Updated Pandemic Re-Emergence Guide

The following section is mainly from the Centers for Disease Control and Prevention (CDC) website on coronavirus: https://www.cdc.gov/coronavirus/2019-ncov/faq.html#basics and from the World Health Organization (WHO) website on coronaviruses: https://www.who.int/news-room/q-a-detail/q-a-coronaviruses

So what are coronaviruses?
Coronaviruses are a large family of viruses which may cause illness in animals or humans.  In humans, several coronaviruses are known to cause respiratory infections ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS).

What is a novel coronavirus?
A novel coronavirus is a new coronavirus that has not been previously identified.

What is the coronavirus that has been in the news and social media?
The most recently discovered coronavirus (a novel coronavirus) that causes coronavirus disease is called COVID-19. This new virus and disease were unknown before the outbreak began in Wuhan, China, in December 2019. A diagnosis with coronavirus 229E, NL63, OC43, or HKU1 is not the same as a COVID-19 diagnosis.

Why is the disease being called COVID-19?
On February 11, 2020 the World Health Organization announced an official name for the disease that is causing the 2019 novel coronavirus outbreak, first identified in Wuhan China. The new name of this disease is coronavirus disease 2019, abbreviated as COVID-19. In COVID-19, ‘CO’ stands for ‘corona,’ ‘VI’ for ‘virus,’ and ‘D’ for disease. Formerly, this disease was referred to as “2019 novel coronavirus” or “2019-nCoV”.

Is COVID-19 the same as SARS?
No. The virus that causes COVID-19 and the one that caused the outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003 are related to each other genetically, but the diseases they cause are quite different. SARS was more deadly but much less infectious than COVID-19. There have been no outbreaks of SARS anywhere in the world since 2003.

Is the Coronavirus (COVID-19) Deadly?
Despite the mass panic, the media frenzies, and advertisers preying on your fears, the Coronavirus (COVID-19) is NOT more deadly than the seasonal flu. Illness due to COVID-19 infection is generally mild, especially for children and young adults. However, it can cause serious illness: about 1 in every 5 people who catch it need hospital care. While we encourage you to get serious about boosting your immune health, the level of fear and stress that many people are experiencing is not helpful and can actually compromise your immune system or lead to less than optimal coping choices, like consuming sugary snacks or drinking alcohol at unhealthy levels.

What are the symptoms of COVID-19?
The most common symptoms of COVID-19 are fever, tiredness, and dry cough. Some patients may have aches and pains, nasal congestion, runny nose, sore throat or diarrhea. These symptoms are usually mild and begin gradually. Some people become infected but don’t develop any symptoms and don’t feel unwell. Most people (about 80%) recover from the disease without needing special treatment. Around 1 out of every 6 people who gets COVID-19 becomes seriously ill and develops difficulty breathing. Older people, and those with underlying medical problems like high blood pressure, heart problems or diabetes, are more likely to develop serious illness. People with fever, cough and difficulty breathing should seek medical attention.

How does COVID-19 spread?
People can catch COVID-19 from others who have the virus. The disease can spread from person to person through small droplets from the nose or mouth which are spread when a person with COVID-19 coughs or exhales. These droplets land on objects and surfaces around the person. Other people then catch COVID-19 by touching these objects or surfaces, then touching their eyes, nose or mouth. People can also catch COVID-19 if they breathe in droplets from a person with COVID-19 who coughs out or exhales droplets. This is why it is important to stay more than 1 meter (3 feet) away from a person who is sick

Why is COVID-19 spreading so fast?
There are a number of factors that are contributing to the spread of COVID-19. For one, it is optimized to spread widely because it causes mild disease in many, has a incubation period that can extend beyond 14 days, and so on. Another reason, as outlined in this people from the Annals of Internal Medicine, is that we do not take upper respiratory infection control seriously enough: https://annals.org/aim/fullarticle/2763036/coronavirus-disease-2019-covid-19-protecting-hospitals-from-invisible

How likely am I to catch COVID-19?
For most people in most locations the risk of catching COVID-19 is still low. However, there are now places around the world (cities or areas) where the disease is spreading. For people living in, or visiting, these areas the risk of catching COVID-19 is higher. Governments and health authorities are taking vigorous action every time a new case of COVID-19 is identified. Be sure to comply with any local restrictions on travel, movement or large gatherings. Cooperating with disease control efforts will reduce your risk of catching or spreading COVID-19.

