UPDATED 3/28/20-New Data, Maps & Travel Advisories.
By now I am sure you have seen the news circulating about Coronavirus infection AKA as COVID-19. This Coronavirus strain was first diagnosed in humans in China in December 2019.
As a physician practicing hospital medicine, an avid traveler and a travel blogger, sometimes my worlds collide. This happened a few years ago when I wrote about Zika virus and again last year when I wrote about keeping kids healthy while traveling abroad. I am now speaking and writing about Coronavirus. I feel it is important for everyone, especially travelers, to have factual and up to date information.
On 2/13/20 I did a Facebook Live entitled “Coronavirus: What Travelers Need To Know”. It was very well received. Therefore, I decided to turn it into a blog post. But, the title has changed to “What Everyone Needs To Know”. This virus has spread to every continent except Antartica. It has been declared a pandemic by the World Health Organization. I believe it is best to know the facts about Coronavirus in order to protect yourself and your family.
Also, since writing this blog post, I appeared on New Day Weekend on CNN (YEAH!!) on Saturday 3/7/20 to discuss travel issues related to Coronavirus.
Disclaimer: Please do not use this article/blog post to diagnose or treat your symptoms or illnesses. You must contact your own doctor, state health department or health care professional for medical advice if you are ill or have medical questions.
Everyday I wake up to new information and new numbers. As of 3/28/20 here is where we stand:
- The United States now has the most confirmed cases in the world overtaking China and Italy. There are approximately 105,470 cases in the US in 17 states. There have been about 1730 deaths in the United States. The states most affected are New York, California, Louisiana and Washington State. Closing of non-essential businesses are taking place as well as city lockdowns and curfews.
- Worldwide there are over 600,000 cases and over 28,000 deaths. Over 137, 300 people have recovered.
- China reported the death of a 10 month old baby. The baby had a condition called intussusception which causes a blockage of the intestines. This is the first death reported under the age of 10. A 17yo in California who was positive for COVID-19 died but it may not be the cause of death.
- The number of new cases in China is actually dropping including in Wuhan (this is a good thing). China is still listed as a Level 4 travel advisory on the US State Department website. This means do not travel to China.
- The State Department has issued a Level 4 Global Health Advisory. This means US citizens should avoid all international travel. Countries around the world are closing their borders. Here is a current list of Coronavirus travel restrictions around the world.
- Italy remains in lockdown. The Northern Lombardy and Veneto regions-areas around Lake Como, Milan and Venice have been the hardest hit. Italy has experienced the most deaths of any country at over 9000 deaths with 86,400 confirmed cases. They recently reported over 900 deaths in one day. This is tragic. Italy is at a Level 3 travel advisory on the CDC and State Department websites but with a Level 4 warning-do not travel-to the Lombardy and Veneto regions.
- A Travel Ban for 26 European countries was put into place on Friday March 13th at midnight for 30 days. As of Monday March 16th it includes the United Kingdom and Ireland. The number of cases in Spain and Germany have been growing. It excludes US citizens, permanent residents and most family members. Foreign nationals that have traveled to any of these countries in the past 14 days will not be permitted to enter the US. US citizens and residents will have to enter through specific airports and go through screenings.
- There has been an online plea from health care professionals for more “PPE”- Personal protective Equipment. There is already a shortage of surgical and N95 masks as well as gloves and gowns in certain areas and hospitals. On Twitter check the hashtag #GetMePPE and support any way you can.
About Coronavirus: What is COVID-19?
It is important to note that Coronaviruses have been around for a long time. They are one of many viruses that cause common cold symptoms like runny nose and cough and fever. They can also cause bronchiolitis in babies, viral pneumonia and “stomach virus” symptoms like vomiting and diarrhea.
