Updates, June 2:
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2A. Avoid people, especially indoors.
[Section renamed from "Avoid people."]
[Deleted the CDC quote that COVID-19 is mainly spread "between people who are in close contact with one another (within about 6 feet)", per Zvi's criticism of the meme.]
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2B. If you do need to be around people, face away from them, minimize talking, etc.
[New section.]
Jonathan Kay writes on Apr. 23,
According to the binary model established in the 1930s, droplets typically are classified as either (1) large globules of the Flüggian variety—arcing through the air like a tennis ball until gravity brings them down to Earth; or (2) smaller particles, less than five to 10 micrometers in diameter (roughly a 10th the width of a human hair), which drift lazily through the air as fine aerosols.
[...] Despite the passage of four months since the first known human cases of COVID-19, our public-health officials remain committed to policies that reflect no clear understanding as to whether it is one-off ballistic droplet payloads or clouds of fine aerosols that pose the greatest risk—or even how these two modes compare to the possibility of indirect infection through contaminated surfaces (known as “fomites”).
Gaining such an understanding is absolutely critical to the task of tailoring emerging public-health measures and workplace policies, because the process of policy optimization depends entirely on which mechanism (if any) is dominant:
1. If large droplets are found to be a dominant mode of transmission, then the expanded use of masks and social distancing is critical, because the threat will be understood as emerging from the ballistic droplet flight connected to sneezing, coughing, and laboured breathing. We would also be urged to speak softly, avoid “coughing, blowing and sneezing,” or exhibiting any kind of agitated respiratory state in public, and angle their mouths downward when speaking.
2. If lingering clouds of tiny aerosol droplets are found to be a dominant mode of transmission, on the other hand, then the focus on sneeze ballistics and the precise geometric delineation of social distancing protocols become somewhat less important—since particles that remain indefinitely suspended in an airborne state can travel over large distances through the normal processes of natural convection and gas diffusion. In this case, we would need to prioritize the use of outdoor spaces (where aerosols are more quickly swept away) and improve the ventilation of indoor spaces.
3. If contaminated surfaces are found to be a dominant mode of transmission, then we would need to continue, and even expand, our current practice of fastidiously washing hands following contact with store-bought items and other outside surfaces; as well as wiping down delivered items with bleach solution or other disinfectants.
Zvi Mowshowitz comments:
Identified Super Spreader Events are Primarily Large Droplet Transmission
The article makes a strong case that in identified super spreader events [SSEs] the primary mode of transmission is large droplets. And that large droplets are spread in close proximity, by people talking (basically everything) or singing (several choir/singing practices) frequently or loudly, or laughing (many parties) and crying (funerals), or otherwise exhaling rapidly (e.g. the curling match) and so on.
There is a highly noticeable absence of SSEs that would suggest other transmission mechanisms. Subways and other public transit aren’t present, airplanes mostly aren’t present. Performances and showings of all kinds also aren’t present. Quiet work spaces aren’t present, loud ones (where you have to yell in people’s faces) do show up. University SSEs are not linked to classes (where essentially only the professor talks, mostly) but rather to socializing. [...]
Zvi argues that surfaces and small aerosolized droplets are unlikely to be major infection vectors for COVID-19. He discusses methods for avoiding large droplet transmission:
Large Droplets: Six Foot Rule is Understandable, But Also Obvious Nonsense
For large droplets, there is essentially zero messaging about angling downwards or avoiding physical actions that would expel more droplets, or avoiding being in the direct path of other people’s potential droplets.
Instead, we have been told to keep a distance of six feet from other people. We’ve told them that six feet apart is safe, and five feet apart is unsafe. Because the virus can only travel six feet.
That’s obvious nonsense. It is very clear that droplets can go much farther than six feet. Even more than that, the concept of a boolean risk function [i.e., one that sharply divides everything into either "risky" or "risk-free", with no shades of grey] is insane. People expel virus at different velocities, from different heights, under different wind conditions and so on. The physics of each situation will differ. The closer you are, the more risk.
Intuitively it makes sense to think about something like an inverse square law until proven otherwise, so six feet away is about 3% of the risk of one foot away. That’s definitely not right, but it’s the guess I feel comfortable operating with.
Alas, that’s not the message. The message is 72 inches safe, 71 inches unsafe.
Unlike the previous case of obvious nonsense, there is a reasonable justification for this one. I am sympathetic. You get about five words. “Always stay six feet apart” is a pretty good five words. There might not be a better one. Six feet is a distance that you can plausibly mandate and still allow conversations and lines that are moderately sane, so it’s a reasonable compromise.
It’s a lie. It’s not real. As a pragmatic choice, it’s not bad.
The problem is it is being treated as literally real.
Joe Biden and Bernie Sanders met on a debate stage. The diagram plans had them exactly six feet apart.