Who is at risk of developing severe illness?
While we are still learning about how COVID-2019 affects people, older persons and persons with pre-existing medical conditions (such as high blood pressure, heart disease, lung disease, cancer or diabetes) appear to develop serious illness more often than others.

Smoking and e-cigarette vaping has been associated with increased risk of adverse effects. Here is a summary of that information form the Center for Tobacco Control Research and Education at the University of California, San Francisco: When someone’s lungs are exposed to flu or other infections the adverse effects of smoking or vaping are much more serious than among people who do not smoke or vape.

Smoking is associated with increased development of acute respiratory distress syndrome (ARDS) in people with a risk factor like severe infection, non-pulmonary sepsis (blood infection), or blunt trauma. (9)

I’m confused. Is this an epidemic, an outbreak, or a pandemic?

• Epidemic: typically defined by Merriam-Webster as an outbreak of a disease that occurs over a wide geographic area and affects an exceptionally high proportion of the population.
• Outbreak: same as an epidemic but is often used for a more limited geographic area.
• Cluster: refers to a disease that occurs in larger numbers even though the actual number or cause may be uncertain.
• Pandemic: relates to geographic spread and is used to describe a disease that affects a whole country or the entire world.

1. Does COVID-19 only affect old people?
A recent CDC analysis (6) of more than 2,400 cases of COVID-19 that have occurred in the United States in March 2020 shows that between 1 in 7 and 1 in 5 people between the ages of 20 and 44 in the sample of those who are confirmed cases require hospitalization. This is a level significantly higher than the hospitalization rates for the flu. It appears to be true that poor outcomes are much worse for older people, especially people over 65.

2. What are the currently known risk factors for contracting COVID-19?

• Older age
• Having another chronic disease such as hypertension, diabetes, and coronary heart disease
• Having an elevated blood marker called D-dimer

3. How long can COVID-19 remain infective outside of the body?
According to a report on Medscape (7) COVID-19 can remain viable in the air (aerosol) for hours and on surfaces for days. This is a primary reason for social distancing, universal precautions, and hand washing. Current information of the viability of COVID-19 on surfaces:

• Plastic: 2-3 days
• Stainless steel: 2-3 days
• Copper: 4 hours
• Cardboard: 24 hours

Be aware that research information on surfaces is typically done in a lab under controlled conditions. How viable COVID-19 is in the wild is still unknown. One report suggests it can be as much as 9 days (14)

4. What is social distancing?
According to the John Hopkins Medicine website: “Social distancing is deliberately increasing the physical space between people to avoid spreading illness. Staying at least six feet away from other people lessens your chances of catching COVID-19”

5. What is self-quarantine?
According to the John Hopkins Medicine website: “People who have been exposed to the new coronavirus and who are at risk for coming down with COVID-19 might practice self-quarantine. Health experts recommend that self-quarantine lasts 14 days. Two weeks provides enough time for them to know whether or not they will become ill and be contagious to other people.”

6. I’ve heard that coronavirus/COVID-19 is basically the common cold. Is this true?
No, it isn’t. See information in the Basics section

7. Isn’t coronavirus/COVID-19 just like influenza?
According to Dr. Tom Frieden, former director of the US Centers for Disease Control and Prevention, here are some of the differences between COVID-19 and influenza (flu):

• Covid-19 is more infectious than flu.
• Covid-19 is more likely to kill than flu.
• Many deaths from flu are caused by secondary bacterial pneumonia and heart attacks. . Covid-19 is different. Most deaths are caused by acute respiratory distress syndrome (ARDS), which causes already-damaged lungs to fill with fluid, causing respiratory distress. there is no pharmaceutical treatment for ARDS, which is why ventilators are critical.
• There is no vaccine for COVID-19.
• There is no treatment for COVID-19
• There is no natural immunity to COVID-19, unlike the flu

8. Why is everything being shut down? Aren’t we overreacting?
There are several reasons why government officials are justifying mandatory shut downs. One is to protect vulnerable populations, which is discussed elsewhere. Another is to prevent our medical system from becoming overwhelmed with very sick people. This is what happened in Italy, for example. This is what “flattening the curve refers to. The graphic below illustrates this.

Without protective measures like social distancing and self-quarantine, the COVID-19 pandemic could get much worse. See the NY Times article on this for more information: https://www.nytimes.com/interactive/2020/03/13/opinion/coronavirus-trump-response.html

Other sources:

• https://medium.com/@tomaspueyo/coronavirus-act-today-or-people-will-die-f4d3d9cd99ca
• https://www.washingtonpost.com/graphics/2020/world/corona-simulator/?utm_campaign=wp_main&utm_medium=social&utm_source=facebook

Stay aware of the latest information on the COVID-19 outbreak, available on the WHO and CDC websites, as well as through your national and local public health authority.

