Novel Coronavirus Update of 04-23-2020

Coronavirus, Corona virus, COVID, Venincasa Dental
Novel Coronavirus: COVID-19

Risk of Dying from COVID-19 Infection

A new report on 1,099 cases from many parts of China, published on [February 28, 2020] in The New England Journal of Medicine, finds a lower [coronavirus infection death] rate: 1.4 percent” (Grady, 03-01-2020).

These rates compare to the common flu; about 1-3% of patients infected with the common flu virus die from flu infection (CDC, 01-10-2020).

According to the Director General of the World Health Organization, “[The WHO-China Joint Commission has] found that there has been no significant change in the DNA of the virus and they found that the fatality rate is between 2% and 4% in Wuhan and 0.7% outside Wuhan. They found that for people with mild disease, recovery time is about two weeks while people with severe or critical disease recovery is within three to six weeks” (Ghebreyesus, 02-28-2020).

According to Dr. Anthony Fauci of the National Institute of Allergy and Infectious Diseases, which is part of the National Institutes of Health (NIH), “the mortality rate of the coronavirus [is] “dropping” to “only” 1%. It now stands at about 3.4%. A 1% mortality rate is 10 times higher than the common flu”(Stanton, 03-12-2020). To clarify this, Fauci and others add in a scholarly journal article, “If one assumes that the number of asymptomatic or minimally symptomatic cases is several times as high as the number of reported cases, the case fatality rate may be considerably less than 1%. This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968)” (Fauci et al., 02-28-2020).

“This first preliminary description of outcomes among patients with COVID-19 in the United States indicates that fatality was highest in persons aged ≥85, ranging from 10% to 27%, followed by 3% to 11% among persons aged 65–84 years, 1% to 3% among persons aged 55-64 years, <1% among persons aged 20–54 years, and no fatalities among persons aged ≤19 years.” With this data within the United States, 12% of COVID-19 infected patients required hospitalization (CDC, “Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19). . ,” 03-26-2020).

The main determining factor in how a patient responds to the coronavirus is their immune system, which resonates with the findings from SARS (severe acute respiratory syndrome) (Johnson, 02-19-2020).  “The people who are at greatest risk are those older and who also have serious long-term health conditions like diabetes, heart disease, or lung disease” (CDC, 03-09-2020).

As of April 15, 2020, there is a 6.4% chance of dying from COVID-19 infection globally, 3.4% in the Western Pacific region, 8.7% in the European region, 5.0% in the Eastern Mediterranean region, and a 4.1% chance of dying from COVID-19 infection within the “regions of the Americas.” Within the United States of America, there is a 4.1% chance of dying from COVID-19 infection, and there have been 23,476 deaths to date (WHO, “Situation Report- 86,” 04-15-2020). These rates do NOT include those who may have been infected but did not have concerning symptoms that led to testing.

 COVID-19: U.S. at a Glance:  approximate total cases: 691,000; approximate total deaths: 35,500 (CDC, “Cases in the U. S.,” 04-18-2020). With these more current results, the risk of dying within the United States, and five territories, is 5.1%. These rates do NOT include those who may have been infected but did not have concerning symptoms that led to testing.

Throughout the state of Texas, there have been about 22,000 “confirmed and presumptive positive” cases with COVID-19 infection, 1649 of them are currently hospitalized, and 561 of the cases have died. Over 225,000 tests have been performed (TDSHS, “Texas Case Counts: COVID-19,” 04-23-2020). This calculates to a 2.55% mortality rate of those with a positive test, which is consistent with worldwide experts for the mortality rate of the common flu. These and past numbers also indicate that at least 16% of those with a positive result become hospitalized, and that about 10% of the tests result in a positive for COVID-19 infection.

“Reports out of China that looked at more than 70,000 COVID-19 [infected] patients found that about 80% of illness [was] mild and people recovered, [and] 15 to 20% developed serious illness” (CDC, 03-09-2020).

 “[COVID-19 infected] patients who reported no underlying medical conditions had an overall case fatality of 0.9%” (CDC, accessed 03-16-2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html). “An overall case fatality proportion of 2.3% has been reported among confirmed cases of COVID-19 in China” (CDC, accessed 03-16-2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html).

Transmission and Spread

Coronavirus is spread by sneezing and coughing within a six-foot range (Johnson, 02-19-2020; NCIRD, 02-25-2020). A secondary way for infection is by contacting a contaminated surface and then touching the mouth, nose, or eye (NCIRD, 02-25-2020).

“People are thought to be most contagious when they are most symptomatic (the sickest). Some spread might be possible before people show symptoms; there have been reports of this occurring with this new coronavirus, but this is not thought to be the main way the virus spreads” (CDC, “How COVID-19 Spreads,” 03-04-2020).

“Based on what is currently known about COVID-19 and what is known about other coronaviruses, spread is thought to occur mostly from person-to-person via respiratory droplets among close contacts. Close contact can occur while caring for a patient, including being within approximately 6 feet (2 meters) of a patient with COVID-19 for a prolonged period of time and having direct contact with infectious secretions from a patient with COVID-19. Infectious secretions may include sputum, serum, blood, and respiratory droplets” (CDC, “What Healthcare Personnel Should Know about Caring for Patients with Confirmed or Possible COVID-19 Infection,” 03-10-2020).

When caring for a loved one within the home, who has or is suspected of having COVID-19 infection, the CDC has specific guidance for caregivers (CDC, https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-prevent-spread.html, 03-06-2020).

“On March 13, [2020], the President of the United States declared the COVID-19 outbreak a ‘national emergency’. . . Different countries can be in different phases of the pandemic at any point in time and different parts of the same country can also be in different phases of a pandemic. . . Different parts of the country are seeing different levels of COVID-19 activity. . . The United States nationally is currently in the initiation phases, but states where community spread is occurring are in the acceleration phase. The duration and severity of each phase can vary depending on the characteristics of the virus and the public health response. . . Three U.S. states are experiencing sustained community spread [New York, California, Washington] (CDC, “Situation Summary,” 03-18-2020).