In an article, someone invites the author, a reporter, to their house to chat. Says he’s prepared two chairs, six feet apart. “I measured them myself,” he says. [...]
And so on. People really are trying to make the distance exactly six feet as often as possible.
[...] This is society sacrificing bandwidth to get a message across. Again, I get it. The problem is we are also sacrificing any ability to convey nuance. We are incapable, after making this sacrifice, of telling people there is a physical world they might want to think about how to optimize. There is only a rule from on high, The Rule of Six Feet.
Thus, we may never be able to get people to talk softly into the ground rather than directly looking at each other and loudly and forcefully to ‘make up for’ the exact six foot distance, which happens to be the worst possible orientation that isn’t closer than six feet.
In theory, we can go beyond this. You get infected because droplets from an infected person travel out of their face and touch your face.
Thus, a line is remarkably safe if everyone faces the same way, modulo any strong winds. The person behind you has no vector to get to your face. And we can extend that. We can have one sidewalk where people walk north, and another on the other side of the street where people walk south. If you see someone approaching from the other direction, turn around and walk backwards while they ensure the two of you don’t collide. If necessary, stand in place for that reason. Either way, it should help – if this is the mechanism we are worried about.
[...] Yes, it’s annoying to not face other people, but you absolutely can have a conversation while facing away from each other. It’s a small price to pay.
In similar fashion, it seems a small price to pay to shut the hell up whenever possible, while out in public. Talking at all, when around those outside your household, can be considered harmful and kept to a bare minimum outright (and also it should be done while facing no one).
Zvi emphasizes that there’s much more benefit to slightly reducing the risk from the largest infection sources (including large droplets as a category), than from hugely reducing the risk from fairly unlikely infection sources:
Focus Only On What Matters
[...] Within those big risks, small changes matter. They matter more than avoiding small risks entirely.
A single social event, like a funeral, birthday party or wedding, might well by default give any given person a 30%+ rate to infect any given other person at that event if the event is small, and a reasonably big one even if large. You only need one. Keeping slightly more distance, speaking slightly less loudly, and so on, at one such event, is a big risk reduction. [...]
Whereas a ‘close contact’ that doesn’t involve talking or close interaction probably gives more like (spitballing a guess, but based on various things) an 0.03% rate of infection if the other person is positive, and likely with a lower resulting viral load. Certainly those contacts add up, but not that fast. Thus, a subway car full of “close contact” might give you 10 of them per day, most of whom are not, at any given time, infectious. If this model is correct.
In another post, Zvi writes:
Risks Follow Power Laws
[...] Slight reductions in the frequency and severity of your very risky actions is much more important than reducing the frequency of nominally risky actions.
The few times you end up talking directly with someone in the course of business, the one social gathering you attend, the one overly crowded store you had to walk through, will dominate your risk profile. Be paranoid about that, and think how to make it less risky, or ideally avoid it. Don’t sweat the small stuff.
And think about the physical world and what’s actually happening around you!
And:
My best guess is there is something like 5-10 times as much risk indoors versus the same activity outdoors. [...]
The combination of quick and outdoors and not-in-your-face probably effectively adds up to safe, especially if you add in masks. During the peak epidemic in New York things were so intense that it would have been reasonable to worry about miasma. Now, I would do my best to keep my distance and avoid talking at each other, but mostly not worry about incidental interactions.
I do expect there to be a spike in cases as the result of protests and civil unrest.. To not see one would be surprising, and would update me in favor of outdoor activities being almost entirely harmless.
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2C. If you do need to be around people, wear something over your mouth and nose.
[Deleted the advice for individuals not to buy medical-grade masks because it doesn't currently seem like good advice (and I'm not particularly convinced it was ever good advice).]
Zvi Mowshowitz writes, “[E]ven cloth masks on both ends of an interaction are almost certainly good for a 25% reduction in risk and probably 50%-75%.”
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2D. Don’t put coronavirus in your face.
Zvi Mowshowitz argues:
It’s been months. We don’t have concrete examples of infection via surfaces. At all. It increasingly seems like while such a route is possible, and must occasionally happen, getting enough virus to cause an infection, in a live state, via this route, is very hard. When you wash your hands and don’t touch your face, it’s even harder than that.
Meanwhile, those who refuse to touch surfaces like a pizza delivery box end up in more crowded locations like grocery stores, resulting in orders of magnitude more overall risk.
[...] Until I get very unexpected evidence, surfaces are mostly not a thing anymore. If lots of people touch stuff and then you touch it, sure, wash your hands after and be extra careful to not touch your face in the interim. Otherwise, stop worrying about it.