1. You can reduce your chances of being infected or spreading COVID-19 by taking some simple precautions:

• Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing. An alcohol-based hand rub can also help. Why? Washing your hands with soap and water or using alcohol-based hand rub kills viruses that may be on your hands.
• Maintain at least 13 feet distance between yourself and anyone who is coughing or sneezing. Why? When someone coughs or sneezes they spray small liquid droplets from their nose or mouth which may contain viruses. If you are too close, you can breathe in the droplets, including the COVID-19 virus if the person coughing has the disease.
• Avoid touching eyes, nose, and mouth.
• Make sure you, and the people around you, follow good respiratory hygiene. This means covering your mouth and nose with your bent elbow or tissue when you cough or sneeze. Then dispose of the used tissue immediately.
• Stay home if you feel unwell. If you have a fever, cough and difficulty breathing, seek medical attention and call in advance. Follow the directions of your local health authority.
• Keep up to date on the latest COVID-19 hotspots (cities or local areas where COVID-19 is spreading widely). If possible, avoid traveling to places – especially if you are an older person or have diabetes, heart or lung disease.

2. Should I wear a mask to protect myself?
According to the CDC:

• Everyone should wear a cloth face cover when they have to go out in public, for example to the grocery store or to pick up other necessities.
• Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance
• The cloth face cover is meant to protect other people in case you are infected.
• Do NOT use a facemask meant for a healthcare worker.
• Continue to keep about 6 feet between yourself and others. The cloth face cover is not a substitute for social distancing. 20

3. Should I wear gloves to protect myself?

For the general public, the CDC recommends wearing gloves when you are cleaning or caring for someone who is sick. In most other situations, like running errands, wearing gloves is not necessary. Instead, practice everyday preventive actions like keeping social distance (at least 6 feet) from others, washing your hands with soap and water for 20 seconds (or using a hand sanitizer with at least 60% alcohol), and wearing a cloth face covering when you have to go out in public. 19

3. Do I need to use hand sanitizer or hand wipes to kill viruses?

• Actually, if you have access to soap and water, soap is very effective at killing viruses. It dissolves the lipid membrane that holds the parts of the virus together. (10)
• If you are going to use hand sanitizer, research indicates that products with over 60% alcohol are most effective.
• Washing hands for a minimum of 20 seconds frequently is the current guideline. Also, try not to touch surfaces (wear gloves, etc.) and try not to touch your face or mucus membranes.

4. What can I do to inactivate viruses on surfaces?
According to one report (14), the following are helpful, if allowed to sit on the surface for at least one minute:

• Alcohol 62–71%
• 5% hydrogen peroxide
• 1% sodium hypochlorite

5. There is so much information out there on prevention! Can you help us condense it all to something more manageable? 

• Decide on a game plan for leaving your house and safely returning. Designate one person to be the “family assistant” to limit your outside exposures. If home occupants are infirmed or elderly, reach out to family, church, or community members. There are many avenues of assistance to help you.
• Imagine that your home is a space ship and that the only way in is through an “airlock.” Set up a disinfecting station either in the garage,  outside your home, or in an entry space like a mudroom where you can disinfect yourself and things you are bringing in. When you get back, wash your hands with soap and water for 20 seconds. Disinfect takeout boxes and packaged foods at your disinfecting station. Thoroughly wash produce before putting it in your kitchen.
• Be aware that many grocery stores offer either delivery or a service to have someone shop for you.
• When you are out, avoid coming within 6 feet of others. Wear disposable gloves if you have them. The use of masks, which previously were de-emphasized except for older people, are now being encouraged.  Wipe handles on carts or baskets prior to shopping. If you don’t have masks or gloves,  just wash your hands frequently while you’re out and avoid touching your face.
• Disinfecting: disinfect everything you touch — doorknobs, light switches, keys, phone, keyboards, remotes, etc. Use EPA approved disinfectants (no, not vodka) and leave surfaces wet for a minimum of two minutes.
• Helpful supplies to have on hand: EPA-approved disinfectants, laundry detergent, pet food, trash bags, prescription medications (these can be mail ordered or delivered in some cases), canned foods, dry goods (breads, pastas, nut butters, etc)
• If someone gets sick: first, consult your doctor. Isolate them in their own room and ask them to use a separate bathroom if possible. Disinfect frequently touched surfaces every day. Avoid sharing items with them. Wear gloves when dealing with them or doing their laundry. Ask them to wear a face mask if they have one.
• Delivery: have them leave on your doorstep. Disinfect packages with EPA disinfectant. After you pick up mail from your mailbox, wash your hands.