As of April 19, 2020, within Texas, COVID-19 infection is “confirmed and presumptive positive” in 2683 Dallas County residents and 584 Collin County residents. Throughout the state, there are about 22,000 “confirmed and presumptive positive” cases with COVID-19 infection, and 561 of them have died. From graphical information, it seems the peak of the infection curve was April 10, 2020. It also seems that there has not been a peak yet with the mortality curve, but based in the infection curve, the mortality curve may peak at the end of April 2020. Over 225,000 tests have been performed. The first known COVID-19 infection within the state of Texas was on March 4, 2020 (TDSHS, “Texas Case Counts: COVID-19,” 04-23-2020).

As of April 23, 2020, within Texas, the COVID-19 infection experience by race are 36.7% white, 25.8% Hispanic, 11.5% black, and 21.1% unknown (TDSHS, “Texas Case Counts: COVID-19,” 04-19-2020). As of April 23, 2020, in Collin County, TX: “There are 14 net new cases of COVID-19 in Collin County today, as of 3:30 p.m. There are 149 current cases of COVID-19 in Collin County (total cases minus recovered and deceased). There have been 584 total confirmed positive cases of COVID-19 in Collin County. 421 people have successfully recovered; 17 are hospitalized; 132 remain in home isolation.  There have been 14 confirmed deaths associated with COVID-19 in Collin County. There have been 4,288 negative COVID-19 tests in Collin County. There are 873 Persons Under Monitoring (PUM) in Collin County” (Collin County, “Health News & Advisories,” 04-23-2020). Collin County has had 4909 tests (City of Plano, “COVID-19 Cases,” 04-23-2020). Based on graphing data, it seems the peak of active infections was April 9, 2020.

As of April 23, 2020, in Dallas County, TX: There are 2683 confirmed positive cases of COVID-19 in Dallas County, with 72 deaths. The peak of hospitalization was March 27, 2020 (Dallas County, “2019 Novel Coronavirus (SARS-CoV-2/COVID-19),” 04-23-2020). As of April 23, 2020, within Dallas County there are 2763 positive cases of COVID-19 infection, 13,000 COVID-19 tests have been performed, and there have been 72 deaths as a result of COVID-19 infection (City of Dallas, 04-23-2020). With this, 21% of the tests have provided a positive result of COVID-19 infection, and the mortality rate in the county is 2.6% of those who tested positive for COVID-19. Based upon graphing data, it seems the peak of current infections in Dallas County was April 6, 2020, and the peak of mortality has not yet occurred.

Dallas County: “The numbers of hospital admissions and intensive care hospitalizations for COVID‐19 for the week ending 4/11  (Week 15) declined from the preceding 2 weeks.” Based on graphical information, the peak of hospitalizations was on March 27, 2020, and the peak of all cases was on April 6, 2020. This is the rationale for the Governor to open up business more (Dallas, County, “Dallas County Health and Human Services: 2019 Novel Coronavirus (COVID‐19) Summary,” April 17, 2020; cf. Abbott, 04-17-2020).

As of April 23, 2020, in Plano, Texas, there are 171 confirmed cases of COVID-19 infection, 9 of them are hospitalized, 131 have recovered from infection, and one city case, who had “an underlying health condition,” had died. . “When you can’t stay home, Be SMART. Work Smart, Shop Smart and always follow the Smart Health Tips” (City of Plano, “COVID-19 Cases,” April 23, 2020).

Symptoms and Testing

Coughing, sneezing, common cold symptoms, infection of the upper airway making breathing more difficult, infection deeper into the lungs, loss of lung function (Johnson, 02-19-2020).

“The following symptoms may appear 2-14 days after exposure:fever, cough, shortness of breath” (CDC, “Symptoms,” 03-16-2020).

“Common signs of infection include respiratory symptoms, fever, cough, shortness of breath and breathing difficulties. In more severe cases, infection can cause pneumonia, severe acute respiratory syndrome, kidney failure and even death” (CDC, https://www.who.int/health-topics/coronavirus, accessed 03-16-2020).

“If you develop emergency warning signs for COVID-19 get medical attention immediately. Emergency warning signs include difficulty breathing or shortness of breath, persistent pain or pressure in the chest, new confusion or inability to arouse, bluish lips or face. This list is not all inclusive. The CDC has a self-checker to assess symptoms: (https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html). Please consult your medical provider for any other symptoms that are severe or concerning” (CDC, “Symptoms,” 03-16-2020).

If you have these symptoms, the CDC recommends that the first thing you do is to CALL YOUR DOCTOR. The CDC does NOT want you to go to your doctor or other health care facility for the safety of all. Your doctor will ask you some questions and directly you appropriately. (CDC, “What to Do if You Are Sick,” 03-16-2020; cf. TDSHS).

“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” (WHO, “Coronavirus Disease (COVID-19) Advice for the Public,” 03-18-2020; cf. TDSHS).

As of March 25, 2020, there have been about 93,000 specimens tested by CDC laboratories and public health laboratories within the United States for COVID-19 infection. After March 16, 2020, the numbers of tests done daily almost doubled (CDC, “Testing in U. S.,” 03-25-2020).

Prevalence of Common Flu and Novel Coronavirus Infection

“The true death rate could turn out to be similar to that of a severe seasonal flu, below 1 percent, according to an editorial published in [The New England Journal of Medicine] by Dr. Anthony S. Fauci and Dr. H. Clifford Lane, of the National Institute of Allergy and Infectious Diseases, and Dr. Robert R. Redfield, director of the Centers for Disease Control and Prevention” (Grady, 03-01-2020).

Since 2012, each year in the United States there are about 24-34 million cases of “symptomatic illness” of the flu (CDC, 01-10-2020).