[... Food] is at most minimally risky, even if it doesn’t get heated enough to reliably and fully kill the virus. You don’t have to ruin all your food. People are often avoiding foods that seem risky. Once again, it makes sense that it could be risky, but in practice it’s been months and it does not seem to work that way. The precautions people are taking will incidentally be more than good enough to guard against contamination of food at sufficient levels to be worth worrying about. I mean, sure, don’t eat at a buffet, but it’s not like any of them are going to be open, and even then the (also mostly safe) surfaces are likely scarier than the food.
[...] Your risk is from the waiter, or from the other diners, being in that room with you for a while. Thus, takeout, delivery and/or eating outdoors.
I agree with Zvi that it seems increasingly likely that surface transmission is rare, though he seems to be wrong that there are no examples (see comments), and I haven’t seen a clear argument for whether the number of COVID-19 cases caused by surface transmission is closer to 1/10 of all cases versus, say, 1/10,000. Given my own circumstances, I’m likely to do things like “order delivery pizza” more often in the weeks to come, but I’ll also likely make use of Yao Lu’s tips while infections are still commonplace in my part of the US:
I’m a chemo nurse, this is what I tell my high-risk patients:
I personally don’t trust takeout that much because I think a lot of restaurant workers don’t have sick leave, so it’s more likely your food was prepared by someone symptomatic. But you can cut the risk to near zero by doing this:
1. Wash your hands well
2. Put your own bowl on your kitchen counter
3. Pick up the restaurant container, and pour the food into your own bowl
4. Throw away the restaurant container
5. Wash your hands well
6. Thoroughly heat up the food. (at least 70C for a minute, or whatever the best current guideline says)
If you do this, in this order, you are extremely safe even if someone coughed viruses all over the food and the container. Heat would kill the virus, and handwashing would prevent indirect transmission from the bag/container.
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2G. Disinfect surfaces.
See also Zvi Mowshowitz’s recommendations to worry less about surfaces, quoted above.
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2H. Maybe stop taking ibuprofen/advil?
[Deleted this section because the post is getting long and this seems messy and uncertain. I'll reproduce the Apr. 26 version of the section in a reply to this comment for when I want to link directly to it.]
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2J. Run an air filter.
[Provisionally deleted "Also, quit smoking." because I haven't been keeping up with the debate about cigarettes or nicotine.]
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3A. Prepare in advance.
Plan in advance what hospital you’ll go to if necessary, and be ready to call a doctor if you have troubling symptoms. Zvi Mowshowitz writes:
Medical care matters [for fatality rates]. Total breakdown of medical care in practice leads to several times the fatality rate under regular circumstances. High quality treatment at current knowledge levels can probably drive death rates down further, so the ratio between full success and complete breakdown can be rather large – something like an order-of-magnitude difference between 0.2% and 2%.
I don’t have a strong opinion at this point about particular medical treatments beyond the above.
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3G. Monitor for clotting problems.
Jim Babcock said on Apr. 28,
My first-pass literature review turned up some claimed mechanisms by which platelets and clotting may serve an immune purpose. I don't know if that's what happening here, but there's a possibility that this works like fever reduction: helpful in extreme cases, bad in minor cases and early in the progression.
Low-dose heparin seems to be common hospital protocol now, so data should be forthcoming for that scenario. I don't know what recommendation to give to minor cases self-treating at home, though.
[I meant to add the above before, but forgot about it. This is part of why I withdrew the recommendation that people take aspirin at home whenever they start showing COVID-19 symptoms.]
Robby posted this to Facebook on March 15th, and just updated section 2 and 3 with new information, making this I think currently one of the best guides to how to respond to this whole situation.
(Added Jun. 4: List of changes to this document.)
(Added Nov. 9: This document evolved from some recommendations I put together for friends, colleagues, and family on Feb. 27, when much less was known about COVID-19. At the time, it made sense to prepare for the worst and emphasize quick, dramatic action.
Over time, this document evolved into more conditional advice: rather than "lock down immediately," I assumed that different individuals would have different risk tolerances, and I try to give advice for how to mitigate risk without building in the assumption that everyone should be maximally cautious. Still, it's worth emphasizing these points explicitly:
For more COVID-19 information and recommendations, try microcovid.org or Zvi Mowshowitz's updates.)
If you live in the US, I recommend that you self-quarantine immediately (to the extent that's possible for you) to avoid exposure to COVID-19, the new coronavirus disease. I'll explain why below, then give tips on how to reduce exposure and what to do if you get sick.
Quarantine isn't all-or-nothing, and every little bit helps. Even if you expect to catch COVID-19, you're likely to get sicker if you're exposed to more viral load early on.
(Paul Bohm says "pretty much any viral/bacterial dose study shows that result". Divia Eden: "As I understand it, the virus replicating is an exponential process, and antibody production is an exponential process too. So an early difference in load should make it easier for the latter to outpace the former.")
So even if you can't (e.g.) work from home right now, I would still recommend taking large measures to reduce your exposure.