1. Has WA State set up a number I can call to be assessed for COVID-19 testing?
Not at the time of this writing. The Washington State Department of Health has established a call center, but it is only to address questions from the public. If you have questions about what is happening in Washington, or how the virus is spreading, please call 1-800-525-0127.

2. What test is being used to identify COVID-19?
In the United States, the most common and widely available test is the  RT-polymerase chain reaction (rRT-PCR), which over the past few weeks has become available at some public health labs across the country

3. How accurate is the test?
PCR is the “gold standard,” for testing COVID-19. However, data on test sensitivity is limited.

4. Why is it taking so long to get testing?
According to one report on Medscape(4), there are a few reasons.

• “Hubris. The CDC was unwilling to use readily available World Health Organization (WHO) test kits.”
• “Laboratory error.”
• “Government red tape.”

5. Who should get tested?
The current focus should be individuals who are symptomatic with evidence of respiratory tract infection. People who are concerned about the virus but have no symptoms are encouraged to forgo testing and self-isolate.

6. What do we know about the current results on testing for COVID-19 in the US? 
There are several sites that offer insights into the results of testing nationwide and by state. One of them is called the COVID Tracking Project: https://covidtracking.com/
Please be aware that reporting and modeling of the data is by no means perfect and there will be unavoidable errors due to time delay, false negative/positives, technological difficulties and so on.

Helpful Resources

Wenatchee World Live COVID Case Count
WA State Safe Start Plan
WA State “Safe Start” Phases page 
WA State Phases Chart (no dates)
WA State Phases Map by county
WA State Public School and Instruction information 
WA State COVID-19 Business Resources 
Wenatchee Chamber of Commerce COVID-19 Resource Page 

Re-Emergence Strategies: General

• Given the past history of developing vaccines and our current technology, a proposed timeline for a safe, viable, mass-produced coronavirus vaccination would break out like this:
  Very optimistic: late 2021 – 2022
  Optimistic: 2023
  More realistic: 2024 – 2025
• How we navigate through the remaining phases of the pandemic depend in large part on our community. If communities do not have the capacity or political will to do the public work that enables relaxed methods and voluntary containment measures, then more extreme measures such as lockdown and extensive social distancing may be required. Invidivial families should prepare for cycles of loosened restrictions followed by tightening restrictions (for example, in fall or winter) in their area as they add “worse-case” scenarios to their planning.

Re-Emergence Strategies: Mental Health

• As re-emergence unfolds, continue to have a set of indoor/solitary entertainment activities to fall back on. This will also be helpful if an outbreak occurs in your area.
• Diversify your exercise routine to include both indoor and outdoor options. Recognize that going to the gym may not be available for a time and that gyms may be forced to close in the event of an outbreak in your area
• Consider practices like gardening, journalling (particularly a gratitude journal), or mindfulness to keep your mood optimized
• Limit your exposure to social media, which has been shown to have a negative impact of mood in large doses, and news programs that evoke anxiety in you
• If things are particularly difficult, consider working with a mental health expert like Dr. Piscopo. Sometimes even a short course of assistance can make a big difference in helping you to cope with your situation. In-office and telemedicine visits are available for you.

What can I do to stay healthy and prevent me or my family from contracting a novel viral illness?

This is where integrative medicine is an excellent resource. Our approach is to boost the body’s own innate healing ability through evidence-based interventions, lifestyle practices, and supplementation.  This creates a less hospitable environment for viruses like COVID-19. Again, please be aware that we are not offering medical advice. All information from the Internet needs to be discussed with your medical provider. These are simply suggestions that may or may not be appropriate for your specific situation.

Please call us if you would like to set up an appointment to discuss these issues further.

Suggestion 1: do those things that help your immune system to work its best

1. Optimal sleep
   • Sleep is a critical part of keeping your immune system healthy. It is one of the 4 pillars of health (including psycho-emotional hygiene, diet, and movement). One study found that less than 5 hours of sleep (monitored over 7 consecutive days) increased the risk of developing rhinovirus associated cold by 350% when compared to individuals who slept at least 7 hours per night. (17)
   • Napping during stressful times can enhance memory, energy, and focus.

