10 COVID-19 Myths: Separating Facts from Fiction

"Everything we do before a pandemic will seem alarmist. Everything we do after a pandemic will seem inadequate. This is the dilemma we face but it should not stop us from doing what we can to prepare."
- Michael Leavitt, 2007 Secretary of the U.S. Department of Health and Human Services

The first case of the novel coronavirus, also known as COVID-19, was confirmed in Wuhan, China, in December 2019. In January 2020, the first confirmed case was reported in the United States. In March 2020, the outbreak was declared a global pandemic, and on March 13, the president of the United States declared the COVID-19 outbreak a national emergency. Paralleling the number of new cases, the level of available information and concern have seemingly grown exponentially daily. With the increase in media coverage and social media attention, it is hard to separate fact from fiction. Make no mistake: This virus is here to stay, and the effect it will have on our lives will only continue to grow.

Myth #1: The flu infects and kills more people every year – so this is nothing to worry about.
Fact: Reports on mortality rates are bound to be erroneous because we don't know how many people are infected. The only number currently known is how many people have died out of those who have been reported as positive. It is therefore misleading to make a conclusive statement about the overall mortality rate of a pandemic while it is still ongoing. Furthermore, preventive measures have improved, quarantines have been initiated, the ability to detect and confirm cases has become more widespread, and the standard of care has evolved - all of which should lead to improvements in the mortality rate. By mid-March, worldwide, about 3.4% of patients with COVID-19 had died. By comparison, seasonal flu generally kills far fewer than 1% of those infected.¹ This pandemic's mortality rate is even higher among the elderly. Approximately 6% of people over the age of 60 infected with COVID-19 die, compared to less than 1% of those same aged people with the flu.

Myth #2: The flu is more contagious.
Fact: The Diamond Princess cruise ship provided valuable insight in what the spread of COVID-19 was like in an isolated environment. Of the 3,711 people on board, there were 355 confirmed cases. Scientists use R0 ("R naught") to estimate the number of people an average infected person is likely to infect, and they extrapolated the data from the cruise ship to determine the R0 was 2.28. By comparison, the flu has an R0 of 1.3. This may in part be due to the fact that there is no vaccine to prevent COVID-19, while the seasonal flu vaccine may prevent influenza relatively well, even when its formulation doesn't perfectly match the circulating viral strains.

Myth #3: Patients who have no symptoms have been screened out.
Fact: There is no "screening" for COVID-19. Many hospitals tried to get ahead of the curve by opening separate triage areas for those with respiratory complaints – or to place a non-surgical mask on patients who did have a fever or cough. We were told by administrators to conserve personal protective equipment (PPE) and only use it for patients who meet specific criteria (fever, cough, travel to an affected area, negative influenza tests). For years, physicians have espoused the lack of sensitivity of a rapid flu test, and yet now we were tasked with making decisions on whether someone is infected with COVID-19 based on this same, unreliable test. There are no longer patients who might be infected and those who might not: Treat all patients as if they are infected until proven otherwise.

A study published on March 16 in Science demonstrated that a large number of COVID-19 cases in China was largely driven by individuals with mild, limited, or no symptoms who went undetected. Says co-author Jeffrey Shaman, “Depending on their contagiousness and numbers, undetected cases can expose a far greater portion of the population to virus than would otherwise occur. We find for COVID-19 in China these undetected infected individuals are numerous and contagious. These stealth transmissions will continue to present a major challenge to the containment of this outbreak going forward."²

Myth #4: Patients in the early stages are not contagious.
Fact: On March 1, U.S. Secretary of Health and Human Services Alex Azar reported that asymptomatic spread is "not the major driver" of the spread of the new coronavirus. "You really need to just focus on the individuals that are symptomatic," he said. "It [the containment strategy] really does depend on symptomatic presentation." According to the CDC website, "Some spread might be possible before people show symptoms; there have been reports of this occurring with this new coronavirus, but this is not thought to be the main way the virus spreads." However, there is now strong evidence that it can be transmitted by people who are just mildly ill or even asymptomatic.³

Viral shedding is what happens when a virus has infected a host, has reproduced, and is now being released into the environment. It is what makes a patient infectious. Initially it was thought that as long as patients were asymptomatic, they weren't infectious. We now know this to be false, as the results of at least one study confirmed that coronavirus patients are shedding large amounts of the virus in these early stages, when they have either no symptoms or just mild ones.⁴ And it doesn't end when the infection ends: a study published on March 11 showed that survivors were still shedding the coronavirus for on average 20 days – and in one case for up to 37 days!⁵ This suggests coronavirus patients may be contagious early and may remain so even after the infection has "cleared."

Myth #5: COVID-19 is only spread through respiratory droplets.
Fact: While the primary method of transmission does appear to be via the respiratory tract, new evidence indicates that fecal-oral transmission may also play a role. This is not entirely unexpected, as both of the coronaviruses behind SARS and MERS are shed in the stool. In one study that looked at 73 hospitalized patients, 39 had viral RNA in their feces; 17 of the patients continued to have viral RNA in their stool after respiratory symptoms had improved.⁶ It's important to note that while the virus was detected in the stool, it is unclear if it was enough to be considered infectious.