Viruses have many different types or strains. They are often identified by letters and/or numbers and/or years. This Coronavirus was initially named 2019-nCoV since it is a “novel” or new strain of the virus. It has never been identified in humans prior to 2019. The official name of this new virus is SARS-CoV-2. This is due to its resemblance to SARS-Severe Acute Respiratory Syndrome caused by a different Coronavirus strain in 2003. COVID-19 stands for Corona Virus Disease 2019 which is caused by the SARS-CoV-2 virus.
COVID-19 was first identified in Wuhan, Hubei Province in China in December 2019. Doctors diagnosed a cluster of patients with pneumonia. All these patients were associated with seafood and live animal markets in Wuhan.
Coronaviruses are zoonotic viruses. This means that they spread from animals to humans. The virus can transfer from animals to humans by humans being in close contact with animals. Human infections may also occur by eating uncooked meat or using parts of the animal for medicines. Once a person is infected with Coronavirus, it can be transmitted from person to person. This often occurs due to a mutation of the virus.
Animal vectors of Coronavirus have included bats, cats and camels. The suspected animal vector for COVID-19 is the pangolin. It is a scaly, ant-eating endangered mammal. It is imported to Chinese markets and used for food and medicines. One article quoted it as the most trafficked mammal on the planet. The genetic sequences are a 99% match to COVID-19. However, researchers still believe bats are the original source and that pangolins may be an intermediate vector.
What are Coronavirus symptoms?
Typical symptoms of a Coronavirus infection are those of the common cold. As mentioned above, this may include fever, runny nose, nasal congestion and cough. You may also have gastrointestinal symptoms of nausea, vomiting or diarrhea. Symptoms may resemble the flu with fever and body aches.
Once infected with the virus, symptoms can take up to 14 days to appear. So far most patients have had symptoms by day 5. But, you can still spread the virus to others if you are infected but do not have any symptoms. A person is most contagious when they are exhibiting symptoms of the virus.
Severe symptoms of Coronavirus include shortness of breath, difficulty breathing, worsening cough and persistent fever. These symptoms may indicate pneumonia and respiratory (lung) failure. 20% of those infected will develop severe symptoms.
Examples of severe Coronavirus diseases are MERS-CoV and SARS-CoV. MERS (Middle East Respiratory Syndrome) occurred in 2012 in Jordan and Saudi Arabia. Camels were thought to be the animal vector. 3-4 out of 10 patients that contracted this Coronavirus died.
SARS-CoV-Severe Acute Respiratory Syndrome occurred in Southern China in 2003. That Coronavirus strain went from bats to cats to humans. It affected 8000 people in 26 countries. 10% of those infected or about 800 people died.
Unfortunately, Coronavirus infections can lead to death from lung, kidney or heart failure. The WHO estimates the death rate to be around 3%. About 15% of patients who have died in China are 80 years of age or older. The death rate has varied by country. It is currently very high in Italy but low in South Korea. The number varies based on how many people are being tested to confirm Coronavirus infection. Younger patients (30s-50s) with serious complications are being reported in Italy.
The high risk population includes the elderly, people with chronic medical conditions, such as Asthma, Diabetes, Hypertension, Heart Disease and people with compromised immune systems. Examples of people that are immunocompromised are those undergoing chemotherapy for cancer or taking immunosuppressive drugs due to auto-immune diseases such as Lupus.
Is Coronavirus contagious? How is it spread?
From what scientists can tell so far, like other Coronaviruses, COVID-19 is spread through respiratory droplets. When a person coughs or sneezes, these droplets get into the air and someone else can breathe them in. These droplets can also land on inanimate objects. If someone else touches these objects then touches their face, they can contract the virus. The virus can live on objects for several days.
We now know that besides person to person transmission of the virus, you can also become infected by community spread. This means that it is being spread in the community by people without known disease or travel history to China or any of the affected countries. This is a great article that goes over how to get your home ready in case the virus spreads to your community.
Coronavirus has spread rapidly among family members and health care workers. Sadly, several health care workers have contracted Coronavirus and have died. This includes the head doctor in China and Italy and a Chinese doctor who first alerted the world about the cluster of pneumonia patients.