2. Optimal diet
   • Switch to an “anti-inflammatory diet” to decrease the inflammatory load on your body. Many of our patients are familiar with these guidelines, which includes increasing items such as fish/fish oil, fruits, legumes, and vegetables and excludes sugar, processed foods, fast foods, etc.
   • A Mediterranean diet or a “Blue Zone” diet has been shown to have some immune protective effects
   • Broccoli and other “cruciferous” vegetables (including Brussel sprouts, cabbage, cauliflower, broccoli, and kale) are naturally high amount of a compound called indole-3-carbinol (I3C). Clinical studies show that this compound has the potential to interfere with the way many viruses reproduce.
   • Onions and garlic are naturally anti-microbial
   • Go easy on the alcohol. In addition to decreasing your capacity to make good decisions and disrupts important immune pathways, it has also been associated with acute respiratory stress syndromes (ARDS), a hallmark of COVID-19. (15)
   • Stay well hydrated

3. Optimal Movement
   • Movement/Exercise has a host of positive benefits, including stress reduction, optimizing sleep, and assisting with immune function
   • There are several apps that will assist you with at-home workout routines and/or programs

4. Do psycho-emotional hygiene measures
   • Breathwork: deep abdominal breathing can help stimulate the vagal nerve and induce a rejuvenating relaxation response
   • Prayer/Meditation: starting or continuing with a practice of prayer and/or meditation can help put things in perspective, calm anxiety, and help manage stress
   • Music is a time-honored way to soothe emotions and brighten one’s perspective
   • Moderate the amount of news and social media you consume because too much of this can make you feel overwhelmed, anxious, or depressed. You may want to consider taking a “news fast.” On the other hand, if you need current medical information on COVID-19, use authoritative sources such as the CDC, WHO, or local health department websites.
   • Do keep touch with people by phone or by using appropriate technology

Suggestion 2: Stress Management

Psychological stress disrupts immune regulation and is specifically associated with increased pro-inflammatory cytokines. Various mindfulness techniques such as meditation, breathing exercises, guided imagery, etc. reduce stress, reduce inflammatory products, and do not appear to increase inflammatory cytokines. (18)

Suggestion 3: use supplements that have been prescribed by your physician
A good example of this is supplements found on our Cold and Flu handout. These include:

• Vitamins/Minerals
  • Vitamin C (ascorbic acid) is helpful to the immune system. Like flavonoids, ascorbic acid inhibits NLRP3 inflammasome activation.  Clinical trials have found that vitamin C shortens the frequency, duration and severity of the common cold and the incidence of pneumonia. The typical daily dosing of vitamin C ranges from 500 mg to 3000 mg daily with even higher doses utilized during times of acute infection. (18)
  • Zinc is essential for immune function. Coronavirus appears to be susceptible to the viral inhibitory actions of zinc. Zinc may prevent coronavirus entry into cells, and appears to reduce coronavirus virulence.  The typical daily dosing of zinc is 15 mg–30 mg daily. Lozenges can potentially direct protective effects in the upper respiratory tract.  Epigallocatechine gallate (EGCG) from green tea has been found to have antiviral activity against a wide range of DNA and RNA viruses, especially in the early stages of infection by preventing viral attachment, entry and membrane fusion. EGCG, is a zinc ionophore, thereby potentially enhancing the antiviral actions of zinc. Quercetin, found in onions and apples, functions as a zinc ionophore, chelating zinc and transporting it into the cell cytoplasm. This could, theoretically, enhance the anti-viral actions of zinc.  (18)
  • Selenium has been shown to be helpful in supporting immune function
  • Vitamin A is useful when a deep cough is present
  • Multivitamin if you have a nutritional deficiency or underlying health issue that requires it. Please be aware that a multivitamin is not a panacea and is often unnecessary if you have an excellent, plant-based diet.
• Herbs
  • Echinacea is a known immune-stimulating agent that is useful, especially at the start of a cold or flu
  • Elderberry is another excellent immune-stimulating agent. There is preclinical evidence that elderberry inhibits replication and viral attachment of Human coronavirus NL63 (HCoV-NL63), which although different than COVID-19, is still a member of the same coronavirus family.
  • Sambucus appears most effective in the prevention or early stage of viral infections. An evidence-based systematic review of elderberry conducted by the Natural Standard Research Collaboration concluded that there is level B evidence to support the use of elderberry for influenza, which may or may not be relevant to novel viral illness prevention.  (18)
• Other Supplements
  • Probiotics: one report on Medscape links probiotic use with being a useful prophylaxis against cold and influenza-like symptoms in children (16)
  • Melatonin: melatonin has been shown to inhibit NFkB activation and NLRP3 inflammasome activation. In fact, the age-related decline in melatonin production is one proposed mechanism to explain why children do not appear to have severe symptoms as frequently as do older adults. Melatonin also reduces oxidative lung injury and inflammatory cell recruitment during viral infections. Typical dosing of melatonin varies widely, but 3mg is a typical dose sold in many retail outlets. (18)

