Coping with COVID-19
FEATURE
Laurie Mueller
DC, CFMP
Chiropractic and the Crisis
As our communities head into shut-down mode over COVID-19, doctors of chiropractic face a plethora of decisions regarding practice and caring for patients. With fear over illness being widespread in the public, health offices being overwhelmed, and hospital waiting rooms overflowing with concerns, one could argue that our services are more important than ever. Not only can we keep patients with intense pain from musculoskeletal issues out of the congested medical waiting rooms, but adjusting people with respiratory illness (mobility in the ribs/thoracics) cannot be underestimated as it can aid in restoring function in those joints and thus the ability to get breath. Then we have wellness care and nutrition, to help the nervous system stay intact and help keep the immune system working at optimum function.
All of these great benefits aside... how do we react to COVID-19? As a vital part of allied health services, will Chiropractic be considered an ‘essential’ business to stay open? I certainly believe it should; however at the end of the day it could end up as a decision from your individual states on whether you can work or not; and most certainly, it is a personal decision if you feel your safety or the safety of your patients is at risk. Be sure to keep an eye on the updated mandates coming from your state governments as all of this continues to unfold.
Meanwhile, this article was created to help outline some of the considerations for patient care for as long as you are keeping your doors open. But first, I’d like to cover a bit of history surrounding respiratory illness and COVID-19.
Did You Know?
There are over 200 viruses that cause the common cold. Rhinoviruses are the most common. However, there are also very common coronaviruses that people get every year that also cause a cold, Eg. mild to moderate infection, (those are corona 229E, NL63, OC43, and KHU1.) In the scheme of seasonal illness we also have influenza viruses types A, B, C, D. We hear a lot about Types A and B. Type A influenza viruses have varying types, groups and sub-types based on the properties of their hemagglutinin (H) and neuraminidase (N) surface proteins. There are potentially 198 different subtype combinations with Type A alone.
We all keep getting similar but different illnesses due to the way viruses can change. These mutations are called ‘antigenic drift’ and it is how ALL types of viruses survive and evade the human immune system. They mutate by changing the surface proteins on their outer layer.
Coronaviruses
Coronaviruses are a family of viruses that can cause respiratory illness in people and animals. Sometimes an animal coronavirus can change so that it can infect people and become a human coronavirus. There are seven known types of human coronaviruses. Four types were mentioned above as causing basic cold symptoms, two types, the Severe Acute Respiratory Syndrome coronavirus (SARS-CoV) and Middle East Respiratory Syndrome coronavirus (MERS-CoV) can cause severe respiratory infections which we have seen in years past. The seventh type (2019-nCoV aka SARSCoV-2 aka COVID19) is a new coronavirus recently discovered in China. Public health officials are trying to learn more about this new virus and the infection it causes.
When termed a ‘novel’ coronavirus as you may have read in the media, it simply means that it is a newly discovered strain that has not been previously found in humans. As a semantic FYI, COVID-19 actually refers to the disease caused by the more formally named SARS-CoV-2 virus (so-named because it is genetically similar to the 2009 SARS virus which is also a coronavirus.) Media tends to use COVID-19 to refer to both the new virus and the disease.
According to the World Health Organization “Most people infected with the (SARS-CoV-2 aka COVID-19) virus will experience mild to moderate respiratory illness and recover without requiring special treatment. Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely to develop serious illness.”
Older people and the immuno compromised being most at risk is nothing different than what we have seen with influenza viruses for many decades.
On the CDC website they list the current 2019-2020 in-season flu burden estimates from influenza. So far this season there have been (from influenza Types A or B):
• 38 Million Illnesses
• 17 Million Medical Visits
• 390,000 Hospitalizations
• 23,000 Deaths
To put this in perspective with the current COVID19 burden taken from the April 16, 2020 situation report (#87) from the World Health Organization, the following numbers are what we have GLOBALLY and these numbers have changed significantly in the last month:
• 1,991,562 Confirmed cases
• 130,885 Deaths (nearly 90k of those are in the European Region)
The CDC has reported that like the flu, fatalities from COVID-19 are the highest in persons over 85 years of age and people who are immune-compromised. Certainly it is difficult to get a full picture of how many COVID-19 related illnesses are out truly out there in the general public but as testing becomes more readily available and utilized we are able to get a more accurate picture. I would also speculate that some of the cases are simply more mild and people didn’t go to the doctor for it. It ran its course like any other cold or flu.