People working in live animal markets, especially in China are also at high risk. On January 30th China enforced a temporary ban on the trade of wild animals. Snakes, rare birds, bats and turtles are not currently being traded in “wet” markets, supermarkets, restaurants and e-commerce locations.
How is Coronavirus diagnosed?
Coronavirus is diagnosed by a PCR (polymerase chain reaction) test. A sample of someone’s secretions from their nose or mouth is collected. The secretions are then checked for genetic markers of the virus.
China had decided to also consider someone infected with COVID-19 if they had the symptoms and pneumonia findings similar to those with positive tests. This is called a “clinical diagnosis”. These patients have been added to the total of people infected with Coronavirus even if their PCR test was negative.
The CDC has had some issues with test kits having faulty reagents. State labs and commercial diagnostic developers are working with the FDA to get new test kits approved.
In the US, testing for Coronavirus was only being done on people who traveled to China and exhibited symptoms. Or, anyone exposed to someone with the virus. However, since the virus has spread worldwide, travel is not the best indicator for testing. But due to a shortage of test kits, doctors and state health departments have to decide who will benefit from the test results in terms of managing the disease. We need more tests since up to 40% of a population can be positive but asymptomatic and still spread it.
Certain private labs like LabCorp and Quest Diagnostics centers are testing samples sent from health care facilities. YOU CAN NOT WALK INTO ONE AND BE TESTED. There are also drive-through testing locations popping up across the country. Contact your doctor, emergency room or local state health department if you feel you need to be tested for Coronavirus. They will do the necessary paperwork and tell you where to go.
Is there treatment for Covid-19?
Unfortunately, there are no specific antiviral medications or vaccines available yet for COVID-19 since it is a new virus. A vaccine is in the works and clinical trials have started. It may still take 12-18 months until it is available and it is unclear who would be eligible and what the costs will be.
The CDC lists “therapeutic options” for patients with COVID-19. Studies are being conducted on Remdesivir. It is an investigational intravenous drug with antiviral activity. The anti-malaria and immunosuppressive drug-chloroquine or hydroxychloroquine AKA Plaquenil is also being tried.
Antibiotics do not work for Coronaviruses since they are not bacteria. Antibiotics may be used for secondary bacterial infections like bacterial pneumonia that may develop after you contract the virus. However, Zithromax in combination with Plaquenil is being used in some patients.
Current Coronavirus treatment consists of supportive care. Patients may be managed in an intensive care unit, be on a ventilator, oxygen and receive dialysis. If you think you have Coronavirus, it has been advised to avoid ibuprofen products such as Motrin, Advil, Naprosyn and Alleve. Try to stick to Tylenol. Elderberry may also cause more severe disease.
Health care systems in the most affected countries such as China and Italy have been stretched beyond their capacities. You may hear the term “Flatten the curve or Flattening the curve”. This is an attempt limit the amount of people infected all at once.
Coronavirus infection may still spread and the same number of people may still get infected, but “flattening the curve” with people getting infected over time will allow healthcare systems to have enough facilities, resources, staff and medications to care for those in the greatest need.
How do I prevent a Coronavirus Infection?
Like most infections, proper prevention consists of washing your hands with soap and water, for at least 20-30 seconds, especially after handling animals and raw meat. Use hand sanitizers, cover your mouth and nose while coughing and sneezing, and avoid people that are sick. Cook meat thoroughly prior to eating.
Use tissues to sneeze and cough into vs. your hands. Dispose of tissues in a closed container then wash or sanitize your hands. Try to avoid touching your face in general unless your hands are clean. Disinfect common areas that you use in your office, hotels, on airplanes, buses and trains. Get used to carrying disinfectant wipes with you.
Should I wear a mask to prevent infection?
You may have seen pictures of Chinese and other Asians wearing surgical masks. They are currently required in a few provinces around Wuhan. Although masks can halt the spread of some viruses, it is not yet recommended for common use.
