What to do

Things you should do

Wash your hands

>20 seconds with soap and warm water. Here are great options of songs to sing to help you pass the time. Unlike some really stubborn viruses (like polio), viruses in the coronavirus family typically don’t survive longer than a few hours on most surfaces hard surfaces; though it can be up to days. Bleach or ethanol are more effective at decontaminating surfaces than they are disinfecting humanskin. So don’t hoard the hand sanitizer, that should be used only when you do not have any access to a soap and water sink. At a restaurant? Wash your hands. At school? Wash your hands. Vigorous handwashing with soap really is vital to reduce transmission; the awesome science of why is here. If you do nothing else at all, do wash your hands.

Stay connected

Stay connected, but avoid crowds

It is best to stand at a distance from people. 6 feet or more is safest from infectious droplet spread. The higher your underlying risk factors (age, recent major surgery, cancer, immunocompromised, asthma, diabetes, etc), the more you should avoid crowds.

CDC has recommended that older adults ‘stay at home as much as possible’. But keep in mind that over the longer term, this isolation could have negative impacts on many people’s mental health. Cultivating meaningful relationships is a well established but under-appreciated determinant for all health outcomes. So DO see the people you love, but consider doing so via lower-risk activities. For instance, go for a walk outside with a smaller group of people rather than attending an event indoors. Go to the beach. Ride bikes. Golf. Picnic more. This is not going away in one week, so pace yourself.

Stay home

From the CDC site:

The United States nationally is currently in the initiation phases, but states where community spread is occurring are in the acceleration phase. The duration and severity of each phase can vary depending on the characteristics of the virus and the public health response.

The United States is a big country, with 50 states, each handling this in a different way. Therefore, community spread is going to be occurring at different rates in different places. The best thing to do, if not required by your employer, is to stay home until this curve has sufficiently flattened.

• Do not dine out.
• Do not go to the movies - listen to the radio, watch TV, listen to podcasts, do puzzles, play board games, create an in-home disco.
• Do not go to church - use home rituals or streaming services.
• Do not go to work unless you must, and when you return have a routine for coming back so as not to bring the virus into your home.
• Do not go shopping for non-essentials.
• If you get restaurant food delivered, use a service that you can prepay and have the delivery person leave the food on the doorstep. Order well before you want to eat so you can isolate the food for a few hours, then heat it up if needed.
• When you go grocery shopping, wear gloves and isolate your purchases (and your gloves!) in a safe spot for a few hours before unpacking.
• Get outside! But keep walking. Say hi to people, get some social interaction, but get it in passing. Keep physical distance from others. Don’t stop and form groups. Make sure and wave to all the pets being walked.

Get your flu shot

Get your flu shot (and if you’re 60+, pneumonia vaccine)

Better late than never. The flu vaccine won’t protect you at all against Coronavirus. However it DOES reduce your likelihood of contracting flu. And therefore your likelihood of needing to be hospitalized, which also reduces your chances of contracting Coronavirus while you are there. If you’re 60+ get your pneumonia vaccine as well for the same reason.

Medic visits

Cancel all non-essential face-to-face medical appointments

Hospitals are hot spots for transmission; get your vaccinations at a pharmacy rather than at the doctor. Find ways to do your physical therapy at home if possible.

Telemedicine professionals, this is your time to save the day, for everyone’s benefit but especially those in rural areas who are hard hit and without easy access to medical care. https://doxy.me and https://vsee.com/clinic/ provide free HIPAA compliant video platforms for telehealth.

JHU is developing resources here for hospital staff and administrators; more info here.

Cancel Travel

Cancel all non-essential travel anywhere

This illness can start slow and accelerate suddenly. If you are away from home when it does, you’re away from the systems that could keep you fed and cared for even if you turn out not to have a bad case. Even if you remain healthy, you could end up being quarantined. It is at best boring, at worst terrible conditions, not to mention potentially really expensive. You could risk getting infected even if you are careful. Travel history is increasingly irrelevant to risk, especially because we are flying a bit blind with the lack of testing, but the available data of confirmed infections is available here from Johns Hopkins University. Strain genetics information is available here.