“As of Feb. 22, [2020], in the current season there were at least 32 million cases of flu in the United States, 310,000 hospitalizations and 18,000 flu deaths, according to the CDC. Hospitalization rates among children and young adults this year have been unusually high. To contrast, on April 18, 2020, COVID-19: U.S. at a Glance: approximate total cases 691,000; approximate total deaths 35,500; jurisdictions reporting cases 55 (50 states, District of Columbia, Puerto Rico, Guam, US Virgin Islands, and the North Marianas)” (CDC, “Cases of Coronavirus Disease (COVID-19) in the U.S.,” 04-18-2020).

 “As of the evening of March 8, [2020],78 state and local public health labs in 50 states and the District of Columbia have successfully verified and are currently using COVID-19 diagnostic tests. Combined with other reagents that CDC has procured, there are enough testing kits to test more than 75,000 people” (CDC, 03-09-2020).

As of April 13, 2020, 287 Texans have died from COVID-19 infection. As of April 3, 2020, 2650 Texans have died from pneumonia and influenza this season (09-29-2019 to 01-29-2020) (TDSHS, “Texas Influenza Surveillance Report 2019-2020 Season/2020 MMWR Week 13,” 04-03-2020).

As of April 4, 2020, there have been 51,256 Texans who have tested positive at hospital laboratories for the flu virus this current season. Over 206,000 Texas have been tested for the flu. Based on graphing information, the peak of the flu season was the last week of December 2019 (TDSHS, “Texas Influenza Surveillance Report 2019-2020 Season/2020 MMWR Week 14,” 04-04-2020).

Risk Factors

Advanced age, underlying chronic illnesses, diabetes, high blood pressure (Johnson, 02-19-2020; TDSHS, 03-15-2020; WHO, “Situation Report 51,” 03-11-2020). “Those with . . .  cardiovascular disease [and] chronic respiratory disease are [also] at risk for severe disease” (WHO, “Situation Report 51,” 03-11-2020; cf. TDSHS, 03-15-2020). Included in this list are those with cancer (TDSHS, 03-15-2020).

“For most people, COVID-19 infection will cause mild illness however, it can make some people very ill and, in some people, it can be fatal. (WHO, 03-08-2020).

Countries Affected by Novel Coronavirus

Began in China (CDC, 02-25-2020; Johnson, 02-19-2020, Noack, et al., 02-20-2020).

“This epidemic is a threat for every country, rich and poor. As we have said before, even high-income countries should expect surprises. The solution is aggressive preparedness” (WHO, 03-05-2020).

“These are plans that start with leadership from the top, coordinating every part of government, not just the health ministry – security, diplomacy, finance, commerce, transport, trade, information and more – the whole government should be involved” (WHO, 03-05-2020).

Prevention of Flu/COVID-19 Spread

“CDC recommends getting a flu vaccine, taking everyday preventive actions to help stop the spread of germs, and taking flu antivirals if prescribed” (CDC, 02-25-2020).

“At this time, there is no vaccine to protect against COVID-19 and no medications approved to treat it” (CDC, 04-02-2020). “The FDA has been working closely with other government agencies and academic centers that are investigating the use of the drug chloroquine, which is already approved for treating malaria, lupus and rheumatoid arthritis, to determine whether it can be used to treat patients with mild-to-moderate COVID-19 to potentially reduce the duration of symptoms, as well as viral shedding, which can help prevent the spread of disease. Studies are underway to determine the efficacy in using chloroquine to treat COVID-19. . . While there are no FDA-approved therapeutics or drugs to treat, cure or prevent COVID-19, there are several FDA-approved treatments that may help ease the symptoms from a supportive care perspective. . . The FDA remains steadfast in helping to foster the development of safe and effective medical countermeasures and ensuring they are available as quickly as possible to protect public health and safeguarding Americans from fraudulent products claiming to prevent, treat, or diagnose COVID-19 as part of the agency’s around-the-clock response to this outbreak.” (FDA, 03-19-2020).

“People can protect themselves and their communities by taking steps such as frequent handwashing, avoiding contact with people who are sick and staying home if they develop symptoms, health authorities say” (Abbott, 03-01-2020).

Definition of contact “A contact is a person who experienced any one of the following exposures during the 2 days before and the 14 days after the onset of symptoms of a probable or confirmed case: 1. Face-to-face contact with a probable or confirmed case within 1 meter and for more than 15 minutes; 2. Direct physical contact with a probable or confirmed case; 3. Direct care for a patient with probable or confirmed COVID-19 disease without using proper personal protective equipment; OR 4. Other situations as indicated by local risk assessments. Note: for confirmed asymptomatic cases, the period of contact is measured as the 2 days before through the 14 days after the date on which the sample was taken which led to confirmation” (WHO, “Situation Report- 90,” 04-19-2020).

“While we won’t have exact figures until after the flu season is over, the 2019-2020 vaccine is estimated to be 45% effective overall and 55% effective in children. In comparison, the 2018-2019 flu vaccine was roughly 29% effective” (Schumaker, February 21, 2020).

“Partly because of these misconceptions, only half of Americans reported that they planned to get the flu vaccine this year, according to a survey conducted by the National Foundation for Infectious Diseases this summer” (Schumaker, 03-02-2020).

“Avoid close contact with people who are sick,  avoid touching your eyes, nose, and mouth, stay home when you are sick, cover your cough or sneeze with a tissue and then throw the tissue in the trash, clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe. Follow [the] CDC’s recommendations for using a facemask; [the] CDC does not recommend that people who are well wear a facemask to protect themselves from respiratory diseases, including COVID-19. Facemasks should be used by people who show symptoms of COVID-19 to help prevent the spread of the disease to others. The use of facemasks is also crucial for health workers and people who are taking care of someone in close settings (at home or in a health care facility). 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. If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. Always wash hands with soap and water if hands are visibly dirty. For information about handwashing, see CDC’s Handwashing website. For information specific to healthcare, see CDC’s Hand Hygiene in Healthcare Settings. These are everyday habits that can help prevent the spread of several viruses. CDC does have specific guidance for travelers” (CDC, 02-15-2020).