Masks can give a false sense of security and may not be worn correctly. People often touch their nose or mouth underneath the mask and even eat with the mask on. They may sneeze or repeatedly cough in the mask and not replace it.
In general, if you are sick and you wear a regular surgical mask, you can prevent infected respiratory particles from getting into the air and infecting others. If you are healthy, wearing a regular mask is not recommended. You will not prevent yourself from contracting Coronavirus.
That is because these masks do not have a tight seal around your mouth and nose. Coronavirus particles are so small that once in the air they can penetrate around these regular masks and you can still get infected.
Health care workers usually wear N95 respirator masks which have a tighter fit and offer better protection against the virus particles entering your respiratory area (face, nose, mouth).This prevents you from breathing in the virus and getting infected. It also prevents your germs from entering the air and infecting others.
These masks are available as disposable masks and reusable masks with replacement filters. This prevents you from breathing in the virus and getting infected. We also wear disposable gloves and gowns. Read this excellent article “No, You do not need face masks to prevent Coronavirus…”
Masks do not take the place of proper hygiene! But, if you have suspected or confirmed Coronavirus infection or if you are caring for someone with the infection, you should wear a mask.
How does Coronavirus compare to Influenza virus?
Two important things that we are learning about this coronavirus is that it is more contagious and more deadly than the flu. Health care workers are being infected and unfortunately dying from repeated viral exposure even when PPE is used.
Those most at risk from serious complications and death from Influenza are the elderly, infants and people with chronic illnesses and compromised immune systems. Except for infants, the risks are the same for Coronavirus. Babies and children tend to have a mild illness with COVID-19. However, the flu usually causes this population to be very ill. Children may have some immunity from contracting other Coronavirus.
There are anti-viral medications available for Influenza that can reduce the duration of the illness and help prevent spread to others. The Influenza vaccination is the best way to prevent infection. It reduces the risk of flu illnesses by 40-60%. There is still time to get the vaccine.
The Chinese Center for Disease Control and Prevention has reported that COVID-19 is 20 times more deadly than the flu. Based on current numbers, the death rate for Influenza this season is 0.1%. The death rate for Coronavirus is much higher at about 3.4% globally.
The mortality (death rate) differs by country. It has been about 2-3% in China and as high as 11% in Italy and Iran. There has been 1 reported death under the age of 10.
Coronavirus Infection: What Travelers Need To Know
The World Health Organization (WHO) has declared it a pandemic. For up to date information on the 2019 Coronavirus please be sure to check these websites:
- CDC (Centers for Disease Control): Traveler’s Health Section at CDC.GOV
- US Department of State: Travel.State.Gov. Sign up for STEP (Safe Traveler Enrollment Program)
- World Health Organization: Coronavirus.
- CNN Live Updates
It is important to become familiar with the State Department travel warnings assigned to countries worldwide:
State Department, Levels 1-4. Level 1: exercise usual precautions, Level 2: exercise increased precautions, Level 3: reconsider travel, Level 4: Do not travel.
Travel advisories for the CDC (Center for Disease Control) are Levels 1-3. Level 1:(Green): exercise usual precautions, Level 2 (Yellow): practice enhanced precautions, Level 3 (Red): Avoid nonessential travel.
For Travelers Returning to the US from China:
For US citizens or residents currently in China and would like to return to the United States, contact the US Embassy in Beijing, China.
Returning US citizens and permanent residents are allowed to return to the US but are redirected to designated airports. Health screenings are done checking for fever, cough and difficulty breathing.
For travelers returning from Wuhan, Hubei Province: If you have been in this area in the past 14 days AND you have symptoms, you will be transferred to a medical facility for further care.
If you do not have any symptoms, you will be transferred to a location for quarantine for 14 days. During this time, you will be monitored for symptoms and tested for Coronavirus.
For travelers returning from Mainland China: If you have any symptoms of Coronavirus infection, you will be taken to a medical facility. If you do NOT have any symptoms, you will be allowed to continue travel in the US to your final destination. You will be asked to stay home and monitor for symptoms for 14 days. This includes checking for fever twice a day. If you have a temperature of 100.4 or greater, develop a cough or difficulty breathing, you should call your local health department.
