What we know about how this coronavirus causes COVID-19 pneumonia hasn’t changed since CNN published it in March of 2020. However, after a year of living in a pandemic and the unconscionable loss of life, we’ve learned many useful precautions that could improve our public health practice and clinical care.
But first, the basics. COVID-19 causes pneumonia, hospitalizations, deaths, and shuts down our world in two ways.* The first is virus finding its way inside your face, inhaled close-range, kissing, or from your finger, that is stopped in your nose or throat but drip down into your lungs when you sleep – a process known as “aspiration.” This process happens to all normal adults during sleep, but not when awake. The other is by inhaling contaminated indoor air from an infected person containing tiny airborne viruses that aren’t stopped in the nose or throat but go directly down your windpipe.
Alcoholic drinks, sleeping pills, being in a coma, all increase how much is aspirated and reduce the amount your lungs can clear back into your throat. Mucus particles in the throat cleared from the lung, including active virus– that isn’t swallowed or spit out – can drip into healthy parts of your lungs the next time you sleep.
Plenty of useful details learned in the past year can reduce COVID-19 pneumonia regardless of the strain. We can inactivate coronaviruses where they’re easy to attack, stuck in the throat while we’re awake before they can reach the lungs during sleep.
Several labs carefully tested different mouthwashes. Listerine Antiseptic and similar generics kill over 99% in the test tube in 60 seconds. Clinical studies showed swishing and gargling for 60 seconds, then spitting, was highly effective against killing another important germ. “Washing the throat” once before sleep for 60 seconds with two-thirds ounce of a correct generic mouthwash costs 5 cents and can protect against aspirating coronavirus.
Furthermore, there are no known COVID-19 strains resistant to disinfecting indoor air. To prevent directly inhaling coronavirus indoors, we can disinfect indoor air by pushing lots of outdoor air inside if weather permits. Another way is by using safe, germicidal UVC light with fans to move the air around, regardless of the weather outside. Unlike ventilation, which can be expensive, these UV lights can disinfect an average school classroom for around $270.
More expensive approaches to mechanical ventilation of indoor spaces involve including lots more outdoor air than usual and replacing generic system filters with more expensive HEPA ones. Currently, most systems include between 0 – 50% of outdoor air and adding ventilation units that can cycle more outside air at higher rates, it would dilute and remove the virus. Unlike normal filters on air conditioners, HEPA filters are highly effective at removing viruses and are commonly used in airplanes. Using either of these measures (or a strategic combination) will make indoor air a lot safer but tend to be much more expensive than UV light treatment.
And then there are masks. The CDC just declared a new set of guidelines for fully vaccinated Americans, which states that vaccinated Americans “can resume activities that you did prior to the pandemic.” Above all else, that means vaccinated people don’t need masks in outdoor and indoor gatherings with other vaccinated people. This declaration has opened the door for larger gatherings and more airplane travel.
However, these new guidelines open new difficulties: we do not know who is unvaccinated, had a poor immune response, or is immuno-compromised and especially susceptible.
Fortunately, there has been more good news, specifically regarding vaccines. The available two-shot vaccines – from Pfizer and Moderna – are highly effective and very safe. The Johnson & Johnson (J&J) single-dose vaccine is effective as well, but the company’s own studies in animals show two doses provide better protection and the company is testing two doses in people now. With this in mind, the J&J vaccine and its European cousin from AstraZeneca can very rarely make pre-menopausal women very seriously ill, so those women should take one of the other two.
Can the COVID-19 vaccines be overwhelmed by lots of virus, or different strains, or both? Sure, the hepatitis B vaccine can fail, and annual influenza vaccines often do. We’ve known since 1975 that coronaviruses – found in chickens, turkeys, calves, rats, and pigs – can get into humans from animals and that getting infected with one doesn’t necessarily provide lasting protection against getting infected by the same or a different one. Unfortunately, plenty of the antibodies humans make to a virus may weakly attach, but can’t inactivate it.
So, with zero or minimal coronavirus around, unmasked vaccinated people are very safe. But as a country, we’re not there yet.
Luckily, we have some terrific, conscientious medical leaders, for example, Dr. Peter Marks, Director of the FDA’s Center for Biologics. He’s exceptionally knowledgeable, a gifted explainer has his ego in his back pocket, and his Center regulates vaccine candidates.