For older adults and those with pre-existing conditions, the CDC recommends “When you have visitors to your home, exchange “1 metre greetings”, like a wave, nod, or bow. Ask visitors and those you live with to wash their hands. Regularly clean and disinfect surfaces in your home, especially areas that people touch a lot. If someone you live with isn’t feeling well (especially with possible COVID-19 symptoms), limit your shared spaces. If you become ill with symptoms of COVID-19, contact your healthcare provider by telephone before visiting your healthcare facility. Make a plan in preparation for an outbreak of COVID-19 in your community. When you go out in public, follow the same preventative guidelines as you would at home. Stay up to date using information from reliable sources” (CDC, “Situation Report 51,” 03-11-2020).

“The World Health Organization (WHO) reminds all countries and communities that the spread of this virus can be significantly slowed or even reversed through the implementation of robust containment and control activities” (WHO, 03-07-2020).

“We must stop, contain, control, delay and reduce the impact of this virus at every opportunity. Every person has the capacity to contribute, to protect themselves, to protect others, whether in the home, the community, the healthcare system, the workplace or the transport system” (WHO, 03-07-2020).

“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” (WHO, 2020).

“If you are not in an area where COVID-19 is spreading or have not travelled from an area where COVID-19 is spreading or have not been in contact with an infected patient, your risk of infection is low. . . If you are in an area where there are cases of COVID-19 you need to take the risk of infection seriously. Follow the advice of WHO and guidance issued by national and local health authorities. For most people, COVID-19 infection will cause mild illness however, it can make some people very ill and, in some people, it can be fatal. Older people, and those with pre-existing medical conditions (such as cardiovascular disease, chronic respiratory disease or diabetes) are at risk for severe disease” (WHO, “Situation Report- 59,” March 19, 2020).

“The fight against rumours and misinformation is a vital part of the battle against this virus. . . If countries act aggressively to find, isolate and treat cases, and to trace every contact, they can change the trajectory of this epidemic” (WHO, 03-05-2020). From Dr. Nancy Messonnier of the CDC, “I want to clarify the reason to stock up is that there is a rationale for being in a higher risk group wanting to avoid congregate settings. . .Right now, in the United States, most communities. . . are not having community transmission. . . We really do not think this is the time for Americans to be going out and getting masks. . . I also think people need to understand that there are personal responsibilities that we’re asking everyone in the United States to take to make sure that they’re doing their best to protect themselves and their families and their communities and right now especially to make really strong efforts to protect those who are older and at underlying risk.  As a community. . . we can really mitigate the impact of this disease and as long as we work together. You will see . . . more communities starting to implement some kind of mitigation measures when they’re seeing community spread. [For those who are] older and [have] underlying illnesses, we are recommending avoiding crowds, congregate settings because those are places where in general there is lots of transmission of respiratory diseases” (CDC, 03-09-2020). Wash your hands often with soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based hand sanitizer. “Avoid touching your eyes, nose, and mouth with unwashed hands, avoid close contact with people who are sick, stay home when you are sick, cover your cough or sneeze with a tissue, then throw the tissue in the trash, clean and disinfect frequently touched objects and surfaces” (TDSHS, 03-15-2020).

“Businesses are strongly encouraged to coordinate with state and local health officials so timely and accurate information can guide appropriate responses. Local conditions will influence the decisions that public health officials make regarding community-level strategies. . . If an employee is confirmed to have COVID-19 infection, employers should inform fellow employees of their possible exposure to COVID-19 in the workplace but maintain confidentiality as required by the Americans with Disabilities Act (ADA). The fellow employees should then self-monitor for symptoms (i.e., fever, cough, or shortness of breath).” (CDC, “Interim Guidance for Businesses and Employers to Plan and Respond to Coronavirus Disease 2019 (COVID-19),” 03-22-2020).

“Avoid gatherings of more than 10 people and non-essential trips into public, cancel events of more than 10 people, limit close contact (at least six feet) with other people, employers should allow alternative work options as much as possible” (TDSHS, 03-18-2020).

“DSHS also recommends that you start practicing social distancing. Social distancing involves staying away from other people to avoid catching or spreading illness. It’s a fancy term for avoiding crowds and minimizing physical contact. This could mean avoiding concerts or weddings, skipping the handshake, and/or staying at least six feet away from others” (TDSHS, 03-18-2020).

“If you work in a critical infrastructure industry. . . such as healthcare services and pharmaceutical and food supply, you have a special responsibility to maintain your normal work schedule” (Trump, 03-16-2020).

“Texas Gov. Greg Abbott on Thursday [March 19, 2020] closed schools for more than 5 million students for at least two week, and warned that during that time the coronavirus outbreak could spread to ‘tens of thousands’ of cases across the state” (Vertuno and Weber, Associated Press, 03-19-2020).

“[Collin] County health officials urge residents to follow advice and guidelines from the CDC or [Texas] DSHS websites, where the daily updated information is posted, including advice and information for travelersbusinesses and healthcare providershow the virus spreadsits symptoms, and how to protect yourself” (Collin County Texas, 03-18-2020).

“On March 16, 2020, The City of Plano declared a local state of disaster for public health emergency. . . Restaurants with or without drive-in or drive through services; drive-in restaurants; drive-through restaurants; or microbreweries, micro-distilleries, or wineries may only provide take out, delivery, or drive-in or drive- through services as allowed by law effective March 18, [2020], at 5 p.m. until April 27, [2020] (may be revisited or repealed by the Mayor or City Council at an earlier date). All bars, lounges, or taverns; theaters; gyms; and private clubs are closed effective March 18, [2020], at 5 p.m. until April 27, [2020] (may be revisited or repealed by the Mayor or City Council at an earlier date)” (City of Plano, 03-18-2020).

“With guidance from [Governor Abbott], the Texas State Board of Dental Examiners is directing all licensees to follow CDC guidelines regarding elective dental procedures. Please note, a strict interpretation may not necessarily be the best interpretation, and each licensee should use their professional judgement when making these decisions” (TSBDE, 03-22-2020).

