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Palm Coast Tuesday, Mar. 24, 2020 1 week ago

COVID-19: A Q+A with DOH-Flagler Medical Director Dr. Stephen Bickel

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'It has two factors going for it that viruses hardly ever have together. One: It’s highly contagious … but coupled with that is it’s capable of causing very serious illness.'
by: Jonathan Simmons News Editor

How does COVID-19 infect people? Are we likely to see a new version of it next year? What should you do if you think you have it? Dr. Stephen Bickel, the medical director of the Florida Department of Health in Flagler County, answered common questions.

A lot of people have been comparing this to the flu. Can you talk about how this is different?

BICKEL: This whole thing is such an unknown right now, because we’re just really at the beginning of it. What I’ve found is ... this is like a Rorschach test, and people react to this anyway they want, because it’s such an unknown. But, one, the [flu comparison] is flatly wrong — and the reason for that is that by the most conservative estimates that I’ve seen, the fatality rate, and even maybe more importantly the serious hospitalization rate, is probably a minimum of 10 times the flu. We’re already seeing, like New York City and Italy, there are places where the hospitals are overwhelmed. That can happen with a really bad flu to a tiny degree, but nothing like this. 

So what makes this different?

BICKEL: The reason this is so different is it has two factors going for it that viruses hardly ever have together. One: It’s highly contagious … but coupled with that is it’s capable of causing very serious illness in many people. The other kinds of viral threats to our world in the last 30 years, usually they’re one or the other. They're very contagious but mild, or they’re really serious but not very contagious. ... There was a very well-respected study that came out of Imperial College; their projection was, absent any control measures, this could infect 81% of the population and cause 2.1 million deaths.

One thing that I find baffling is how one person can apparently get it and not have any symptoms or just think it's a cold, and the next person can get it and die, and they can both be young, healthy. Is that unusual for a virus?

BICKEL: It is unusual, and it’s also not happening that often with COVID, either. Far and away the most serious illnesses are in older people. You look at the age groups for hospitalization … it shoots up quite a bit after 70, and also after 80, and also with chronic illness. [Young, healthy people having serious cases], that’s the exception rather than the rule. It is hitting the elderly hard. The flu does that, but not to this degree.

Do you know why that is?

BICKEL: Nobody knows for sure why it hits the elderly like it does. Part of it is that there’s no inherent immunity to this virus. ... Each virus has certain characteristics in terms of what tissues it goes to, what damage it does, how virulent it it.

It's also not affecting kids as much, right? 

BICKEL: Influenza can hit really young children really hard; this one doesn’t seem to. But that’s kind of typical. If a child gets infectious hepatitis, like Hep A, a lot of the time it’s like a cold for them; their immune system is so revved up. Same thing with mono. 

How does this virus actually work? How does it get into people, and what does it do once it's there? 

BICKEL: The way it’s transmitted, for the most part, is what's called droplet transmission. The infected person coughs, and little droplets with virus particles in them land on certain places, and people inadvertently will be touching those surfaces. People put their hands on their face about 90 times a day, without knowing it. ... And then they inhale it from there, or swallow it and then it gets into their respiratory tract. It isn't like people cough or breathe and it goes into air particles and that’s how we get it; when that happens, its called aerosolized. 

How does it cause damage?

BICKEL: It really focuses in, when it causes serious illness, on the lower respiratory tract and also the lung tissue adjacent to these airways, and it causes pneumonia. If the invasion is serious enough, the cells get damaged. The tissue fills up with fluid and you can’t exchange oxygen. You can ultimately die, because eventually that causes too much damage to the rest of the body.

How is that different from what the H1N1 virus does, or SARS or MERS? 

BICKEL: They're all similar, even just a regular flu … they all have predilections for different tissue. All the corona viruses are RNA viruses.

Is this something we might see again next year, maybe in a slightly different form, the way the flu comes back yearly?

BICKEL: Yes. It may mutate a little, so it's a little less virulent. People may develop some immunity. Some people think … it might just settle into the background of viruses that work their way through every winter. There’s a lot of speculation that if we’re successful in our containment now, that there’s going be another two, three waves of it in the next 12 months. The only thing that really stops these things is herd immunity, either through a vaccine or already having had the infection.

Is it known that people really develop immunity after getting it?

BICKEL: We really don’t know yet — it’s too early — but it's usually happened. The question is, is it complete [immunity] or partial.

When this is transmitted, to what extent is this something that's being mostly passed among family members or people living and working together, versus, say, someone picking it up from a stranger in the supermarket?

BICKEL: It does seem to require some degree of close contact; it’s not just a random encounter. There’s no absolute dividing line; there’s really a spectrum. If you're living with someone who has it, it’s going to be hard not to get it. But you don’t generally get it walking by someone in the supermarket. You could get it from a shopping cart or something … but it’s generally closer contact.

What about transmission over water? If someone who has it is in a body of water, say they're swimming or they're fishing and getting their hands in the water, and then I enter that water, can the water bring that virus to me?

BICKEL: It would be very unlikely. And with the beach closures, I think what’s motivating people more … is that it’s hard for people not to fall back on their social instincts to touch people or be close to people; it's kind of hard to switch into this mode where you’re keeping your distance from everybody. It's typical for sunlight to inactivate viruses to some degree; I think outside spread is much less likely, but it’s just that we’re social animals and people tend to get close to each other when they’re doing outside group activities. It’s hard not to.

How much should we worry about getting this from things we bring into our homes? Like if we order pizza, and the pizza delivery guy has it when he hands you your box of pizza?

BICKEL: It's pretty small. It’s not zero, but it’s not a large risk. But if you want to make it even less, the way to do it is every time people come in front outside ... thoroughly wash your hands, and if you touch the same box again ... wash again.

Do you have a sense of where things are going here in Flagler with COVID?

BICKEL: It's hard to say. I’m preparing for the worst, hoping for the best. We kind of got started late. Part of it was the testing, part of it was it’s just hard to motivate people to do something where the threat seems so abstract, theoretical. ... I don’t know, if our government would have pushed harder two, three weeks ago, if the public would have stood for it. But now, I’ve been pretty pleased with state, local agencies. They’ve really ramped it up. There’s been a lot of really impressive activity in the last couple weeks, and also, we’re getting into a pretty strict containment strategy ... which is kind of the level you need to really stop this. I think we're close. The thing I worry about, though, is the last month, what's already happened: We had Bike Week, we had Spring Break — there could be just thousands of cases incubating in Florida right now. And these containment measures seem to work with a 20-30 day lag, so we could have a real spike. We might have a rough month. Potentially enough to overwhelm some of our hospitals. That rough.

Do you have confidence that we'll be able to get outside aid if we need it, and equipment, ventilators?

BICKEL: That one’s hard to say. They're really trying; they’ve put in even for mobile intensive care units. They’ve been ordering ventilators all over the place — it’s hard to say.

What else should people know?

I just urge people to take this seriously. There are many, many people who are going to die from this. And some of the younger people think, 'Oh, it's no big deal.' And that’s generally true — for them. But if they have a grandparent around, and help to spread this, it’s not good for anybody. We’re really in a kind of a war.

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