Stock up

Stock up on food and essentials - Early, gradually, and responsibly

Thread:

“If the virus is everywhere, what’s the point of preparedness?”

On neither why continuing about your day as usual OR buying every can in the shop are helpful responses to #COVID19 #SARSCoV2 #Coronavirus #SARSCoV19 :\ (1/n)

— Dr Emma Hodcroft (\@firefoxx66) February 29, 2020

“Experts aren’t telling you to stock up on essentials because they think you’re going to run out of food & society is going to collapse. It’s because a few days of panic buying & high demands cause more panic & stress systems unnecessarily. Also, being in line with hundreds of people isn’t wise. Go off peak. Buy a little more than what you need. Preparedness isn’t about doing nothing, but also about not overreacting. It’s about doing your part to put the *slack in our systems* so that short disruptions are smooth as possible, can absorb extra load, & resources remain available for those most in need.

Buy food and other supplies responsibly. Some tips: Wherever possible, make delivery a top priority, especially for those at highest risk, and especially in regions at the beginning of the exponential curve.

• Go to the store at off-peak hours.
• Make a written list, organized by location in store, so you can be efficient.
• Retain a 6 feet (2 meters) distance between yourself and others at all times. More distance is better.
• Phones are hard to disinfect completely; instead, while out, put your phone in a baggie (it still works this way)
• Bring disinfectant wipes and/or wear washable cloth gardening gloves for handling doors, elevators, and other frequently touched hard surfaces that may retain the virus. Remember you are protecting yourself as well as others.
• Use non-physical means to pay, such as PayPal or Apple Pay where possible. If not, use disinfecting wipes to disinfect your credit card. Don’t use cash.
• Create a decontamination protocol and location for your home, where you can either quarantine for >72 hrs at room temperature (easiest) or disinfect all items (with wipes, bleach, hydrogen peroxide, or alcohol; or washed with soap and water in the case of vegetables) that may have come in contact with other people. Inner items can be carefully removed and placed in a clean bag or box, and brought inside by having one hand be considered contaminated while the other is clean; alternatively, two people in the same home can operate similarly, one tasked with ‘dirty’ items and the other ‘clean’ items.
• Leave your shoes outside when you return

Work from home

If you can work from home, do so as much as you can

Not everyone can work from home (WFH) 100% of the time; that is ok. Part time WFH is better than none. Don’t wait for your employer to mandate WFH for everyone. Ask your manager if it would be permissible for you personally. Encourage your colleagues.

If you can WFH, do it precisely because your barber, your kid’s teacher, your local restaurant staff, your barista, and your doctors etc. can not.

Great software now makes distance collaboration easier than ever. Some commonly used tools are listed below. The choice of collaboration tools isn’t important: use whatever works for you and your team.

• Google Drive, Cryptpad, and Nextcloud for collaborative documents
• Zoom, Skype, Jitsi, or Wire for video conferencing
• Slack or Gitter for instant messaging

Do a dry run. See what is missing so that you’re ready for when it is not optional. Some resources here for people with ADHD working from home for the first time.

Flu buddy

Get a flu buddy (aka ‘pandemic pal’) and make back-up plans for care of children, pets, and those in need of special assistance

Especially if you live by yourself. In the event of local transmission call each other daily. If anyone is sick, call them twice daily and have an agreed-upon contactless plan for delivering food, pain relief, and prescribed medications as well as for back up care of dependents.

Those who are already struggling with pre-existing demanding medical conditions may have useful experience to share about preparedness and about how to navigate the kinds of operational challenges the rest of us may be just coming to grips with. Ask them what they need from you, then provide it.

It is a good opportunity to think about longer term versions of these care contingency plans (if for some reason the patient were to pass away).

Social interactions

Pick your battles; reduce non-essential social interactions

On a lighter note, go ahead and use the pandemic excuse to beg out of any in-person meeting / party / wedding you would attend only out of some vague sense of duty. If you’re not really certain to enjoy it yourself or to bring joy to someone you really love then just. skip. it. Attend remotely if you can. Or show your face for a few mins and head back out. Send a gift instead.