“In his press conference today, Governor Abbott issued an executive order restricting healthcare professionals and facilities.  According to the Executive Order No. GA-09, “beginning now and continuing until 11:59 p.m. on April 21, 2020, all licensed health care professionals and all licensed health care facilities shall postpone all surgeries and procedures that are not immediately medically necessary to correct a serious medical condition of, or to preserve the life of, a patient who without immediate performance of the surgery or procedure would be at risk for serious adverse medical consequences or death, as determined by the patient’s physician; PROVIDED, however, that this prohibition shall not apply to any procedure that, if performed in accordance with the commonly accepted standard of clinical practice, would not deplete the hospital capacity or the personal protective equipment needed to cope with the COVID- 19 disaster. . . The Governor is addressing a shortage of hospital capacity” (TSBDE, 03-29-2020; cf. Abbott, “Executive Order No. GA-09,” 03-22-2020). With this, dental offices not using N-95 respirator masks can be open as usual, as long as their procedures will not have a likelihood of causing a hospitalization. “A surgical mask protects against microorganisms generated by the wearer, with >95% bacterial filtration efficiency, and also protects DHCP from large-particle droplet spatter that might contain bloodborne pathogens or other infectious microorganisms . . . When airborne infection isolation precautions (expanded or transmission-based) are necessary (e.g., for TB patients), a National Institute for Occupational Safety and Health (NIOSH)-certified particulate-filter respirator (e.g., N95, N99, or N100) should be used (20). N95 refers to the ability to filter 1-µm particles in the unloaded state with a filter efficiency of >95%” (CDC, “Guidelines for Infection Control in Dental Health-Care Settings — 2003,” 17).

FACEMASKS: “Use facemasks according to product labeling and local, state, and federal requirements. FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays” (CDC, “Resources for Clinics and Healthcare Facilities,” 03-17-2020). WHO recommendation is to wear a facemask “if you are taking care of a person with suspected 2019-nCoV infection; if you are coughing or sneezing; and, only when used in combination with frequent hand-cleaning with alcohol-based hand rub or soap and water. If you wear a mask, then you must know how to use it and dispose of it properly. Before putting on a mask, clean hands with alcohol-based hand rub or soap and water. Cover mouth and nose with mask and make sure there are no gaps between your face and the mask. Avoid touching the mask while using it; if you do, clean your hands with alcohol-based hand rub or soap and water. Replace the mask with a new one as soon as it is damp and do not re-use single-use masks. To remove the mask: remove it from behind (do not touch the front of mask); discard immediately in a closed bin; clean hands with alcohol-based hand rub or soap and water” (WHO, “Coronavirus Disease (COVID-19) Advice for the Public: When and How to Use Masks,” undated).  “To prevent infectious disease transmission, elimination (physically removing the hazard) and substitution (replacing the hazard) are not typically options for the healthcare setting. . . N95 respirators are the PPE most often used to control exposures to infections transmitted via the airborne route, though their effectiveness is highly dependent upon proper fit and use. The optimal way to prevent airborne transmission is to use a combination of interventions from across the hierarchy of controls, not just PPE alone. Applying a combination of controls can provide an additional degree of protection, even if one intervention fails or is not available. Respirators, when required to protect HCP from airborne contaminants such as infectious agents, must be used in the context of a comprehensive, written respiratory protection program that meets the requirements of OSHA’s Respiratory Protection . The program should include medical evaluations, training, and fit testing” (CDC, “Strategies for Optimizing the Supply of N95 Respirators,” 02-29-2020).

“Healthcare facilities and clinicians should prioritize urgent and emergency visits and procedures now and for the coming several weeks. The following actions can preserve staff, personal protective equipment, and patient care supplies; ensure staff and patient safety; and expand available hospital capacity during the COVID-19 pandemic: delay all elective ambulatory provider visits, reschedule elective and non-urgent admissions, delay inpatient and outpatient elective surgical and procedural cases, postpone routine dental and eyecare visits” (CDC, “Resources for Clinics and Healthcare Facilities,” 03-16-2020).

“Caring for patients requiring Transmission-Based Precautions is not possible in most dental settings as they are not designed for or equipped to provide this standard of care. For example, most dental settings do not have airborne infection isolation rooms or single-patient rooms, do not have a respiratory protection program, and do not routinely stock N95 respirators. . . Services should be limited to urgent and emergency visits only during this period of the pandemic. These actions help staff and patients stay safe, preserve personal protective equipment and patient care supplies, and expand available health system capacity. . . Call all patients before their scheduled appointments and screen for symptoms of respiratory illness over the phone (e.g., fever, cough, shortness of breath). People with COVID-19 who have completed home isolation clearance can receive emergency dental care. This is defined as at least 3 days (72 hours) have passed since recovery (resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms, e.g., cough, shortness of breath), and at least 7 days have passed since symptoms first occurred, or for individuals with laboratory-confirmed COVID-19 who have not had any symptoms, at least 7 days have passed since the date of the first positive COVID-19 diagnostic test and have had no subsequent illness” (CDC, “Dental Settings: Interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response,” 03-26-2020).

“TDA has been in contact with the Texas State Board of Dental Examiners and Governor Abbott’s office. As of March 16, 2020, at 5:00 p.m. central, there are no federal or state directives mandating dental office closures. State governments and dental associations are issuing specific COVID-19 guidance, including the American Dental Association’s recommendation issued on Monday, March 16. TDA members are encouraged to review available resources and apply that information to their individual situations when making a decision about whether to keep offices open and whether to triage non-emergency dental care. Absent governmental directives (whether federal, state, county, or municipal), it is up to each individual dentist to exercise their professional judgement in deciding what additional precautions should be implemented and whether or how to continue dental office operations. . . Should your practice remain open, TDA recommends all offices implement heightened levels of disinfection” (TDA, 03-29-2020).