Suggestion 4: be careful with the use of Ibuprofen until more information is available

• Consider using Acetaminophen (Tylenol), where appropriate, as a 1^st line agent

Suggestion 5: if you smoke or vape e-cigarettes, now would be a good time to quit

• Several reports have shown that smokers have far worse outcomes than the general public when it comes to COVID-19
• There is currently no consensus about the impact of vaping cannabis in terms of COVID-19

Suggestion 6: consider canceling or rescheduling travel plans, especially those that involve public transportation like airplanes or international travel

• As travel becomes allowed, places like cruise ships, airplanes, and airports are among the worse places to be from an immune perspective
• Another consideration is that you may be stuck at your destination, and subject to severe restrictions, if an outbreak occurs in either the local area or at your home location
• Something else to consider is that the medical systems in other countries can be majorly different from the US and travelers are not the first priority when it comes to treatment during an outbreak

1. CDC COVID-19
   https://www.cdc.gov/coronavirus/2019-ncov/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2Findex.html

2. World Health Organization (WHO)
   https://www.who.int/emergencies/diseases/novel-coronavirus-2019

3. Medscape: CDC Expert Answers Top COVID-19 Questions
   https://www.medscape.com/viewarticle/927015?nlid=134545_3901&src=wnl_newsalrt_200317_MSCPEDIT&uac=95708FZ&impID=2314666&faf=1

4. Medscape: Where Are the Tests? COVID-19 Sidelines Clinicians
   https://www.medscape.com/viewarticle/926973

5. Medscape: Risk Factors for Death From COVID-19 Identified in Wuhan Patients
   https://www.medscape.com/viewarticle/926504

6. CDC: Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020
   https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm?s_cid=mm6912e2_w

7. Medscape: Coronavirus Stays in Aerosols for Hours, on Surfaces for Days
   https://www.medscape.com/viewarticle/926929?nlid=134545_3901&src=wnl_newsalrt_200317_MSCPEDIT&uac=95708FZ&impID=2314666&faf=1

8. CNN: Former CDC director: Covid-19 is different from flu and we must respond differently
   https://www.cnn.com/2020/03/14/health/coronavirus-covid-19-flu-comparison-frieden-analysis/index.html

9. UCSF Center for Tobacco Control and Research and Education
   Reduce your risk of serious lung disease caused by corona virus by quitting smoking and vaping
   https://tobacco.ucsf.edu/reduce-your-risk-serious-lung-disease-caused-corona-virus-quitting-smoking-and-vaping

10. Virology Down Under: Why does soap work so well on SARS-CoV-2?
    https://virologydownunder.com/why-does-soap-work-so-well-on-sars-cov-2/

11. Scientific American: Flattening the COVID-19 Curves
    https://blogs.scientificamerican.com/observations/flattening-the-covid-19-curves/

12. NY Times: How Much Worse the Coronavirus Could Get, in Charts
    https://www.nytimes.com/interactive/2020/03/13/opinion/coronavirus-trump-response.html

13. John Hopkins: Coronavirus, Social Distancing and Self Quarantine
    https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-social-distancing-and-self-quarantine

14. Journal of Hospital Infection
    Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents
    https://www.sciencedirect.com/science/article/pii/S0195670120300463

15. Alcohol Research Current Review: Alcohol and the Immune System
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590612/

16. Medscape: Probiotics May Be Useful Against Colds, Flu-Like Symptoms in Children
    https://www.medscape.com/viewarticle/707329
17. Prather AA, et al. Behaviorally Assessed Sleep and Susceptibility to the Common Cold. Sleep. 2015;38(9):1353-9.
18. Integrative considerations during the COVID-19 pandemic: https://www.sciencedirect.com/science/article/pii/S1550830720301130?via%3Dihub
19. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/gloves.html
20. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html