If you are planning a wedding and wondering what to do, a mini-thread here with some options.

Your home

Keep your home clean and develop routines for coming back

You can find CDC Recommendations here.

Clean AND disinfect frequently touched surfaces daily. This includes tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks. If surfaces are dirty, clean them with detergent or soap and water prior to disinfection.

To make a bleach solution, mix 5 tablespoons (1/3 cup) bleach per gallon of water OR 4 teaspoons bleach per quart of water.

If you have the ability to do so, consider a ‘staging’ area for clean entry into your home. Remove shoes, outerwear. If you work in a high risk environment like a hospital, nursing home, etc, wash your clothes immediately and then dry them at high heat or at least dry in the sunshine. Wash hands right away. Isolate your mail, packages and purchases (including food) before bringing them into the house and leave them isolated a few hours at a minimum. If you are in an especially high risk group, you might want to consider leaving goods isolated a longer time (a few days) and avoid eating raw produce, and also decontaminating products that come into your house. The latest research shows that the virus can survive up to 4 hours on copper surfaces, up to 3 days on plastic and stainless steel, and up to 24 hours on cardboard.

Look beyond yourself

At all times, be kind to each other and be mindful of other people’s worries. You may be in a low risk group and feel this is nothing to fret about, but your 80-year old neighbor or your friend with recent heart surgery may feel quite differently. Every person matters; no one is “expendable.”

Hot zone

Prepare a hot zone in your home just in case someone falls ill

Prepare your home for the possibility you’ll need to isolate and care for an infected member of your household. Stock the room in advance with food that the infected person can consume with zero preparation and without face-to-face interaction with others. If you have a dedicated bathroom for the infected person, that is best. Realistically, given shortages you won’t have access to a surgical mask, but if you do have one, prioritize its use on the infected person rather than caretakers. Consider use of a cloth mask for the infected person as well as for the uninfected in the same household.

Wear a facemask when in public

Context: facemask here means any “face coverings”, including scarves and bandanas.

If you absolutely have to venture into public where other people may be, buy a cloth mask or make your own as even US hospital chains are beginning to do.

Studies in previous years as well as COVID-19 ones in the last couple of months have shown for Influenza that a face covering may have a self-protection benefit. The viron (complete virus particle) that causes COVID-19 is roughly the same size as the Influenza viron at 125 nanometers and it has the same mechanisms of entering the human body, and the older studies showed facemask protected you to some degree from being infected with Influenza.

On April 3, the US Center for Disease Control (CDC), “recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies) especially in areas of significant community-based transmission”. See the article on their site

On April 3, the World Health Organization’s top emergencies expert, Mike Ryan, during their daily news conference, said: “… The idea of using respiratory coverings or mouth coverings to prevent coughing and sneezing projecting disease into the environment and towards others … that in itself is not a bad idea …” (and more). There’s no page reflecting this change of policy yet. See the the video on youtube. Specifically, starting 59 mins and 20 seconds in.=======

Many hospital groups have asked for cloth masks to be made by people with sewing machines. Deaconess Health System on the March 20 - (PDF and Video) and Providence health services as part of their “100 million mask” initiative on March 21 - (Video).

By the third week of March, the countries of Vietnam, The Czech Republic (Czechia), and Slovakia are now operating a “wear a mask when in public” policy for their citizens and that includes homemade cloth masks. Austria is mandating that supermarket shoppers wear facemasks while shopping - see Reuters article. South Africa is encouraging facemask wearing too (since April 1).

Since April 2, the cities of New York and Los Angeles have mandated mask for people mixing in public.

Monitor symptoms

Monitor your symptoms, when to go to hospital (recommended in US)

Compiled from this WHO report
Common symtoms

Only go to hospital when you have trouble breathing or you are short of breath (sitting, going to bathroom, walking, etc).

Gastrointestinal Symptoms (rare): Diarrhea, nausea, vomiting, or abdominal discomfort are all possible early symptoms. They may appear a couple of days BEFORE the respiratory symptoms.