“Should your practice remain open, TDA recommends all offices implement heightened levels of disinfection. TDA recommends anyone identifying with the following, including staff, not go to the dentist for elective procedures: Fever, currently has a cough or shortness of breath, history of significant chronic illness, compromised immune system, you or a family member are considered high-risk, you or a family member have travelled to a location with a level 3 travel health notice, airline travel in the past 2 weeks, previously asked to self-isolate or self-quarantine, close contact to an individual diagnosed with COVID-19 infection” (TDA, 03-25-2020).

“During a March 17, 2020, White House press conference, Dr Deborah Birx, who is coordinating the Trump administration’s response to the pandemic, announced that all doctors and dentists should avoid performing ‘elective surgeries’ . . . As of noon today [03-18-2018] there is no Texas state directive for dental office closures” (Miller of Texas Dental Association, 03-18-2020).

Governmental Actions to Prevent Community Spread

Dallas County, TX, March 24, 2020 through April 3, 2020: “All elective medical, surgical, and dental procedures are prohibited anywhere in Dallas County. Hospitals, ambulatory surgery centers, dental offices, and other medical facilities are directed to identify procedures that are deemed “elective” by assessing which procedures can be postponed or cancelled based on patient risk considering the emergency need for redirection of resources to COVID-19 response” (Dallas County, “2019 Novel Coronavirus (COVID-19),” 03-23-2020).  The 2020 population of Dallas County is over 2.6 million while the same for Collin County is just over one million (World Population Review, “Population of Counties in Texas (2020),” 03-23-2020). 

Collin County, TX, March 24, 2020, for possibly up to seven days: “If any person in a household has tested positive for COVID-19, all persons in the household are hereby ordered to stay home. Members of the household may not travel to work, school, or any other community function until cleared by a medical professional. This order does not prohibit any person from leaving his or her home to seek necessary medical or emergency care. All persons in Collin County are hereby ordered to stay home, except for travel related to essential activities. Entertainment activities are not considered essential activities. . . This order does not prohibit any person from leaving his or her home to seek necessary medical or emergency care. . . All businesses and employers are hereby ordered to take actions necessary to prevent the spread of COVID-19, to increase social distancing in the normal course of business activities, and to provide for a safe and healthy work environment. . . Where social distancing is not possible in the normal course of business activities, extreme care should be taken to reduce the risk of exposure to, and transmittal of, germs and COVID-19. . . Pursuant to Governor Greg Abbott’s March 19 Executive Order, every person in Texas shall avoid gatherings in groups of more than 10. Furthermore, persons shall avoid eating or drinking at bars, restaurants, and food courts, or visiting gyms or massage parlors. However, the use of drive-thru, pickup, or delivery options for bars, restaurants, and food courts is allowed and highly encouraged throughout the limited duration of his Executive Order. All businesses, jobs, and workers are essential to the financial health and well-being of our local economy and therefore are essential to the financial health and well-being of Collin County citizens. Persons who are employed need to stay employed. Persons who lack employment need to gain employment. Businesses that are able to remain open need to remain open” (Hill, 03-24-2020).

Dentists are considered as Essential Critical Infrastructure Workers by the United States Department of Homeland Security, Cybersecurity and Infrastructure Security Agency. Included are “workers required for effective clinical, command, infrastructure, support service, administrative, security, and intelligence operations across the direct patient care and full healthcare and public health spectrum. Personnel examples may include, but are not limited, to accounting, administrative, admitting and discharge, engineering, accrediting, certification, licensing, credentialing, epidemiological, source plasma and blood donation, food service, environmental services, housekeeping, medical records, information technology and operational technology, nutritionists, sanitarians, respiratory therapists, etc. . . [and] workers that manage health plans, billing, and health information and who cannot work remotely” (Krebs, March 28, 2020).

“All persons in Collin County are hereby ordered to stay home, except for travel related to essential activities. All businesses and employers are hereby ordered to take actions necessary to prevent the spread of COVID-19, to increase social distancing in the normal course of business activities, and to provide for a safe and healthy work environment. All persons are hereby ordered to take actions necessary to prevent the spread of COVID-19 and to increase social distancing in the normal course of business activities” (Collin County Texas, “Health News & Advisories,” 03-29-2020).

President Trump on March 29, 2020: “President Donald Trump said Sunday [March 29, 2020] he would extend nationwide social distancing guidelines for another 30 days, an abrupt back-down from his push to reopen the country as coronavirus continues to spread” (LeBlanc et al., CNN, 03-29-2020). 

Dallas County Judge Clay Jenkins on March 29, 2020: This order is “effective as of 11:59 p.m. on March 29, 2020 and continuing until 11:59 p.m. on April 3, 2020. All individuals currently living within Dallas County are ordered to shelter at their place of residence. . . All persons may leave their residences only for Essential Activities, or to provide or perform Essential Governmental Functions, or to operate Essential Businesses. . . All public or private gatherings of any number of people occurring outside a single household or living unit are prohibited, except as otherwise provided herein. . . All elective medical, surgical, and dental procedures are prohibited anywhere in Dallas County (Dr. Venincasa’s office is in Collin County). . . For purposes of this Order, individuals may leave their residence only to perform any of the following “Essential Activities”: To engage in activities or perform tasks essential to their health and safety, or to the health and safety of their family or household members; to obtain necessary services or supplies for themselves and their family or household members, or to deliver those services or supplies to others (for example, food, pet supply, and any other household consumer products, and products necessary to maintain the safety, sanitation, and essential operation of residences; to engage in outdoor activity, provided the individuals comply with social distancing requirements of six feet (for example, walking, biking, hiking, running, golfing, and tennis); to perform work providing essential products and services at an Essential Business or to otherwise carry out activities specifically permitted in this Order; o care for a family member or pet in another household; to move to another residence either in or outside Dallas County; to engage in “Essential Travel,” which includes travel for any of the following purposes: (1) travel related to the provision of or access to Essential Activities, Essential Governmental Functions, Essential Businesses Essential Critical Infrastructure, and Minimum Basic Operation; (2) travel to care for elderly, minors, dependents, persons with disabilities, or other vulnerable persons; (3) travel to or from educational institutions for purposes of receiving materials for distance learning, for receiving meals, and any other related services; (4) travel to return to a place of residence from outside the jurisdiction; (5) travel required by law enforcement or court order; (6) travel by church staff or clergy for the purpose of production of remote delivery of religious services and other ministries requiring travel; (7) travel related to attending a funeral service; or (8) travel required for non-residents to return to their place of residence outside the County. . . Due to increased demand for bath or toilet tissue resulting from stock up buying and individuals who purchase for resale, a mandatory limit on toilet paper sales is instituted until the supply chain meets the demand or two weeks, whichever comes first. All sales of bath or toilet tissue occurring in Dallas County are limit.” (Jenkins, Dallas County, 03-29-2020).

