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Virus Management 101

March 16, 2020


Which Virus is it?

In 2020 we are all just as likely to get colds and flus as we are every other year. These are going to be diagnositcally hard to distinguish from COVID 19. This is going to have to alter how we behave when we are sick and how doctors manage you. Normally we are really happy to help with coughs and colds, even if only to give reassurance and advice. However, this year your cough and cold may be really dangerous to others, especially the elderly. If our staff get sick we will no longer be able to provide a service, so please do not come into the building with a cough, cold, sore throat, runny nose or fever, especially if you are a contact of someone with COVID 19, if you have been overseas, if you are in quarantine or live with someone who is. General practice has not been provided with much personal protective equipement, (we only got given 11 sets) and no indication if we will get more. We are going to need to use it for all patients with coughs and fevers and when we run out we will not be able to risk our staff getting sick so will have to decline service. This is a terrible situation for us, and unprecedented in our careers. Please try and manage at home the best you can with support from us by video or phone consult. If you are not managing at home, then the hospital is probably where you will need to be.

The common cold is an upper respiratory tract infection with a multitude of symptoms caused by over 200 different respiratory viruses. Antibiotics do absolutely nothing to help colds. Fortunately, colds are short lived and our bodies are effective at managing them. Despite this, colds are a significant cause of lost work or school-days and cause us all much misery. Flu is another viral infection that will be doing the rounds - at least we can get vaccinated against flu. COVID 19 is highly contagious virus, not everyone exposed will get it, and the majority of those who get it will have a mild case. It seems, so far, not to have affected children, but those who get most sick with it are older adults with other health issues.

With COVID 19, 80% or more of those who get it get a mild version, with mild coryzal symptoms (more like a cough and cold). Up to 20% get a lower respiratory tract infection (pneumonia) and have symptoms like cough, shortness of breath and fever. Those who do get more unwell tend to do so in week 2. A few of them will go on to become very septic and to develop ARDS (acute respiratory distress syndrome). About 10% of confirmed cases require intensive care in hospital, some of them need ventillation. There is going to be very little if anything we can do in primary care, therefore please think twice before bringing any cough or cold to Medplus. Get a telephone or video consultation or call Healthline.

Key features of COVID 19 are fever (98%), non-productive dry cough (70%), shortness of breath (63%) and fatigue (70%). Unlike influenza, not many people get muscle pains (11%) or joint pains (2%). Other less common symptoms include diarrhoea and nausea (10%) and runny nose (6%). This is slightly different from the flu, where fever, achy bodies, sore throat and runny nose are more common.

PLEASE NOTE, WE THINK THAT THERE MAY BE SOME ISSUES USING ANTI INFLAMMATORIES IF YOU HAVE COVID 19 AND RECOMMEND JUST PARACETAMOL. PREDNISONE POTENTIALLY MAKES COVID 19 WORSE - SO WE DO NOT RECOMMEND USE IF YOU ARE HAVING AN ASTHMA FLARE. PLEASE IGNORE THE POSSIBLY FAKE NEWS CIRCULATING, WE DO NOT RECOMMEND STOPPING ACE INHIBITORS (A BLOOD PRESSURE MEDICATION) NOR DO WE SUGGEST STOPPING RHEUMATOID DRUGS LIKE METHOTREXATE.

What can be done to feel better??

Rest and stay at home

Stay at home and rest. You can be assured that your work colleagues or school friends will be concerned that any cough or sneeze is COVID 19, so stay at home and try not to share your bugs. Do not send sick children to school, day care or to visit grandparents. To protect those you live with, cover your mouth with your elbow if you cough, catch sneezes in a tissue and place in a bin, and wash your hands frequently. Use hand sanitiser liberally if you are lucky enough to have it. Think of moving to the spare room or sofa so you do not cough and sneeze over your nearest and dearest all night. Stay away from the elderly who are far more vulnerable to COVID 19.