Myth #6: The 14-day surveillance period is adequate. 
Fact: The flu has an incubation period of, on average, 2 days. This means that an infected person will begin to show symptoms within 48 hours of infection. One early study done in Wuhan based on 88 confirmed COVID-19 cases estimated that the median incubation period was 6.4 days.⁷ Another study of 158 confirmed cases estimated that the range was between 2 and 14 days. Furthermore, 97.5% of those who develop symptoms did so within 11.5 days of infection. The authors concluded: “We estimated the median incubation period of COVID-19 to be 5.1 days and expect that nearly all infected persons who have symptoms will do so within 12 days of infection. We found that the current period of active monitoring recommended by the U.S. Centers for Disease Control and Prevention (14 days) is well supported by the evidence.”⁸ Since this is a novel virus, our level of understanding its complexities is constantly evolving. Survivors are still shedding the virus for up to 37 days after the infection has cleared. Put another way, no one knows how long of a surveillance period is enough.

Myth #7: COVID-19 affects mostly older people with underlying medical conditions.
Fact: The World Health Organization directly addresses this question on its website: "People of all ages can be infected by the new coronavirus (2019-nCoV). Older people, and people with pre-existing medical conditions (such as asthma, diabetes, heart disease) appear to be more vulnerable to becoming severely ill with the virus." It is true that the older population is at greater risk. The chance of dying from COVID-19 clearly increases with age. However, according to China's National Health Commission (NHC), about 20% of those who have died were under the age of 60. One study from China showed that 41% of serious cases occurred among persons under the age of 50, compared to 27% of serious cases among persons aged 65 or older.⁹

Myth #8: Droplet precautions will protect you.
Fact: This is a myth that persists and unfortunately the one that has the gravest ramifications for health care providers. Public health officials reinforce this notion that droplets laced with the new coronavirus don't remain aloft for long – that they only travel 6 feet at most before falling to the ground – and that droplet precautions will provide ample protection. World Health Organization director-general Tedros Ghebreyesus assured people just last week that "actually it's not airborne." He went on to clarify that "[i]t spreads from person to person through small droplets from the nose or mouth which are spread when a person with #COVID19 coughs or exhales." A study published on March 4 reviewed the isolation rooms of 3 patients in Singapore with COVID-19. The air vent blades in one patient's room tested positive.¹⁰ A second study published March 10 examined the rooms of COVID-19 patients in Wuhan, China. The study did find the presence of the virus in aerosol form.¹¹ Whether it is enough to be considered infectious is yet to be determined, but the fact remains: COVID-19 is airborne.

Myth #9: There is no way to prevent it. 
Fact: This is a novel virus with no real vaccine or treatment. The best way to fight it is prevention - be aware of it and how it is spread and take steps to protect yourself. Hand hygiene is important. Avoid touching potentially contaminated surfaces and then making contact with your face. Recognize that the virus can remain on inanimate objects for up to 9 days. Take care when handling delivery boxes, fueling the car, or even buying groceries. Social distancing is all the rage these days. At work, take precautions when entering the room of patients with respiratory or GI complaints. Utilize airborne precautions. But even more so, recognize that anyone at any time could be infected with the virus.

Myth #10: By using full PPE, emergency physicians will be protected.
Fact: Two emergency physicians in the U.S. are currently in the ICU after being infected with COVID-19. Some avenues continue to wrongfully purport the idea that young and healthy people will remain free of serious complications. One of the critical doctors is in his 40s with reportedly no prior medical history. The other leads his institution's emergency preparedness, and both were purportedly wearing full PPE. The nationwide shortage of N95 protective masks has led some hospitals to condemn the routine use of full PPE. Nationwide supply shortages must be considered but should be weighed against the safety of physicians on the frontlines. Some emergency departments are adapting their facilities to minimize the risk of exposure, opening tents to triage patients outside their buildings and creating separate entrances for patients and doctors. From the time the virus first revealed itself to today, our knowledge of it grows every day. We must remain vigilant in protecting ourselves if we are to protect others.

More COVID-19 resources

• March 25, 7 pm Eastern: COVID Response Briefing with Dr. Nida Degesys from UCSF, brought to you by the EMRA Administration & Operations Committee. Register and join on Zoom.
• Playing Through the Pain: Important Update on COVID-19 Exposure
• ACEP COVID-19 Clinical Alerts
• Navigating Uncertain Times: Impact of COVID-19 on Medical Trainees

References

1. WHO Director-General's opening remarks at the media briefing on COVID-19 - 3 March 2020 - World Health Organization. March 3, 2020.
2. Li R, Pei S, Chen B, et al. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science. 2020 Mar 16.
3. Hoehl S, Rabenau H, Berger A, et al. Evidence of SARS-CoV-2 infection in returning travelers from Wuhan, China. N Engl J Med. 2020 Feb 20.
4. Woelfel R, Corman VM, Guggemos W, et al. Clinical presentation and virological assessment of hospitalized cases of coronavirus disease 2019 in a travel-associated transmission cluster. MedRxiv 2020.03.05.20030502.
5. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients With COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020. Mar 09. [Epub ahead of print]
6. Gu J, Han B, Wang J. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology. 2020 Mar 3. {Epub ahead of print]
7. Backer JA, Klinkenberg D, Wallinga J. Incubation period of 2019 novel coronavirus (2019-nCoV) infections among travellers from Wuhan, China, 20-28 January 2020. Euro Survell. 2020;25(5).
8. Lauer SA, Grantz KH, Bi Q, et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020 March 10. [Epub ahead of print]
9. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24. [Epub ahead of print]
10. Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. JAMA. 2020 Mar 04. [Epub ahead of print]
11. Lui Y, Ning Z, Chen Y, et al. Aerodynamic Characteristics and RNA Concentration of SARS-CoV-2 Aerosol in Wuhan Hospitals during COVID-19 Outbreak. BioRxiv 2020.03.08.982637.