So, Why the Uproar?
This is the first time we have seen such wide-spread shut downs and cancelling of schools over a virus. It didn’t happen with the 2012 MERS (killing 34% of the roughly 2,500 cases), Zika, Swine Flu, or even the SARS epidemic of 2003 which killed around 10% of the 8,098 confirmed cases of respiratory illness.
The current concern is that the outbreak of COVID-19 is more severe than past viral outbreaks. According to experts, that is because the issue we face is that COVID-19 has been much more widespread than other diseases like SARS and MERS. More people are getting infected all over the globe and not in one area. With trends of infection showing a spike and then tapering in China where it originated, the goal for other countries (where it has swiftly spread) is to avoid the spike. So the issue right now is containment to stop the spread and protect our most vulnerable from the spike that China and Italy have seen. The goal is also to reduce an overwhelming effect on our healthcare systems where we have limited staff and resources.
Food for Thought
An important thing to keep in mind with the lungs being a target for the virus is patients who are taking ACEIs and ARBs (angiotensin-converting enzyme inhibitors and angiotensin receptor blockers). Older individuals are often on these daily medications for cardiovascular issues, diabetes, and chronic kidney disease. Research in experimental models is pointing to the drugs increasing ACE2 receptors in patients. Research is showing that the SARS beta coronaviruses, SARS-CoV, which caused the SARS (Severe Acute Respiratory Syndrome) outbreak in 2003 and the new SARSCoV-2, which causes COVID-19, bind to angiotensin converting enzyme 2 (ACE2) receptors in the lower respiratory tracts of infected patients to gain entry into the lungs. More receptors=more places for more vims to bind to and a very swift progression. Viral pneumonia and potentially fatal respiratory failure may result in susceptible persons after 10-14 days. This is a really important potential risk factor for patients on these medications. (Diaz, Louisiana State Univ. Health Sciences Center)
Symptoms
Keep in mind that colds, flu and COVID19 can all present with very similar symptoms. This is one of the issues that makes it so hard to limit spreading. The following chart may aid in basic differentiation. A main note of concern is how hard COVID-19 can hit the respiratory system. The CDC says the ‘big three’ symptoms to watch for are fever, respiratory symptoms, and cough. If exhibiting any of those, the CDC is making the recommendation that you stay home and isolate.
COLD
Incubation/Exposure
Symptom Onset
Fever
Cough
Fatigue
Runny Nose
Nasal Congestion
Diarrhea
Body Aches
Sore Through
Headache
Loss of Appetite
Shortness of Breath
Respiratory Issues
1-3 days
Gradual
Rare
Mild-Moderate
Sometimes
Common
Common
Rare
Slight
Common
Rare
Sometimes
Mild
Mild
FLU
1-4 days
Abrupt
Common
Common
Common
Sometimes
Sometimes
Sometimes
Common
Sometimes
Common
Common
Sometimes
Sometimes
COVID-19
1-14 days
Gradual
Common
Common
Common
Sometimes
Sometimes
Sometimes
Sometimes
Sometimes
Sometimes
Sometimes
Common
Common
What can we do as Health Providers Keeping Doors Open?
As you maintain practice and availability for patients during this time, think about the strategies you can take to minimize risk:
• Sanitize your entire office and do it often (door handles, waiting room chairs/clipboards, pens, bathrooms etc.)
• Pay special attention to changing face paper/ cleaning the face piece in between patients/ cleaning the head piece, sanitizing hand rests. Talk to your table company about disinfectants and cleaners that can be used on your table surfaces. A mixture of bleach water is great for many surfaces to kill germs.) It has been shown that the COVID-19 virus can live on surfaces so clean between every single patient. Wipe down door handles on both side of your entry door and the restroom.
• Ensure you wash your hands thoroughly between patients.
Got masks? Wear one.
If a patient has symptoms have them wear a mask (and then they can take it home to limit exposure to others as well.)
Have patients wash/sanitize hands before and after entering treatment rooms.
Ensure that there are tissues to cough/sneeze into.
Consider a separate intake room where you take a recent history (ask about medications that the patient is taking) and screen for illness and fever. (Those who have a fever and trouble breathing send out for testing...especially if they are on the ACEIs and/or ARBs medications as the virus could have very fast implications for them.)