Within the state of Texas on March 31, 2020. “Texas Gov. Greg Abbott (R) issued an Executive Order Tuesday [March 31, 2020] implementing Essential Services and Activities Protocols for the entire state of Texas. The governor did not issue a statewide stay-at-home order, as some had called on him to do, and the public is free to continue accessing essential services or conducting essential daily activities as defined below. The protocols put into place Tuesday will run through April 30 and, ‘direct all Texans to minimize non-essential gatherings and in-person contact with people who are not in the same household.’ The order was expanded to include avoiding tattoo studios, piercing studios and cosmetology salons. . .  those in essential services such as healthcare, grocery stores, banking and financial services, utilities, childcare for essential service employees, and government services are permitted to continue operations. . . Abbott added no public school will return to class or in-person instruction before May 4, [2020]. In accordance with federal guidelines, people are still prohibited from visiting nursing home, state supported living centers, assisted living facilities, or long-term care facilities unless to provide critical assistance. . . Essential Daily Activities [include] going to the grocery store or gas station, providing or obtaining essential services, hunting or fishing, engaging in physical activity like jogging or bicycling, so long as “physical distancing” guidance is followed; and religious services conducted in churches, congregations, and houses of worship are allowed. All critical infrastructure will remain operational, and government entities and businesses will continue providing essential services. . . Essential Services Sectors healthcare / public health, law enforcement, public safety and other first responders, Food and agriculture, Energy, Water and wastewater,  transportation and logistics, public works and infrastructure support services; communications and Information Technology; community or government-based operations, critical manufacturing, hazardous materials, financial services, chemical, defense industrial base, commercial facilities, Residential/Shelter facilities and services, Hygiene products and service, and religious services conducted in churches, congregations, and houses of worship. . . As with all the actions the state is taking, the Essential Services and Activities Protocols is informed by the expertise and guidance of the CDC as well as state and local health officials. . . In accordance with federal guidelines, people are still prohibited from visiting nursing home, state supported living centers, assisted living facilities, or long-term care facilities unless to provide critical assistance. Additionally, schools will remain temporarily closed to in-person classroom attendance through May 4, 2020.” (Abbott, in NBC5DFW, 03-31-2020; cf. Abbott, 03-31-2020).

State of Texas: “At this time, dental offices are not mandated to close. Dental offices may stay open to see patients for emergency procedures only. Patients in pain and/or suffering from infection/abscess would fall under the executive order provision that states, ‘a patient who without immediate performance of the surgery or procedure would be at risk for serious adverse medical consequences.’ Non-essential dental procedures, such as cleanings and fillings, must be postponed. Again, only emergency procedures are allowed at this time, period.  Violation of executive orders could lead to potential fines and even jail time for those who do not comply” (TSBDE, 03-31-2020).  

State of Texas: Because “a shortage of hospital capacity or personal protective equipment would hinder efforts to cope with the COVID-19 disaster; and . . . hospital capacity and personal protective equipment were being depleted by surgeries and procedures that were not medically necessary to correct a serious medical condition or to preserve the life of a patient, contrary to recommendations from the President’s Coronavirus Task Force, the Centers for Disease Control and Prevention, the U.S. Surgeon General, and the Centers for Medicare and Medicaid Services, . . . I issued Executive Order GA-09 on March 22, 2020, in an effort to avoid a shortage of hospital capacity or personal protective equipment, and it is subject to expiration at 11:59 p.m. on April 21, 2020, absent further action by the governor. . . Therefore, I, Greg Abbott, Governor of Texas, by virtue of the power and authority vested in me by the Constitution and laws of the State of Texas, do hereby order the following on a statewide basis beginning at 11:59 p.m. on April 21, 2020, and continuing until 11:59 p.m. on May 8, 2020: All licensed health care professionals and all licensed health care facilities shall postpone all surgeries and procedures that are not medically necessary to diagnose or correct a serious medical condition of, or to preserve the life of, a patient who without timely performance of the surgery or procedure would be at risk for serious adverse medical consequences or death, as determined by the patient’s physician; provided, however, that this prohibition shall not apply to . . .  any procedure that, if performed in accordance with the commonly accepted standard of clinical practice, would not deplete the hospital capacity or the personal protective equipment needed to cope with the COVID-19 disaster” (Abbott, Executive Order GA-15, 04-17-2020; cf. TSBDE, 04-20-2020).

State of Texas: “Shelter-in-place mandates may prohibit non-emergency care or elective procedures” (TDA, 04-21-2020).

