By Michael S. Saag/Infectious disease expert at UAB

ED. NOTE: This is one in a series of answers to questions by Saag as the threat of the coronavirus to Alabama remains unknown regarding its size and ferocity. Saag believes the power to limit the harm is in all of our (washed) hands.

Here’s Saag:

I am heartened by the positive comments I received regarding the Op-Ed posted on AL.com this past Friday.

Many friends have reached out to me asking follow-up questions about the emerging epidemic, mostly seeking practical advice on what they specifically can do to minimize their risk of acquiring the infection and how they should manage evaluation and testing if they feel ill.

In response, I am posting several of the questions I have received with my answers. Please note that, in many cases, I am providing advice based on evidence. In other cases, I simply am making a ‘best guess’. Please understand that the medical advice I am providing below are general recommendations. Specific medical advice is best obtained from your personal health care provider.

Here goes:

1. How do I know whether I should cancel an event (e.g. a wedding) or travel plans?

My best advice is to filter the answer through the lens of two questions:

· How many people will attend; and

· “Is it essential?”

No matter what, everyone should avoid gatherings of more than 25 people, the fewer the better. And when in any crowd, maintain ‘social distance’, which is typically 4 to 6 feet apart from one another.

So, in the case of a wedding, I suggest postponing the event to a later time. If that is not desired, reduce the gathering to ‘essential’ guests: close family, closest friends at the ceremony. One viable option is to have a small ceremony but cancel the reception and reschedule it to a later time when everyone can attend without concern about contracting the virus. Call it a “Celebration of Marriage”. You could even hold it on the first wedding anniversary.

Regarding travel, the fundamental question remains: Is it essential. In reality, most travel is optional. Even a long-awaited big vacation does not have to happen and can be postponed to another time when the fear of contagion is reduced and an unexpected travel ban does not restrict your ability to get home.

Also consider the location. You may be traveling to a region that does not have healthcare services readily available. You do not want to become ill, in another country for example, and need to seek care for coronavirus symptoms. Many of the ‘air ambulance’ services have restrictions on transporting individuals with coronavirus infection.

Fortunately most air carriers have now waived their change and cancelation fees so there is no penalty for delaying your trip. Similar supportive policies are now active in the hotel industry.

2. What about religious services?

I have had several conversations with clergy and lay leadership of churches. My advice: Cancel formal religious services and Sunday School activities until the threat blows over. Many congregants are over the age of 60, the group of people with the highest morbidity and mortality from coronavirus. Sharing pews, prayer books (from one service to another), holding hands, and simply greeting one another can spread the virus unwittingly from one person to another. <SEE GREG GARRISON’S COVERAGE>

We are metaphorically in the middle of a hurricane. No one would hold or attend services while the storm is hitting our neighborhood.

If your place of worship refuses to cancel services, my advice is to stay home. Many congregations employ webcasting of services. This is a safe way to participate from a distance.

It’s easy to understand why clergy and church leadership would resist such advice. But we are in new and unprecedented times. Never in our lifetimes have we encountered this type of threat to such a large number of our citizens. As covered in the article I wrote on Friday, the threat is direct (someone getting ill) as well as indirect through the destabilization of our health care delivery capacity. We all must do our part to minimize risk.

3. What do I do if I feel ill?

First off, stay calm. With all of the conversation and media coverage about the virus it is normal to be frightened if symptoms appear. Fortunately, for 4 out of 5 people who become ill, the symptoms are mild and do not progress. In circumstances when the disease worsens, the usual progression is as follows:

· Initially, onset of malaise (not feeling well) and fatigue (tiredness)

· This tends to progress over the next few days. (Note, this is very different than the flu, which has a sudden onset of illness with all of the symptoms occurring all at once and progressing quickly over 4 to 12 hours)

· Next is muscle aches and headaches. Some people have stomach upset or diarrhea. Appetite diminishes.

· By day 6 or 7, fever appears. While the fever may occur early in the course, it typically is one of the later symptoms.

· Finally, cough develops. This may occur earlier in the course, but often is one of the later symptoms to occur. It is also the symptom that should be monitored very closely.

There are two Cardinal Rules for those who feel sick:

· STAY AT HOME. (except to get tested, see below; for those with advancing symptoms, see further below). Self-quarantine should remain in place until symptom-free (without the help of medications) for at least 24 hours. Otherwise, do not leave the house while the symptoms are ongoing.

· DO NOT go to the providers office or the emergency room! (unless you have progressive cough or shortness of breath, see below) If you have mild symptoms, you can call your provider to report you are sick but going to their office or the ER will unnecessarily expose others to the virus and will overcrowd the health care facility. There is nothing that can be done to treat the viral infection. For most cases, the symptoms are best managed at home with acetaminophen (e.g., Tylenol) or a non-steroidal anti-inflammatory agent (e.g, Aleve, Advil and the like). As always, drink plenty of fluids and take it easy.

Now that testing is becoming available, you can go get tested at one of the ‘drive- thru’ sites. If your symptoms are quite mild, you may elect to not get tested. However, it often is good to know if your symptoms are due to coronavirus. You can discuss this with your healthcare provider over the phone (not at the providers’ office, please). The provider’s office may be able to phone ahead and save you some time at the testing facility (Note: The situation with testing is very fluid and is changing daily; hopefully more clarity on process will emerge in the coming week).

For those whose symptoms progress to sustained coughing with associated shortness of breath: You will need evaluation at a healthcare facility. Do not ‘tough this out’ at home without a formal evaluation when the symptoms become more advanced.

If possible, please discuss where to go with your healthcare provider. They may be set up to manage cases of coronavirus in their office/clinic, but many providers do not have the capacity to evaluate folks with this infection in their outpatient clinics / offices. Please call before arriving unannounced at their office. Those that do have the capacity are setting up specific, protected areas within their facility for patients who have suspected coronavirus infection. Waiting rooms that are not divided are not safe for those who do not have the infection.

In most instances, you will be instructed to go to the Emergency Room (this recommendation may change in the coming days should ERs develop specific Coronavirus assessment outposts to de-congest the ERs). If you do not have a healthcare provider, you should go to the Emergency Department

4. What do I do if someone living in my household becomes ill with symptoms of coronavirus infection?

As recommended above, first of all stay calm. You likely will become the support person for the patient with the virus. If you stay calm, they have a better chance of staying calm.

Second, you should try to minimize your chances of picking up the infection. Suggestions include:

· Isolating the person to a specific area of the house or apartment.

· Try to minimize direct contact with the patient

· Use gloves (if available) when picking up dishes, trash, or materials used by the patient and immediately dispose of the items.

· Wash your hands thoroughly (at least 20 seconds with soap and water) any time there is contact with materials / items handled by the patient and immediately after removing gloves

· Clean down surfaces with disinfecting wipes or alcohol-based cleansers that may have been touched or used by the patient over the prior 48 hours

· Place alcohol-based hand sanitizer in areas around the house; use frequently, even if you don’t recall touching any items from the source patient

· Avoid touching your face

You should help monitor the person for advancing symptoms (described above). If the symptoms are progressing to coughing spells with shortness of breath or difficulty breathing, you should help them get to an Emergency Room as soon as possible. If the symptoms are mild, the symptoms should be managed at home as indicated above.

Michael S. Saag is Associate Dean for Global Health; Jim Straley Chair in AIDS Research; Director, UAB Center for AIDS Research; Professor of Medicine, University of Alabama at Birmingham.