this treatment is in combination with the antibiotic azithromycin and the mineral zinc. While not proven, several countries have been stockpiling hydroxychloroquine. The USA, for example, ordered 29 million doses of Plaquenil for use in treatment of COVID-19 patients. However, despite the euphoria, it is important to know that there is no hard evidence that this treatment is universally effective in Covid-19 patients.
What about the TB vaccine (BCG) as a cure for COVID-19?
In the ongoing scramble to find new treatments for COVID-19, a vaccine that is more than 100 years old has piqued the interest of health care providers. The bacillus Calmette-Guerin (BCG) vaccine was developed in 1922 to fight off tuberculosis. The BCG vaccine is considered one of the safest vaccines ever made and has been administered to more than three billion people worldwide.
The interest in this TB vaccine springs from a recent study, published online, suggesting a correlation between countries where it is mandatory to be vaccinated against tuberculosis and the impact of the new coronavirus. The study found that countries without universal policies of BCG vaccination (Italy, the Netherlands and USA for example) have been more severely affected compared to countries like Japan with universal and long-standing BCG policies. If this theory holds true, Jamaica should expect to gain some benefit. However, it should be noted that no prospective, randomised clinical trial has been performed to confirm this observation. One such trial is expected to start soon in Australia. At the present time, there is no hard evidence that BCG vaccination is a cure for COVID-19.
What do we do next?
Understandably, individuals are in a heightened state of anxiety and some may experience varying degrees of stress, panic, and depression as this pandemic lingers. It is important to get reliable information and to have opportunities to engage, ask questions, and obtain credible answers. In light of this, Heart Institute of the Caribbean (HIC) will be hosting a periodic, virtual webinar series on COVID-19 to provide an opportunity for the public to interact with experts and have their questions and concerns addressed. These virtual forums are open and free to the public. Our first virtual public forum on this subject is scheduled for April 14, 2020, from 6:00 pm to 7:00 pm. Those interested in participating should contact our office at 876-906-2105 or 2018 to register.
Meanwhile, we encourage everyone to follow established precautions and stay safe.
Ernest Madu, MD, FACC, is consultant cardiologist at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital; Paul Edwards, MD, FACC is consultant cardiologist at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital.
Correspondence to firstname.lastname@example.org or call 876-906-2107
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