Disclaimer: I put this document together in my free time to collect tips and background information I’d seen on COVID-19 from a variety of sources. I am not a doctor or an epidemiologist. In writing this, I prioritized breadth, clearness/useability, and getting information out quickly. I didn't put a lot of my own time into vetting each claim (though I plan to continue correcting errors as they’re pointed out to me), and I’d expect some of the information below to turn out later to be incorrect.
1. Why I think you should self-quarantine
[Section omitted from the crosspost, since most people appear to understand the importance of self-quarantine by now. The section can still be found here.]
2. Ways to reduce risk now:
A. Avoid people, especially indoors.
The CDC believes that COVID-19 is mainly spread person-to-person, "through respiratory droplets produced when an infected person coughs or sneezes. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs."
COVID-19 has a long incubation period and high transmission rate, including significant asymptomatic transmission. This means that talking is also probably a common vector — you'd be surprised how much spit flies when people talk.
(Added Apr. 26: evidence continues to accumulate that talking is an important vector. COVID-19 superspreader events have typically involved large groups of people talking, singing, or shouting indoors. From Scott Gottlieb: “Study of 318 outbreaks in China found transmission occurred out-of-doors in only one, involving just 2 cases. Most occurred in home or public transport. Raises key chance for states to move services outdoors (religious, gym classes, restaurants, etc). https://www.medrxiv.org/content/10.1101/2020.04.04.20053058v1”)
So my top recommendation is to avoid being near other people (unless you're self-quarantining together), especially in crowded or indoor spaces.
(Added Mar. 16, from Michael Keenan: "Starting at midnight, all non-essential work and movement outside homes is banned in Alameda county and most other bay area counties. Grocery stores and pharmacies will remain open, and restaurants may still do takeout food (and presumably delivery), for those who are still using that." Similar measures may be taken elsewhere in the US soon; be prepared for the possibility.
(Added Apr. 26: cf. quick thoughts about the COVID-19 endgame.))
Added May 8: I recommend reading immunologist Erin Bromage’s The Risks — Know Them — Avoid Them in full. Some key claims:
“The principle is viral exposure over an extended period of time. In all these cases, people were exposed to the virus in the air for a prolonged period (hours). Even if they were 50 feet away (choir or call center), even a low dose of the virus in the air reaching them, over a sustained period, was enough to cause infection and in some cases, death.
“Social distancing rules are really to protect you with brief exposures or outdoor exposures. In these situations there is not enough time to achieve the infectious viral load when you are standing 6 feet apart or where wind and the infinite outdoor space for viral dilution reduces viral load. The effects of sunlight, heat, and humidity on viral survival, all serve to minimize the risk to everyone when outside.”
Bromage says grocery stores aren't "places of concern", but I gather he means they’re relatively safe if you’re keeping a good distance from everyone, going when the store is pretty empty, etc. If a single cough from someone a few feet away who isn’t facing in my direction can give me COVID-19 within a few seconds, that still seems “concerning” to me!
Additionally, Jim Babcock comments on “infections while shopping appear to be responsible for 3-5% of infections”:
And:
Bromage has softened the grocery store claim to “In contrast, outbreaks spread from shopping appear to be responsible for a small percentage of traced infections.”, and now cites an additional two studies for the 1000-particle claim: 1, 2.
B. If you do need to be around people, face away from them, minimize talking, etc.
Added Jun. 2: Jonathan Kay writes on Apr. 23,
Zvi Mowshowitz comments:
Zvi argues that surfaces and small aerosolized droplets are unlikely to be major infection vectors for COVID-19. He discusses methods for avoiding large droplet transmission:
Zvi emphasizes that there’s much more benefit to slightly reducing the risk from the largest infection sources (including large droplets as a category), than from hugely reducing the risk from fairly unlikely infection sources:
In another post, Zvi writes:
And:
C. If you do need to be around people, wear something over your mouth and nose.
Be sure not to touch/adjust the mask/covering (or your face) while wearing it, except to take it off (and throw it away or sanitize it) when you're done using it.
I've heard some people claim masks aren't useful, but this is wrong, provided you're careful to wear them correctly.
If you don't have surgical masks, home-made masks or scarves can also be effective. This study shows that home-made masks (made from tea cloth) were less effective than surgical masks, but still useful.
Added Mar. 28: Scott Alexander reviews the literature and concludes, "If the shortage ends, and wearing a mask is cost-free, I agree with the guidelines from China, Hong Kong, and Japan – consider wearing a mask in high-risk situations like subways or crowded buildings. Wearing masks will not make you invincible, and if you risk compensate even a little it might do more harm than good. Realistically you should be avoiding high-risk situations like subways and crowded buildings as much as you possibly can. But if you have to go in them, yes, most likely a mask will help."