Timeline

• Mild cases usually clear up in 7 days (no hospitalization).
• It can take 2-14 days for the first covid19 symptom to develop. 88% of them eventually have fever. For nearly half of the hospitalized patients, fever may not develop before you need to be admitted to hospital.
• By day 5, patients of preconditions may have trouble breathing (go to hospital).

Recovery time: (for all patients that develop pneumonia)

• Mild: a few days.
• Severe: 2-1/2 weeks.
• Critical (with ARDS): 30-40% fatal. Recovery could take months.

Symptom tracking apps:

• US: covidaware.me
• UK: covid.joinzoe.com
• CA: flatten.ca
• Japan: coronatracker.com

Get enough vitamin D

Vitamin D deficiency is highly correlated with respiratory infections in general and probably COVID-19 in particular. Here is some evidence. According to this study, 41.6% of Americans are deficient. The two main ways to ensure you are getting enough of this essential vitamin are to (1) get enough sunlight and (2) take vitamin D supplements. Some research suggests darker-skinned people may need significantly more sun exposure to get adequate vitamin D. The US Institute of Medicine suggests taking 400–800 IU of vitamin D daily, but many experts think 1,000 IU or more is needed if you don’t have regular sun exposure.

Shopping when at risk

Shopping when at risk

If you can afford to have groceries delivered, or can have someone shop for you, so. Else, if you are elderly or immunocompromised go to the store first thing in the morning when things are less touched.

Some stores are extending their hours or dedicating special hour(s) for these vulnerable populations, more info here.

Spread the word

Spread the word and lobby your reps for vital research

If it is any indication, the link tracking for this very guidance document (stats can be viewed at bit.ly/corona-guidance+) shows that the word is getting out on twitter, where scientists have a larger usership; however it is lagging on facebook and on direct shares where the general public need it most. Call a friend. Call your family. You will have the most influence on people you personally know. While there are certainly reasons not to panic, most people should be more concerned than they are. Raise the floor of awareness, not the ceiling; this will be much more effective in the long run.

“One aspect of that policymakers desperately need more information on is how readily children can transmit the virus. We know children experience milder disease than adults but do they transmit to others?” There’s been some seemingly contradictory evidence on this front so far.

In the meantime, do your best to demonstrate, teach, and reinforce good hand hygiene for kids, but be realistic too. In the absence of a clear signal on the degree to which kids are vectors, keep your kids’ fingernails (and yours) as short as is (safely) possible so that virus has fewer crannies in which to hide. I’ve stopped wearing rings for that same reason; I don’t know that there’s been a formal study on this ring idea.

Only if you are in a financial and operational position to do so, consider temporarily tutoring or home schooling, or even just keeping kids home from after-school activities or for part of the school day.Don’t compromise your kids’ education, but every little bit of distancing helps. Do what you can and don’t sweat the rest. You should not feel personally responsible for everyone.

Things you should not do

Do not just wait

Do not just wait to see how this plays out. Speed is the key

See above and #FlattenTheCurve now. There is no advantage to being late to adopt policies. We are not yet in the peak and already many people are being turned away.

Do not touch your face

This is a way that the virus can enter the body. It is really hard to avoid; this is also why we advise staying home and avoiding crowds. It is also why top-down measures (event cancellation and imposed quarantine etc) work. The average person, even ones with baseline good hygiene, touch their faces constantly already without thinking about it. Especially with allergy season coming up, please keep this in mind.

Be on guard

Be on guard against false hope of “remedies”

Be good to your body. Expect companies to capitalize on your fear. Don’t buy products that claim to protect or heal you at this point. Currently available products like ibuprofen and paracetamol can be useful to lessen some symptoms; however so far, nothing has been proven to do above random noise. Don’t believe individuals who say that crystals, essential oils, etc. have helped them; the folks sharing these products may have the best intentions, or they may be predatory. But the idea is the same: many patients spontaneously do get better on their own because most cases are mild and resolve without pharmaceutical intervention. Instead of worrying about remedies, eat good food. Exercise. Meditate. Rest. Don’t neglect your mental health and don’t use your anxiety as an excuse for poor behavior towards others.