Care for musculoskeletal complaints in a different treatment room than folks who have any symptoms. Alternatively, consider caring for symptomatic patients with a home visit.
Open by appointment only so that social distancing measures can be adhered to and you aren’t exposing patients directly to each other.
• If you are ill yourself don’t come in.
Other Advice for Patients
• Wash hands and do it often. Keep hands away from face (eyes, nose, mouth where disease spreads).
• Follow containment guidelines in your area.
Drink plenty of water (add lemon or lime to get more vitamin C, get plenty of sleep, and exercise at home.
Up intake of anti-oxidants and D3 (immune boosting).
• At the first sign of any runny nose, watery eyes, or cough start gargling with salt water regularly. (Not an old wives tale, viruses cannot live in a salty environment so keeping the pharyngeal cavity coated will help prevent spread to the lungs).
• Many patients may ask about the flu vaccine: Every year we hear about the current season’s flu vaccines that are available. According to the CDC “ ...seasonal flu vaccines do not protect against influenza C or D viruses. Getting a flu vaccine may protect against flu viruses that are like the viruses used to make the vaccine. In addition, flu vaccines will NOT protect against infection and illness caused by other viruses that also can cause influenza-like symptoms. There are many other viruses besides influenza that can result in influenza-like illness (ILI) that spread during flu season. ”
To surmise this , Flu vaccines are aimed at the current most common Types of A and B. They do not cover every mutation in the Type A strain. Researchers try to determine which viral changes will be most common during the upcoming season. Typically the vaccines are aimed at 3-4 individual viruses: influenza A (H1N1), influenza A (H3N2), and 1-2 influenza B viruses (not all 200 varieties in the influenza type A category). Some patients may think that getting the flu vaccine may protect them from COVD-19 but that is not the case.
Conclusion
There are many different opinions on the feasibility on how COVID-19 is being handled. Only time will tell if governmental mandates made during this crisis were the right ones. Meanwhile, we all need to practice wisely, protect our patients, and continue to make our daily decisions based on rationale critical thinking. As vaccines start to enter the market also pay special attention as these are substances that are being developed very quickly and that will be introduced into the bloodstream. Faster is not necessarily better as exemplified by the tragic outcomes of the swine flu vaccine for example. We also know that SARS (which Covid is most like), Ebola, and Zika did not follow a typical path. The epidemics actually ended before vaccine development was complete. As we know, viruses can also mutate very quickly, so a developed vaccine may not have effect on a new strain. I would encourage all of us to stay abreast of what is happening with Covid-19 vaccine development and safety to make informed choices.
References
1. Center for Disease Control
https:/ www.cdc.gov antibiotic-use community for-patients common-illnesses colds, html
2. World Health Organization
https://www.who. ini health-topics coronavirus lah tab 1
https://www.who.int/emergencies/diseases/novel-coronctvirus-2019 situation-reports
3. United States Dept, of Labor
https://www. osha. govSLTC covid-19medical information, html
4. Virginia Dept, of Health
http:/ www. vdh. Virginia.gov/epidemiology/epidemiology-fact-sheetscoronaviruses
5. American Society for Microbiology Clinical Microbiology Reviews
https ://cmr. asm. org/content/21/2/27 4
https://www. sciencedaily. com relaes/2020/03/200323101354.htm
6. https:/ www. nejm. org doi pdf 10.1056/NEJMp2005630?articleTools=true Developing Covid-19 Vaccines at Pandemic SpeedNicole Lurie, M.D., M.S.P.H., Melanie Sciville, M.D., Richard Hatchett, M.D., and Jane Hcilton, A. O., P.S.M.
Laurie Mueller, BA, DC, CFMP served in private practice in San Diego, California. She served as the ACC Post Graduate subcommittee chair for 6 years, peer reviewed for the Research Agenda Conference, and was the post-graduate director for the Palmer Colleges from 2000-2010. Dr. Mueller currently works as a private eLearning consultant with a focus on healthcare topics and functional medicine through her company, Impact Writing Solutions, LLC. She partners with companies and organizations to launch/administer elearning initiatives and she is also the founder of www. cccaonline.com (for CA's) and www.FxMedOnline. com for allied health professionals. TAC readers can enjoy $10 off their first registration bundle by utilizing TAC's exclusive discount code at the time of purchase TACFXMED.