Hydrate

You will be losing fluids quicker than normal from your inflamed airways. Drink plenty of water. Hot drinks can be very soothing, particularly hot lemon drinks or fruit teas. At night, your throat will become sore as it dries out, because you are likely to breath though your mouth when your nose is blocked. Keep water beside your bed.

Skip the alcoholic beverages – they will only dehydrate you!

Cool down

If you have a fever you will likely feel miserable. A fever is anything over 37.5C, but most of us will normally run in the 36 C range. Turn off the heaters, open windows or even pop out for some fresh air, although stay away from others. Cool drinks help. Hot showers or baths will likely make you feel worse.

If you are really hot, your body's thermostat malfunctions and you believe you are freezing cold and start shivering. This is when a thermometer is useful.

Paracetamol is the first-choice medication for those who are symptomatic with a fever, but you do not need to use it if cooling yourself down physically works well. Paracetamol will also help sore throats, headaches and painful ears. An adult does is two 500mg tablets up to four times daily. Ibuprofen is the second-choice medication, it is very effective at controlling fever and pain but can be harsh on the stomach and kidneys and is not suitable for everyone. The dose depends on the type you have. Beware, lots of medications contain paracetamol and ibuprofen, so make sure you know what you are taking if you buy Lemsip, Panadeine, Neuromol or Maxigesic for example.

Aromatics

Essential oils such as menthol and eucalyptus have been used for hundreds of years in the treatment of the common cold. Lozenges with menthol may relieve a sore throat by acting as a local anaesthetic. Menthol makes your nose feel cooler and clearer, which is often much appreciated. Vicks has been found to be effective in those over 2 years, to use to help with coughs and congestion. Use it either on the chest, under the nose, or inhale a small amount of it mixed in a bowl of boiling water.

Honey

Another oldie but a goodie. There is some evidence to suggest it works with coughs and sore throats. Do not use it in infants under one year of age, because of a small risk of botulism. Use 1 teaspoon as needed. It is probably as effective as most cough mixtures.

Nasal sprays

If your nose is running then a nasal spray may calm it down, particularly useful at night so you can sleep. Simple saline nasal sprays actually can help and is one of the few treatments that can be used for babies. Studies positively show that using saline nasal irrigation reduces time off school or work for colds. However, it can cause nose bleeds.

Medicated sprays, such as Otrivin Plus, contain ipratropium which can reduce a runny nose but cannot clear a blocked nose. It can cause nosebleeds. Do not use it for more than 5 days otherwise it will cause a rebound runny nose when you stop.

Zinc

A big review of many studies found a significant reduction in duration, severity and incidence of the common cold in patients using zinc supplementation. However, in overdose it can cause nausea, constipation, diarrhoea or abdominal pain if taken at doses greater than 40mg daily.

Echinacea

A large analysis of multiple studies found no evidence for Echinacea preventing colds, although it may provide some symptomatic relief of a cold if the plant is used early on. Multiple preparations are available, and there may be difference in effect with different brands and dependent on which part of the plant is used. It is thought the stems and leaves are most effective.

Vitamin C and Garlic

These have been studied repeatedly to see if they can help with colds. It looks like there may be a role in preventing colds and a limited benefit in treating them. Certainly having some mandarins and kiwi fruit is worth a try or use some supplements. Use garlic in your cooking, but there is probably no benefit in consuming it raw!

Cough mixtures

Save your money – these expensive preparations will not do any good and potentially could do you harm. There is little evidence that cough and cold preparations containing antitussives, mucolytics, expectorants, decongestants or antihistamines, have any clinically significant effect on reducing the symptoms or duration of the common cold and Medsafe has banned the use of most of them in the under 6-year-old age group.

If you are coughing continuously you may find you are better off sitting up rather than lying flat. A distraction from your cough may help you get to sleep – e.g. listening to the radio or watching TV. Sometimes going outside into cool air can stop a coughing spasm. Steam can be helpful for an annoying cough.

Commonly asked questions about colds.

I have a horrible cold. Do I need antibiotics?

Not for a cold. Antibiotics punch holes in the cell walls of bacteria but have no effect on viral infections. If it is COVID 19 antibiotics have no role to play.