For travelers returning from Europe or South Korea: Based on the new European travel ban, you will be required to self quarantine at home for 14 days. This also applies if you have returned from South Korea. Check your temperature twice a day. Per the CDC website “practice social distancing”. That means no public transportation, going to malls or events and staying at least 6 feet away from other people.
If you develop a fever, cough or cold symptoms try to remain at home so you do not infect others. Wear a mask to try and prevent others in your home from getting sick. If you are experiencing trouble breathing or worsening symptoms, seek medical care at your doctor’s office or emergency room. Please let them know your travel history in advance.
For travelers returning from Iran: The US is implementing restrictions on entry to the United states for citizens and permanent residents returning from Iran. These travelers must enter through an approved airport. Entry of foreign nationals Iran has been suspended.
There is currently no restriction on travel within the United States.
Be aware that there are destinations worldwide that are screening passengers on arrival and departures back to the US. This may consist of using thermal body scanners to check for elevated body temperatures and asking you to complete a health questionnaire. This is to prevent anyone who is ill, especially with coronavirus, from entering that country and putting the population at risk. You will likely be directed to a medical facility if you have a fever or cold symptoms. A lot of countries have also closed their borders.
Airlines: Update 3/12/20: All flights between the US and Shanghai and Beijing remain suspended. Flights to Italy: American Airlines and Delta have suspended flights to Milan from NYC’s JFK airport. Delta has also reduced service between the US and Seoul South Korea. United Airlines has suspended flights to Hong Kong. Most flights have been suspended until late April or early May. Other International airlines have also changed routes and cancelled flights such as Japan based ANA-All Nippon Airways.
Most major US airlines are allowing cancellation or rescheduling of international flights through March or April without change fees. You will have to pay the difference in fares. And, most flights will have to be rescheduled for 12/31/20 or earlier although some are allowing travel within 1 year of the original ticket.
As an incentive, for new flights booked through March 31st, you will be allowed to change once without a fee. A lot of travelers are taking advantage of this and travel deals to book future travel.
Cruise ships: The CDC is recommending that all travelers reconsider cruise ship travel in Asia. And, for anyone over the age of 60 or with chronic medical conditions to reconsider all cruise ship travel. There is a high risk of person to person transmission of Coronavirus infection as seen on the Diamond and Grand Princess cruise ships. Princess and Viking cruise lines have suspended cruises at this time.
In addition, Cruise Lines International Association is screening passengers at Port Canaveral Florida and may extend this to more ports. The plan is to deny boarding to anyone who is ill, who has traveled to or transited through airports in China, South Korea, Iran, Hong Kong, Macau or any municipalities on lockdown in Italy in the 14 days prior to embarkation. They will also deny boarding to anyone who has taken care of a known or suspected Coronavirus infection patient 14 days prior to embarkation.
All major cruise lines now have policies in place for passengers wishing to cancel or reschedule bookings. This article is a great resource to find out what you may be eligible for based on the cruise line and dates of travel. Be sure to call the cruise line or your travel agent directly.
Events: Coronavirus has affected events worldwide. NCAA has cancelled March Madness, the current NBA season has been suspended and Disneyland has been temporarily closed. Major travel conferences such as TBEX Catania and ITB Berlin have been cancelled or postponed. Conferences with an international draw have also been canceled in the US.
The Louvre in Paris France recently closed but has reopened. Japan announced a reduction in runners for a marathon. Shanghai Disneyland and parts of the Great Wall have been shut down. The Mobile World Congress Trade Show in Barcelona has been cancelled. Therefore, check with hotels, tour companies and local websites for additional travel information.
Should I cancel my trip because of Coronavirus?
3/22/20 There is currently a Level 4 Global Travel Advisory. Therefore, do not travel internationally until further notice. Also, many countries are closing their borders. Here is a list of Coronavirus travel restrictions around the world.