Added Apr. 26: For homemade masks, Hrothgar says:
Added Jun. 2: Zvi Mowshowitz writes, “[E]ven cloth masks on both ends of an interaction are almost certainly good for a 25% reduction in risk and probably 50%-75%.”
D. Don’t put coronavirus in your face.
From Patrick LaVictoire:
PBS says (added Mar. 30):
So I could imagine it being quite helpful to switch from touching your mucous membranes once every few minutes to doing so once every few hours.
I hear that surface transmission wasn't the primary way SARS spread, so I'm not sure how worth worrying about surfaces are. A lot of people have noted that coronavirus can survive on surfaces up to 9 days in certain conditions (or even longer if it's cold), but Will Eden says: "This paper is the source of the 9 day figure. However that’s the maximum length on any surface under ideal conditions. In some cases it only lasts hours. And it doesn’t establish whether any of that is infectious!"
Regardless, my other three main recommendations are: spend less time touching surfaces that a large number of other people touch (added: or talk near); try to minimize how much you touch your eyes, nose, or mouth; and wash your hands more often, using full medical hand-washing protocol (image; mnemonic; animated version). Note that for COVID-19, hand sanitizer isn't a good replacement for hand-washing.
Added Jun. 2: Zvi Mowshowitz argues:
I agree with Zvi that it seems increasingly likely that surface transmission is rare, though he seems to be wrong that there are no examples (see comments), and I haven’t seen a clear argument for whether the number of COVID-19 cases caused by surface transmission is closer to 1/10 of all cases versus, say, 1/10,000. Given my own circumstances, I’m likely to do things like “order delivery pizza” more often in the weeks to come, but I’ll also likely make use of Yao Lu’s tips while infections are still commonplace in my part of the US:
E. Have emergency supplies.
I would recommend stockpiling at least a month of non-perishable food. 2-3 months is even better. Err on the side of buying food that you like; idiosyncratic favorite foods are less likely to be sold out on Amazon right now, and it's important to make your self-quarantine pleasant so you're less likely to want to take unnecessary risks later.
From residents of the Event Horizon house (https://docs.google.com/…/1Rn6WrTat0Cb6gfatWv-TcSBToh3…/edit): "Most dedicated disaster prep food is already sold out, but you could get a bunch of canned foods (e.g. beans, fish, vegetables, fruits) and dry foods (e.g. rice, pasta, dried fruit, peanut butter) that you like and can eat."
I would similarly stock up on other essential items, especially medications you need.
Added Apr. 26: The CDC recommends having a two-week backup supply of clean drinkable water. I would recommend stockpiling 1+ months of water (i.e., 30+ gallons per person) if you have room. The Guardian reports Apr. 20 that there’s an emerging shortage of CO2, and The Prepared notes that “CO2 is an essential input for the municipal water treatment process. (It’s also vital to many critical industrial processes–from agriculture to meat processing to food preservation).” The Prepared also notes other chemicals used in water treatment whose supply could be disrupted in various scenarios.
F. Print out copies of your health records.
From Event Horizon: "If hospital infrastructure is overwhelmed, you may not be able to access this information. The most important information to have on hand is your history of major health problems and surgeries, immunization records, and medications you are currently taking. Here is a template for such a health record: https://docs.google.com/…/1fCCTcwrULo5w4vnymhziCVdctM…/edit…"
G. Disinfect surfaces.
(Especially commonly touched surfaces like door handles and light switches.)
The WHO notes, "In China, human-to-human transmission of the COVID-19 virus is largely occurring in families [...] most clusters (78%-85%) have occurred in families." Divia Eden comments: "One of my takeaways was that delivery of packages was unlikely to be a major vector, in China anyway."
That said, packages may still be the main risk source for you if relying on packages for food; and the risk may rise in contexts where containment measures have failed and the virus is more widespread globally. So if it's not too much trouble for you, or if you're unusually at risk, it probably makes sense to sanitize packages too.
The easy version of this is letting packages sit in direct sunlight for a while before opening them. Heat and UV radiation are good for killing coronavirus. (Added Mar. 28: https://www.nejm.org/doi/full/10.1056/NEJMc2004973 reports, "SARS-CoV-2 was more stable on plastic and stainless steel than on copper and cardboard, and viable virus was detected up to 72 hours after application to these surfaces (Figure 1A), although the virus titer was greatly reduced[....] On copper, no viable SARS-CoV-2 was measured after 4 hours[....] On cardboard, no viable SARS-CoV-2 was measured after 24 hours[.]")
Fortunately, the hard version is only slightly harder, since coronaviruses are easy to kill with a wide variety of cleaning agents. From https://en.wikipedia.org/wiki/Viral_envelope, discussing enveloped viruses in general: "The lipid bilayer envelope of these viruses is relatively sensitive to desiccation, heat, and detergents, therefore these viruses are easier to sterilize than non-enveloped viruses, have limited survival outside host environments, and typically transfer directly from host to host."