My nasal mucous is green. Do I need antibiotics?

Green snot does not signify anything really, it is an old wives' tale that green snot is a bacterial infection. As long as it is a cold nothing can be done unfortunately.

My cough is really "chesty". Do I need antibiotics?

Coughs almost always seem chesty. Mucous in the upper airways causes turbulence and makes everyone feel chesty. If you have a lower respiratory tract infection (e.g. a pneumonia or chest infection) then you may need antibiotics. Normally you would be very unwell in yourself, off food, short of breath and coughing a lot.

How can you tell it's an upper respiratory tract infection?

If you are not feeling too bad it is probably upper respiratory. We can tell partly from the history and then from examination. When we do see patients we look at heart rate, respiratory rate, oxygen saturations, and sound the chest. We also inspect the ears and throat, look for cervical lymph nodes and assess general wellbeing. If you are having a phone or video consultation you could measure your pulse rate, take your temperature and possibly even measure your oxygen saturations on your smart phone. This will be useful information for us.

Will antibiotics prevent me from getting a secondary bacterial infection?

Again, mostly no.

Sometimes an upper respiratory tract infection can lead to a secondary bacterial infection. This is not a frequent event. In children, middle ear infections can occur after colds, but the majority of these resolve in 48 hours and do not benefit from antibiotics. Some unlucky people may get a secondary bacterial infection such as pneumonia – this is more likely in those with pre-existing severe lung disease. It is thought that antibiotics given early will not necessarily prevent a secondary bacterial infection and in most cases, should only be used if one arises.

I have a horrible cold and I am going on holiday next week/I can't afford to take time off work/I have a sick relative, should I have antibiotics?

Unfortunately, antibiotics are still not likely to do any good. They will however strip your bowel of beneficial good bacteria, may potentially cause an allergic reaction and are likely to cause diarrhoea and vomiting. Overuse of antibiotics is also causing a massive problem as bacteria are now resistant to them. At the moment the advice is not to travel overseas, do not go to work if you are unwell and stay away from ill people. Stay away from well people if you are sick - especially the elderly.

My brother/sister/son/daughter/neighbour has the same thing and their GP gave them antibiotics. Should I have it too?

Their GP either may have given them antibiotics as they suspected a secondary bacterial infection such as pneumonia. Or they may be high risk for lung infections for example, they have had multiple episodes of pneumonia or have bronchiectasis.

I have had my cold for 2 weeks now so should I have antibiotics?

If you are coping and not too unwell then no. The cough may last 4-6 weeks. If you are really unwell please book a phone or video consultation with your doctor.

Last time I had a cold I was given antibiotics and it cleared up immediately. Should I have them now?

The funny thing is that even when there is a proven bacterial infection (i.e. a pneumonia), and we know from sputum testing which antibiotic the bacteria is sensitive to, it can still take a long while to get better on the right antibiotic. You probably got better just because your immune system had got on top of the virus about when you started antibiotics.

Should I come in early to get on top of it?

Please no. Not this year with COVID 19. Sit it out at home, we have nothing to speed up the process.

When to seek help

Seek help if you are concerned, but be realistic in your expectations. We can help over the phone, or with a sick certificate if needed or giving advice but we regrettably cannot cure a cold or COVID 19.

Seek help if you feel really unwell in yourself, if you are short of breath, if you have chest pain, if you cannot drink, if you stop passing urine, if you develop a rash, neck stiffness or an aversion to being in a bright room. Phone Healthline or have a video or phone consult. We may direct you to hospital. Please do not come into Medplus with a cough and fever, especially if you have travelled overseas, phone ahead so we can advise. If we do see you we may do so in the car park wearing protective gear.

Asthmatics, those with chronic obstructive airway disease or bronchiectasis may need a video or telephone review sooner if their respiratory symptoms have been triggered.

With children, normally things are not too bad if they are eating and drinking and relatively playful. A lethargic and still child is concerning, so is one who will not take fluids and or who is not passing urine. If a child perks up when their temperature is controlled with medication then it is often a good sign.