1) If your trip is to China, Italy, South Korea, or Iran then yes, cancel or reschedule. Reconsider travel to any Level 2 countries and those listed under the European travel ban which are now a Level 3. We are not sure how this will enfold in the next 1-2 months. If your trip is for later in the year, do not cancel. Wait, watch and stay informed. I for one hope the Olympics occur in Tokyo without a hitch. However, the news reported recently that Japan is keeping a close eye on the situation and there is a possibility it may be cancelled.
Something else to consider is traveling to one of these countries and getting stranded or quarantined if you are exposed to Coronavirus infection. The situation is so fluid that new restrictions may be placed on the above countries.
2) If you suffer from chronic illnesses especially respiratory illnesses such as Asthma and COPD, a Coronavirus infection could be very problematic. Also, if you are immunocompromised, your body may not be able to fight off the infection. The second thing to consider in this category is if you are a caretaker for the elderly. If you get a coronavirus infection and pass it on, that person will have a harder time recovering from the infection. The death rate is higher in the elderly.
3) Does your trip include attending a lot of public crowded events? Does it involve sharing rooms in hostels or AirBnbs? This is something else to consider. You do not want to be stuck in close proximity to anyone who is sick. You will need to be careful about cleaning and sanitizing common use areas. We have seen the spread of Coronavirus infection at International conferences. Therefore, countries around the world are cancelling or reducing the capacity of major events to try and contain the virus.
4) Is the city you are traveling to on lock down i.e. the towns around Venice, Italy? Are people in quarantine due to the Coronavirus infection? If so, I would cancel or reschedule. The Carnival in Venice Italy is scheduled to end early and Milan’s Fashion Week will have limited access.
5) Do you have travel insurance that will reimburse you for cancellations? If so, it may be worth it to cancel or reschedule. It is important to note that most travel insurance plans do not cover epidemics like Coronavirus or pandemics. I found this article to be very helpful.
If you will be booking travel or have travel plans in the next few months, consider purchasing “cancel for any reason” travel insurance. This “Coronavirus Advisory” article by Travel Guard reviews what is covered and would be reimbursed with this type of policy. It is always important to have medical evacuation as part of your policy in case you get sick while traveling.
6) Check with employers, companies, schools and colleges about any policies on traveling to areas affected by Coronavirus or international travel. Some places have implemented work restrictions and home quarantines after international travel. Many colleges are shutting down campuses and doing online study. Be sure to read my article on how to keep kids healthy while traveling abroad.
Important Travel Advice for COVID-19:
Do Not Panic. But, Do Prepare.
Prevent spread of infections by hand washing, hand sanitizers and disinfecting common areas with disposable wipes.
Check the CDC and the State Department websites for Up To Date information on the Coronavirus infection.
If you have suspected or confirmed Coronavirus infection or if you are caring for someone with the infection, seek medical attention and wear a mask.
If you travel to any of the countries affected, please follow proper protocol when you return. Observe any imposed quarantines so you do not put others at risk.
If you become ill, seek medical attention. Alert your doctor, emergency room or medical facility about your recent travel and exposure PRIOR to your arrival.
Get travel Insurance. Make sure it includes medical evacuation and consider a “cancel for any reason” policy. Reputable companies include World Nomads and Allianz.
Call airlines, hotels and tour companies prior to your travel dates. If you decide to postpone or cancel your trip and a refund isn’t available, ask for credit towards a future trip. Kerwin of CruisinAltitude posted a great article on how coronavirus has affected air travel and hotel stays.
I hope you have found this informative guide about Coronavirus infection helpful. As a physician practicing hospital medicine, I feel it is very important to share detailed, practical and helpful information on Coronavirus. I will try to keep this blog post updated weekly. But, be sure to follow The Sophisticated Life Facebook page for daily updates. I am sharing relevant articles there.
I also did a webinar on Facebook for the Wanderful Community!
Stay Healthy and Travel Safe!