Good options for cleaning agents include 70% isopropyl alcohol (note: higher or lower percentages may be less effective; see also Sarah Constantin’s review) or the items on this (CDC-referenced) list: https://www.americanchemistry.com/Novel-Coronavirus-Fightin….
Important update from Duncan Sabien (added Apr. 29): “PSA: if (e.g.) getting ice cream delivered by a third party, or doing disinfection that involves wiping or dunking the ice cream such that it melts a good bit before you finally get it into the freezer ... Haagen Dasz is like 3x better at refreezing back to ice cream texture and consistency than Ben and Jerry's. Don't know why; just know the brute fact.”
Added Jun. 2: See also Zvi Mowshowitz’s recommendations to worry less about surfaces, quoted above.
H. Use copper tape or UVC light on commonly touched surfaces.
(Updated Apr. 1)
From Sarah Constantin:
UVC is used in germicidal lamps and germicidal irradiation. Far-UVC light (207-222 nm) seems safest for human skin.
Solid copper doesn't kill viruses on contact, but it makes it hard for viruses to survive on a timescale of minutes or hours (https://www.lesswrong.com/…/coronavirus-justified-practical…). Putting copper tape (Amazon link) on things like cell phones, door handles, and light switches can therefore reduce risk.
Try to minimize wrinkles in applied copper tape, so that taped surfaces remain easy to disinfect as needed. Robert Miles suggests: "Tape should be cut to the right size, and you need a tool which is finger shaped, harder than a finger but softer than copper - wood or plastic is good, I use the rounded end of a swiss army knife. Running that along seams and small creases makes them mostly disappear". Be careful of papercuts.
I. Consume 2,000-6,000 IU of Vitamin D daily, in the morning.
"Since COVID usually kills via pneumonia, and insufficient vitamin D appears to be a surprisingly large risk factor in respiratory infection, it’s probably pretty important to keep vitamin D levels sufficient (which in most people means supplementing it specifically, esp if there’s any quarantine that affects food)." (https://www.lesswrong.com/…/coronavirus-justified-practical…)
Added May 8, from Jim Babcock:
J. Run an air filter.
Sarah Constantin: "In a retrospective study in Utah hospitals, high concentrations of particulate matter in the air were associated with slightly but significantly higher (OR = 1.004) rates of admission to the emergency room for pneumonia, and slightly (OR = 1.02) but significantly higher rates of pneumonia mortality.[12] Having air filters in the home may be slightly protective."
K. Stay healthy: eat well, sleep well, get exercise.
(Added Apr. 27: And consider avoiding things that might put you in a hospital, like motorcycle races or getting pregnant; hospitals are risky during pandemics.)
3. Things to do if you get sick:
(Mar. 28 update: I largely rewrote this section today. This section remains relatively speculative and subject to change. COVID-19 is a new disease that we're still in the early stages of understanding, and as Sarah Constantin notes, there aren't many good studies on how best to treat flu- or pneumonia-like illnesses from home. Still, phlegm and flu wait for no man, and we're forced to make the best guesses we can with the available evidence.)
A. Prepare in advance.
Things to buy right now for if you get sick: Pedialyte or gatorade powder, over-the-counter inhalers, a humidifier, acetaminophen, mucinex/guaifenesin, pseudoephedrine, zinc lozenges, oral thermometers, and a finger pulse oximeter. Maybe hydroxychloroquine or chloroquine and/or a home oxygen concentrator, if you can find it online or get it prescribed by your doctor. See below for details.
While still healthy, take your temperature (orally) and use your finger pulse oximeter. Do this multiple times per day over several days, to make sure the devices are working and to get a sense of your baseline numbers.
(Added Apr. 26: given the “silent hypoxia” update at the bottom of 3D below, and the blood clot update in 3G below, you should probably use the pulse oximeter regularly even if you’re showing no symptoms, and should stay alert for signs of stroke, heart attack, or pulmonary embolism even if you’re showing no other symptoms.)
Figure out who can help take care of you if you get sick.
Added Jun. 2: Plan in advance what hospital you’ll go to if necessary, and be ready to call a doctor if you have troubling symptoms. Zvi Mowshowitz writes:
B. Understand how COVID-19 usually presents and progresses, so you can make an informed guess about how likely you are to have it.
Direct testing can obviously help, but depending on where you are and what symptoms you have, it may be very difficult to get tested in the US, and the test results may come back too late to be useful. It's still worth getting tested if circumstances allow, e.g., to clarify treatment priorities, aid in containment, or check for other infections. Per Sarah Constantin:
As of Feb. 24, the WHO listed COVID-19 as causing these symptoms with the following frequencies:
(Also, up to 50% of infections might be asymptomatic, while still being contagious.)