Public gatherings

Do not attend non-essential public gatherings

There is overwhelming historical evidence for cancellation as an effective public health measure. I’ve retweeted some good resources here, you can use that thread alone to help convince decisionmakers to cancel events. Here’s the money shot:

Don’t wait to cancel until things are demonstrably really bad; this leaves available only the most socially disruptive interventions (like closing schools). Measures as extreme as closing schools tend to burden vulnerable populations the most. (E.g., because the poorest kids only eat at school). If you’re in a position to help kids in these scenarios, try to give money directly; the case for this is well established. When elementary schools close, it also makes it harder for health workers, teachers, city officials, etc. to get to work and keep things on track. Kids may have nowhere to go when parents are at work. Aggressive social distancing measures are never too late, but they are most effective at flattening the curve if undertaken before 1-2% of the population is infected [ I read this somewhere but lost the citation, please DM if you can help]. It isn’t just large events to avoid, even small meetings can have consequences.

I’ve put out the call for tooling that would help event planners model go/no-go decisions more appropriately. If you are a scientist interested in collaborating on this, let me know. In meantime, here is this:

What’s your risk of inadvertently allowing the death of someone in your community from COVID-19?

• A local school district shifting to online learning will save 10 lives every week.
• A 100,000 person conference canceled saves 200 lives.
• If you and 20 coworkers work from home for 4 days, that action on average will save one life over the next two months.
• Staying home when sick with #COVID19 prevents you from transmitting to 2-3 other people and causing 100 others to get it, of whom 15-20 are likely to be hospitalized and 1 is likely to die.

by @ScottLeibrand and @DanaMLewis, see http://bit.ly/COVID19communityimpact

Do not shake hands

Do not shake hands; get creative with zero-contact greetings

Some fun alternatives are:

• hand over heart
• wakanda forever
• bow
• curtsey
• live long and prosper
• finger wag,
• princess wave
• jazz hands

…are best.

One awesome side benefit is that contactless greetings don’t even need to be agreed-upon in advance. Unlike handshakes, hugs, kisses, etc, there is no need to have an understood protocol. Do what works for you.

Do not touch public surfaces

Do not touch public surfaces with your fingers; get creative

Where possible, use knuckles rather than finger tips (e.g., for elevator buttons, light switches, etc.). Open doors with your hips rather than your hands. You may use your elbows to open door handles, if it’s an option. Use a sleeve to open a doorknob if needed.

If you are sick

Do not go to work if you are in any way sick

A good idea — even if it is not coronavirus. Health systems need every available capacity. Don’t cause unnecessary panic. Don’t assume it is just a common cold. Definitely stay home if you have a fever or cough.

Call ahead

Do not go to the doctor without calling ahead

Do NOT go directly to the hospital. More guidance from CDC here.

Call centers are understandably overwhelmed right now with the “worried well” so please try to leave those lines open for the people who really need them.

Sources: World Health Organization, Centers for Disease Control and Prevention

Do not spread misinformation

I can’t stop people from repurposing this document and mixing in guidance that is not backed by science. However, if you do so, do not attribute me. There are no treatments yet.

Do not be careless

Don’t be that person. It might not be about you but it is everyone’s problem. Don’t be careless in the hopes you get sick when you can “avoid the rush.” There is zero benefit to individuals or the population to getting sick early in the pandemic. You would be putting the lives of others at risk. It is not just that people are dying, but how they are dying. To say nothing of the physical trauma, emotionally speaking this is the opposite of a “good death”. People are dying alone, quarantined from those they love.

Early reports are that people who recover develop antibodies that provide immunity if they are infected with the same strain again. However, this is great news for vaccine development, so flatten the curve and wait it out.