State of Texas: “The disease [COVID-19] still presents a serious threat across Texas that could persist in certain areas. . . apart from the threats to health and safety, COVID-19 has also wrought havoc on the many Texas businesses and workers affected by social-distancing restrictions that were necessary to protect human life; and . . . over one million unemployment claims have been filed during the COVID 19 disaster by conscientious Texans who want to get back to work as soon as it is safe to do so. . . [Gov. Abbott} does hereby order the following on a statewide basis effective immediately, and continuing through April 30, 2020, subject to extension based on the status of COV1D-19 in Texas and the recommendations of the CDC and the White House Coronavirus Task Force. . . Every person in Texas shall, except where necessary to provide or obtain essential services or reopened services, minimize social gatherings and minimize in-person contact with people who are not in the same household. . . People shall avoid eating or drinking at bars, restaurants, and food courts, or visiting gyms, massage establishments, tattoo studios, piercing studios, or cosmetology salons; provided, however, that the use of drive-thru, pickup, or delivery options for food and drinks is allowed and highly encouraged throughout the limited duration of this executive order. . . This executive order does not prohibit people from accessing essential or reopened services or engaging in essential daily activities, such as going to the grocery store or gas station, providing or obtaining other essential or reopened services, visiting parks, hunting or fishing, or engaging in physical activity like jogging or bicycling, so long as the necessary precautions are maintained to reduce the transmission of COVID- 19 and to minimize in-person contact with people who are not in the same household. . . This executive order shall supersede any conflicting order issued by local officials in response to the COVD-19 disaster, but only to the extent that such a local order restricts essential services or reopened services allowed by this executive order or allows gatherings prohibited by this executive order. . . This executive order supersedes Executive Order GA- 14, but does not supersede Executive Orders GA-09, GA-b, GA-li, GA-12, GA-13, or GA-15. This executive order shall remain in effect and in full force until 11:59 p.m. on April 30, 2020, unless it is modified, amended, rescinded, or superseded by the governor” (Abbott, “Executive Order GA-16,” 04-17-2020). “Dentists, hygienists, and patients have spent the past five days attempting to interpret whether trips to the dentist are allowed under Abbott’s executive order. . . ‘We get so many calls from so many doctors trying to say: Is this okay? Is that okay? Is this not okay?”’ Gov. Abbott said Wednesday morning during a radio appearance on KFYO-Lubbock’s Chad Hasty Show. ‘And there’s been a lot of— if you would— misreading on the doctor side more on the conservative side, we actually had allowed more surgical procedures than what doctors were thinking were allowed” (Rapoport, TDA, 04-22-2020).

This week, the Texas State Board of Dental Examiners issued new guidance interpreting Abbott’s updated order.

Dallas County: “Effective as of 11:10 a.m. on April 3, 2020, and continuing until 11:59 p.m. on April 30, 2020. . . All elective medical, surgical, and dental procedures are prohibited anywhere in Dallas County. Hospitals, ambulatory surgery centers, dental offices, and other medical facilities are directed to identify procedures that are deemed “elective” by assessing which procedures can be postponed or cancelled based on patient risk considering the emergency need for redirection of resources to COVID-19 response” (Jenkins, 04-03-2020). The dental office of Dr. Venincasa is in Collin County.

Treatment Options, The Future

“COVID-19 is an emerging disease and there is more to learn about its transmissibility, severity, and other features and what will happen in the United States” (NCIRD, 02-17-2020).

“There’s still a lot we don’t know, but every day we’re learning more, and we’re working around the clock to fill in the gaps in our knowledge” (WHO, 03-05-2020).

“If you are not in an area where COVID-19 is spreading or have not travelled from an area where COVID-19 is spreading or have not been in contact with an infected patient, your risk of infection is low” (WHO, 03-08-2020).

In China, Starbucks has “continued to see encouraging signs of recovery with over 90% of stores reopened” (Johnson, K., 03-11-2020; cf. Dahstrom and Duong, March 5, 2020). In their experience with China, “Starbucks would be among the first major brands to proactively close their retail stores, eventually totaling more than half of the company’s 4,300 stores that employ 58,000 people. . . In China, in normal times, a new Starbucks opens about every 15 hours” (Dahlstrom and Duong, March 5, 2020).

Are there any specific medicines to prevent or treat the new coronavirus? To date, there is no specific medicine recommended to prevent or treat the new coronavirus (2019-nCoV). However, those infected with the virus should receive appropriate care to relieve and treat symptoms, and those with severe illness should receive optimized supportive care. Some specific treatments are under investigation and will be tested through clinical trials. WHO is helping to accelerate research and development efforts with a range or partners” (WHO, “Coronavirus Disease (COVID-19) Advice for the Public,” 04-10-2020).

Mental Health Resources: The outbreak of COVID-19 may be stressful for people throughout the community. Fear and anxiety about a disease can be overwhelming and cause strong emotions in adults and children. Accordingly, we suggest the following recommendations: People with preexisting mental health conditions should continue with their treatment plans, stay connected with their healthcare provider, and monitor for any new symptoms; Call your healthcare provider if stress reactions interfere with your daily activities; Call the LifePath Crisis Hotline at (877) 422-5939 if you are experiencing emotional distress related to COVID-19” (Collin County, “Public Guidance for Novel Coronavirus (COVID-19),” April 19, 2020).

“WHO Director-General Dr. Tedros, in his regular media briefing yesterday, cautioned that ‘we have a long way to go. This virus will be with us for a long time.’ He added that ‘the world cannot go back to the way things were. There must be a new normal – a world that is healthier, safer and better prepared’” (WHO, “Situation Report- 94, 04-23-2020).

Sources Cited

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Abbott, Greg. Executive Order. “Executive Order GAO8 Relating to COVID-19 Preparedness and Mitigation” (March 19, 2020). Accessed March 22, 2020. https://www.tda.org/Portals/0/EO-GA_08_COVID-19_preparedness_and_mitigation_FINAL_03-19-2020_1.pdf?ver=2020-03-19-145021-520.

Abbott, Greg. Executive Order. “Executive Order No. GA-14 Relating to Statewide Continuity of Essential Services and Activities During the COVID-19 Disaster” (March 31, 2020). Accessed March 31, 2020. https://gov.texas.gov/uploads/files/press/EO-GA-14_Statewide_Essential_Service_and_Activity_COVID-19_IMAGE_03-31-2020.pdf.

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***American Dental Association. https://www.ada.org/en/member-center/coronavirus-resource-toolkit-for-ada-members.

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***Federal Emergency Management Agency. https://www.fema.gov/coronavirus-rumor-control.

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