The WHO report continues:
(For adults, you’re generally considered to have a fever if you have an orally measured body temperature of 100.4°F / 38 °C.)
(Added Apr. 5: Anna Salamon says, “Median incubation period is probably 7 days, not 5 days; early studies that resulted in the 5-day estimate were done only on people who end up hospitalized, and those who don't (and who have somewhat milder infections) turn out to have somewhat longer incubation periods. Source: https://www.medrxiv.org/content/10.1101/2020.03.15.20036533v1”)
From Vox:
From Business Insider, a day-by-day progression of typical cases:
Elizabeth van Nostrand has been looking into what the earliest symptoms of COVID-19 infection tend to be. She writes:
From Sky News:
Stat reports that anywhere from 30% to 67% of COVID-19 patients temporarily lose their sense of smell.
One study found higher rates of digestive issues (103 out of 204 cases), broadly construed. 40% of patients experienced lack of appetite, 17% diarrhea, 2% vomiting, 1% abdominal pain. "Moreover, the digestive symptoms among the larger group grew more severe as the severity of COVID-19 increased[.]"
COVID-19 can also present with rashes on the limbs. And the virus can apparently infiltrate cerebrospinal fluid and can cause neurological symptoms.
So... apparently COVID-19 symptoms include "approximately everything".
COVID-19's presentation seems to vary a lot. Typically, if you see symptoms at all, you'll see respiratory symptoms such as coughing, chest tightness, or shortness of breath; and these are the symptoms to keep the closest eye on, since COVID-19 deaths are usually via respiratory failure. But I've also heard accounts of pretty debilitating-sounding fatigue or intense/long-lasting fever. E.g. (from an unconfirmed case):
The "ebbs and flows" aspect of COVID-19 seems very common in anecdotal reports. E.g., from another unconfirmed case:
Symptoms like runny noses are useful to track because their presence provides some evidence that you don't have COVID-19. Colds tend to cause sneezing, whereas COVID-19 and flu don't cause sneezing. Colds also cause runny or stuffy nose, which are rare in COVID-19 (and somewhat uncommon in the flu). And the flu has a sudden onset, whereas COVID-19 and colds usually have gradual onsets.
That said, since COVID-19 is especially dangerous and can present in a variety of ways (and it's always possible you have COVID-19 and another illness), you should be careful not to prematurely rule out the possibility that you have COVID-19.
C. Take zinc immediately if you start feeling any cold-, flu-, or COVID-19-like symptoms.
From virologist James Robb:
The discussion on LessWrong suggests that ordinary zinc lozenges may be ineffective for various reasons, and that one of the only products that seems likely to be effective is 'Life Extension Enhanced Zinc Lozenges' (which are currently sold out on Amazon).
One option that maybe makes intuitive sense is mixing liquid ionic zinc with water and using it like mouthwash when you start feeling ill? I'm not sure. Be warned, however, that zinc nasal sprays have been found to permanently remove people's sense of smell, and regular use of zinc in other forms may also damage your sense of taste or smell over time.
From Elizabeth van Nostrand:
D. Start monitoring your oxygen more often at the smallest warning sign.
(Added Apr. 26: ... including if you’re asymptomatic but have exposed yourself to possible infection vectors in the last two weeks. If you develop a fever or experience significant chest tightness or difficulty breathing, definitely start monitoring your oxygen; but don’t wait that long if you can avoid it.)
From residents of the Event Horizon house:
Eli Morningstar adds:
I now think “respiratory involvement... is the pathway by which it kills” is wrong, or at least very incomplete. I’m moving toward thinking of COVID-19 as a vascular or clotting disease at least as much as a respiratory one. Asthma isn’t a major risk factor for COVID-19 death; age, obesity, diabetes, heart disease, and hypertension are.
From the Washington Post May 10:
Oncologist Tatiana Prowell describes (on May 5) a Swiss autopsy series on Twitter:
And quoting CellBioGuy (Apr. 13, Apr. 22):
I want to emphasize that you may need to go to the hospital on very short notice. Serious COVID-19 cases appear to not-infrequently progress from 'little or no care needed' to 'serious care needed immediately' on very short timescales. E.g., from ProPublica:
The second week of symptom presentation seems like it may be particularly dangerous. Please monitor symptoms carefully, even if your symptoms were relatively mild in the first week. From the CDC:
Depending on how serious your symptoms are, and on how crowded nearby hospitals are at the time, you may want to go to the hospital even if your breathing is OK. If possible, talk to a doctor over the phone/video to get their recommendations. The above is meant to be advice about when you definitely should receive hospital-level care; but it's not necessarily smart to wait until the last moment.