This can get very serious; one person described the pain as feeling like her lungs were being put through a pasta maker. 10% of cases require ICU care and mechanical ventilation. Even if autopsy reports from China have been misrepresented or overstated, there is a possibility of long term or permanent lung damage if you do get sick and recover. There are lot of gaps in the information about lung damage, mostly because everyone qualified to let the public know exactly what is going on is already very busy saving lives and putting their own at risk.

Do not be racist

Racist assumptions lead to racist behaviors. Racist behaviors divide us, and in this pandemic situation, definitely work against us. If we divide ourselves according to race, ethnicity, or nationality, the virus wins and we all lose, plain and simple. If we unite ourselves regardless of race, ethnicity, or nationality, the virus loses and we all win.

Be present, do not binge the news

Once you’ve done everything you can, step back. Way back. Watch something funny. Read a good book. Learn an instrument. Garden. Hug your kid. Call your mom. Hug your mom. Call your kid. Be present. Take this moment to be grateful that you are alive on this amazing planet. We are in this together; look after each other.

Do not hoard supplies

Items can easily become in short supply due to hoarding. Common products experiencing shortages include toilet paper, bottled water, and medical supplies.

Avoid purchasing large quantities of products, particularly those in short supply. Get what you need for 2-4 weeks. Leave the rest for others who need it. If you have a large quantity of surgical/N95 masks or other supplies consider donating it to groups in need such as healthcare providers or a local food pantry.

Do not mix cleaning products

Do not mix the following cleaning products

These cleaning products become dangerous when mixed:

Products	Negative outcome
Bleach + Vinegar	Produce chlorine gas
Bleach + Ammonia	VERY toxic gas
Bleach + Alcohol	chloroform
Hydrogen Peroxide + Vinegar	corrosive acid

Sources: American Chemistry Society and Good Housekeeping

Myths

It’s just the flu.

It’s just the flu.

It isn’t! The severity is more similar to pneumonia. Many patients require respiratory support. It is also more contagious than the common flu. (source)

I’m young and healthy…

I’m young and healthy so I don’t need to care.

Young and healthy people are generally less likely to die if infected, but this is not the point! Treatable conditions easily become deadly if the health system collapses. We are not equipped to handle hundreds or thousands of respiratory patients at the same time. In places where the outbreak is full-blown, the medical facilities are completely overwhelmed. Patients are in hallways and gymnasiums. Doctors are being forced to ration limited resources like ventilators, oxygen, and even basic supplies like surgical masks and gloves. You might be lucky, but it will likely be at the expense of others in your community.

There are no infections near me.

There are no infections near me.

There are almost definitely infections near you! But you cannot see them yet because there is a two week delay between the time of infection and when someone shows symptoms. During that time, the infected person is contagious and spreading the infection. For every single diagnosed case of COVID-19, there are likely hundreds of undiagnosed cases. For this reason, our only chance to avoid a massive public health disaster is if we take preventative measures before we see it everywhere. (source)

I cannot afford to stay home.

I cannot afford to stay home or close my small business.

This is a public health and economic crisis. Everyone is impacted. All the evidence indicates that the pandemic will force most businesses to close soon whether we want to or not. Ideally, public officials will take decisive steps to mandate social distancing as it is currently one of the only tools available to flatten the curve of infections and save lives. We can’t opt out of this pandemic, but we can opt out of unnecessary risk of infection. If a tsunami was coming towards your town, would you complain about the economic cost of evacuating? This outbreak is an invisible tsunami, but unlike the countries where it hit first, we have advanced warning. The US wasted much of that head start with inaction, but one of the lessons becoming increasingly clear is that every single day counts.

The media is overblowing this.

The media is overblowing this. People are just panicking.

There has been a lot of misinformation and the media is predisposed to fearmongering. But this does not change the fact that the situation is very serious. Panicking is dangerous and unproductive, but so is ignorance and inaction.

Other people aren’t staying home.

There’s no point in me staying home because some people aren’t.

The goal of social distancing is to slow the rate of infections and more is better, but it is not “all or nothing.” In the context of an exponential growth pattern, even small reductions have large effects. If the well-being of your greater community doesn’t motivate you, remember that you are risking infecting yourself and your family.