Now that society is starting to return to a “new normal,” some people are skeptical – even paranoid – about returning to some activities. Perhaps no activity generates more fear than airplane travel.
Exhaled air is warmed and normally rises. Ventilation engineers prefer ventilation systems to introduce air slowly near our feet and remove it at the ceiling. Unfortunately, for all the airlines’ chatter about safety, their 737-type airplanes do the exact opposite: blowing possibly infected ceiling air down past passenger faces to be removed at the shins of the window passengers. If you’ve already been infected on the way, the cabin air’s next stop at the HEPA filters and new outside air introduced won’t do you much good.
Also, we know that on-the-ground passenger loading and unloading makes lots of stale air in the cabin, proven by CO2 monitors, and in-the-air also, when pilots can turn fresh air flow down or off. Moreover, the airlines tell us to zero about cabin air handling in their many smaller regional prop-jet aircraft.
So, wear a very good N95 respirator if you fly, let someone else have the window seat, and try to convince the airlines to distribute all the food and beverages masked, then have 20 minutes unmasked for everyone to eat and drink while setting cabin ventilation to overdrive.
Where does all that leave us now? Fully vaccinated people, unmasked, are well-protected against Covid-19 from low exposures to the current US circulating viruses. But when persons from epidemic areas visit or high indoor exposure sites meet unmasked vaccinated people in the US, those bets are off.
What then? By following all the measures above, you will lower the chance of contracting the virus and suffering symptoms. Still, it is worth noting that measures like “washing the throat” before sleep and disinfecting indoor air have been in the category of “whatever” so far as our public health officials and media “experts” are concerned. You might have noticed some of their earlier advice – like saying masking isn’t necessary, needing more contact tracers and apps, more testing of everyone, and repeated hand washing and surface sanitizing – has largely vanished.
The US defeated repeated typhoid and cholera outbreaks across the country, and yellow fever in the Panama Canal Zone and Louisiana, without vaccines, or antibiotics, or butt swabs. They were curbed largely through hygiene and source control – sewage and water treatment plants for typhoid and cholera and draining standing water for yellow fever. No more Anopheles mosquitoes meant no more yellow fever deaths.
A consistent problem throughout this epidemic has been weak public health leadership. Most are doing the very best they can but too many are undertrained and working out of their fields. All past source control projects mentioned above required on-site work. Too many leaders these days only announce case numbers, talk to media, and tweet. Their internal compasses broke down. They forgot that modesty and humility are intrinsic to medicine – not like masks to put on and take off. They became the star narrators of their own docudramas, like some media “reporters.” Rather than recognizing that “less is more” and sticking to facts and succinct best advice, the media stokes the experts to mutual benefit with further COVID-19 “news” episodes guaranteed.
A. J. Liebling wrote that when you fill news reporting with only 10% news, you create a doubt in the public’s mind that any of it is news. Some Americans have resisted sometimes shrill calls for truly important control measures like masking and vaccination because they wonder if it isn’t Wall Street and Silicon Valley grubbing for money.
No doubt, the vaccine industry, manufacturers, and promoters certainly do want to promote and sell regular booster injections. After updating simple true public health explanations, money could have been spent for cheap indoor-air UVC disinfection – in nursing home common areas, houses of worship, and cafeterias for working people.
Instead, it went to multinational advertising conglomerates, COVID-19 test-makers, and the contact tracing industries. These for-profit businesses will continue to do extremely well from this disaster, meanwhile insulting the public with inane truisms like “Meet them where they are” and peppering us with annoying juvenile animations inserted in TV and internet breaks. Plenty of Americans resent that, helping explain why so many are resistant – even that has a slick name, “hesitancy.”
Those same resentful, semi-resistant, and hesitant Americans do want to know what to fix when their car won’t start. They want to know how not to have a heart attack or get cancer. Sober qualified public health explanations about what to do and why would help. Explaining both the advantages and limits of vaccines and explaining and implementing source control – removing the virus from people’s throats and indoor air – might get more people vaccinated and onboard with simple, sound prevention. It will allow us to normalize and unmask nearly everywhere. It’s likely to help us next time, too.
*Correction Issued at 3:27 P.M, 5/2/21 – A previous version of this article stated that “…COVID-19 causes pneumonia, hospitalizations, deaths, and shuts down our world in one of two ways…” , but both ways can occur in the same person at the same time. Smerconish.com regrets this error.