All that said, for several reasons, it's often a bad idea to go to a hospital during a pandemic when it isn't absolutely necessary:
Similar advice from Elizabeth van Nostrand: https://www.lesswrong.com/…/what-should-we-do-once-infected…
Added Apr. 26: streawkceur writes, “According to this article, it seems clear by now that low oxygen is in fact dangerous even when you feel fine, so buying a pulse oximeter is useful. https://www.nytimes.com/2020/04/20/opinion/sunday/coronavirus-testing-pneumonia.html” Quoting the article:
Relatedly, Paul Bohm notes, “54% of asymptomatic cases and 79% of COVID-19 symptomatic cases on the Diamond Princess had ground-glass abnormalities in their CT scans.”
This suggests that even if you seem completely asymptomatic (or have very mild symptoms), you should periodically use a home pulse oximeter if there’s a nontrivial risk you recently caught the virus. Additionally, unusually fast and deep breathing is a thing to watch out for, even in otherwise asymptomatic or mildly symptomatic people.
Added May 12: Stat reports Apr. 21:
E. Take care of yourself.
From Duncan Sabien:
I believe that most (though not all!) sources these days think fevers are good by default, and you shouldn't try to lower your fever unless it gets dangerously high. Regarding what counts as "dangerously high", Elizabeth van Nostrand says: "I was taught 103ºF, some people say 104ºF, that’s probably the range."
From Event Horizon:
(As noted here, the warnings against NSAIDs above are plausibly overstated.)
From Divia Eden: "I would get mucinex and a humidifier if possible." See the nurse recommendations here. Elizabeth van Nostrand says: "Take pseudoephedrine if you have unpleasant sinus pressure." (Note: not phenylephrine / Sudafed PE, which is apparently useless.)
Stay warm, take it easy, and get lots of rest.
F. Lie on your front.
(Added Mar. 31.)
Leora Horwitz, a New York doctor working in a non-ICU COVID-19 unit, says:
In response to the question "Is proning something we can do at home to help with milder symptoms? My brother is short of breath but not at ICU level, should he try this?", Horwitz says:
Koulouras et al. and Pan et al. also suggest that ARDS patients may see better outcomes from lying on their chest.
If you’re showing COVID-19 symptoms, you may want to start lying on your chest instead of your back or side (using pillows for support as needed), at least if you can sleep and rest well in that position.
Relatedly, postural drainage strikes me as something that might help ameliorate symptoms in people with relatively serious symptoms, and can be done at home.
G. Monitor for clotting problems.
(Added Apr. 27.)
Evan Hubinger says:
From Live Science on Apr. 23:
From CNN on Apr. 23:
From the Washington Post on Apr. 25:
Symptoms to watch out for:
For heart attack in cis men: "(1) Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. (2) It used to be thought that only chest pain was a sign of heart attack, but it’s possible to have discomfort that doesn’t register as painful. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. (3) Shortness of breath with or without chest discomfort. (4) Other signs may include breaking out in a cold sweat, nausea or feeling lightheaded."
I don’t know of research on heart attack signs in people undergoing transgender hormone therapy; data may be scarce because this is a relatively young population.
The Heart Foundation adds: "Don’t wait to get help if you experience any of these heart attack warning signs. Although some heart attacks are sudden and intense, most start slowly, with mild pain or discomfort."
Added May 3: I previously echoed Evan’s recommendation of taking aspirin prophylactically. Based on a comment from John Maxwell, I’m no longer recommending that:
Added Jun. 2: Jim Babcock said on Apr. 28,
H. Consider taking more extreme measures if you're experiencing serious COVID-19 symptoms, or if you have the resources to take bonus precautions.
Moderate-to-severe cases might benefit from a home oxygen concentrator. Sarah Constantin discusses oxygen supplementation topics: Oxygen Supplementation 101 + Non-Invasive Ventilation Outcomes + How Effective is Non-Invasive Ventilation in COVID-19? (Mar. 19-22), CPAP for COVID-19 (Apr. 5); and Avoiding Intubation in COVID-19 Silent Hypoxemia (May 4). Connor Flexman adds some thoughts (Mar. 17).
Speculative and risky, but: If you can, you may want to acquire chloroquine or hydroxychloroquine. Be sure to read the entire write-up at https://docs.google.com/…/160RKDODAa-MTORfAqbuc25V8WDkLjqj…/.
Specifically for people in high-risk groups, Anjali Gopal suggests: "can you sign [...] up for clinical trials for antiviral drugs in nearby research hospitals? Some research coming out around this has started to show efficacy of remdesivir, chloroquine, and hydroxychloroquine wrt covid, though of course, this is still all very speculative and needs to be verified by RCTs. (A lot of these trials are often only open for people in high risk groups[.)]" Elizabeth van Nostrand: "One place I have found to find RCTs is https://clinicaltrials.gov/ . Normally I would verify the details of how to join but I assume they are busy right now."
Added Apr. 27: If you’re worried about blood clot risks from COVID-19 (discussed in 3G), you may want to use home coagulation tests.