Safely Sweating as Gyms Reopen

Photo: Personal Archive, Used with Permission

By Janet von Konsky Miller, MPH

3/16/21

Today marks the 1-year anniversary of the Santa Clara County Shelter in Place (SIP) order. For 365 days we have been social distancing. We have become used to days filled with Zoom meetings and screen time. With all this added screen time, finding creative ways to remain physically active has become more important than ever.

I recently heard the term “exercise snacks”1 to describe short physical activity breaks during the day. To accommodate increased computer time, I often take my “exercise snacks” outdoors with short neighborhood walks or garden puttering. For some, remote work means less time spent commuting in traffic. Substituting this commute time with physical activity is another way to keep the body moving. Standing desks and walking meetings are among other ideas for detaching from that chair.

But what about working up a sweat?

With gym doors closing to help mitigate SARS-CoV-2 transmission, the economy has experienced sky rocketing home gym equipment sales, new virtual gym technologies, and rising online streaming and fitness app options.2 Despite this, many have found it difficult to stay active. One multinational study of 1047 adults found that time spent in sedentary activity increased 28% and frequency of physical activity decreased 24% during shelter in place orders.3

While the fitness and wellness industry quickly pivots to provide pandemic exercise options through technology, embracing new technologies is nothing new to the fitness and wellness industry. Jack LaLanne used the blossoming television era in the 1950s to advocate for fitness and lead exercises over the TV screen.4 In the late 1960s, Kenneth Cooper introduced the term “aerobics”5 and Jackie Sorensen and Judi Sheppard Missett set exercise routines to music introducing aerobic dance and Jazzercise, respectively.6,7 This paved the way for home VHS workouts in the 1980s with fitness celebrities like Jane Fonda, Richard Simmons, and many others. As the popularity of step aerobics exploded and spinning dawned on the scene in the 1990s, DVD technology soon replaced VHS tapes.8 Today, DVD and VHS have been filed away in the history books as streaming and fitness apps take to the mainstage.  The music that group exercise instructors used over time also adapted to new technologies beginning with vinyl and progressing to cassette tapes followed by CDs. Now, exercise class music is downloaded and accessed through the instructor’s electronic devices. Wearable heart rate tracking technologies introduced in the 1970s have developed and become more sophisticated over time to motivate, monitor, and track the exerciser’s progress. While not an exhaustive list, this illustrates some ways the fitness and wellness industry has been influenced by technology.

While the pandemic has nurtured the industry trends of online apps and virtual training, what is in store for the industry as we look toward a post-pandemic future? As we reach the 1-year social distancing anniversary, Santa Clara County has re-opened gyms at a 10% capacity and will increase this to 25% capacity when the county moves from red into an orange level tier status.9 Some gyms have the space available for additional outside exercise. The California Department of Public Health suggests personal training and group exercise modifications to ensure social distancing is maintained.10

The question remains: How safe is it to go back to the gym? 

In February of 2020, 27 exercise instructors employed at 12 gyms attended a 4-hour workshop in South Korea. Of the 27 instructors, 30% were positive for SARS-CoV-2 despite a lack of symptoms. Through contract tracing, 112 COVID-19 cases were connected to these instructors, over half of which were from exercise class participation and the rest due to transmissions to family and coworkers. Note that this report indicates that transmission occurred prior to initiating pandemic restrictions.11

In June of 2020, an instructor taught a group cycling class at a gym in Hawaii. No one, including the instructor, wore masks. The instructor was symptom free at the time of class, but began experiencing symptoms within hours after class. All 10 class participants were diagnosed with COVID-19 the following week. Six of these participants had taken a class with the same instructor along with 4 others on the previous day, but the 4 others remained free of COVID-19. Another instructor who contracted COVID-19 from the first instructor trained 5 personal training clients and 9 group exercise clients over the 2 days before symptoms began, transmitting the virus to 10 of these clients. No masks were worn in any of these contacts.12

A Chicago gym offered 8 high intensity group exercise classes over a 1-week period at a reduced (25%) capacity during August of 2020. Face masks were required to enter the gym but not during classes. During this period, a COVID-19 outbreak occurred. Out of 91 people exposed, 81 were interviewed. Of those interviewed, 55 had contracted COVID-19. It is discouraging to learn that 4 of every 10 of these individuals attended an exercise class the day symptoms began or thereafter, with 3 who attended class with a positive COVID-19 diagnosis.13

While these cluster cases are alarming, it is important to look at what we know about SARS-CoV-2 transmission.

As one breathes, respiratory droplets are dispersed into the air. If these droplets are large enough, they fall quickly to the ground. Therefore, larger droplets infected with SARS-CoV-2 will be capable of transmission to another if the other is close enough to contact the droplet before it falls.14,15 A droplet that has fallen to the ground can reenter the air if the space is disturbed.16 An exercise class, therefore, may be capable of sending these fallen particles aloft, keeping them in the air.15 Larger droplets may evaporate into smaller droplets and the smaller the droplet, the longer it lingers in the air. The longer it lingers in the air, the greater the chance for contact by a new host.14,15

The amount of viral contact, or load, is also a consideration with SARS-CoV-2 transmission. A sneeze can project 10,000 droplets into the surrounding environment, far more than a cough at up to 1000 droplets. While talking is far less yet at 50 droplets, it has the potential to produce cumulatively more because it is more continuous than a cough or sneeze. No numbers exist specific to droplets in exercise exhalation, and it is suggested that numbers will likely vary between individuals. Virus infected respiratory particles exhaled by individuals can build up in indoor environments.15

If amount and size of droplets projected into the environment influences transmission, then inadequate facility ventilation becomes an important transmission mitigation factor.14  The number of people in the room, the amount and velocity of the fresh air contributed to the room, the amount of extracted air that is recirculated, the air cleaning and filtering technique, and the placement of the vents may all impact the particle concentrations in a room.14,17 In addition to closing group classes or limiting class size, the CDC recommends that exercise facilities maximize fresh air availability and filtration as well as maintain a 40-60% humidity level during the pandemic.18 The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) clarify that ventilation systems management cannot eradicate risk of viral transmission but instead reduce risk as a part of risk management.They recommend not only maximizing fresh air when weather permits, but also a continuous air filtration with a MERV-13 filter system.19 (MERV ratings designate filtration efficacy based on size of particles. The higher the number the smaller the particulate filtered, but using a rating higher than the system can handle reduces effectiveness of the system.)20 Portable air cleaners are suggested by the ASHRAE as a supplemental system option.19 UV germicidal radiation may not be an option for cleaning air as exposure is harmful to humans.21 In addition, the CDC recommends against floor fans that direct air flow onto members.18 Comparatively, Blocken and colleagues (2020) report recommendations established in the Netherlands with ventilation flow at 70% greater in Dutch fitness facilities compared to other stores and offices. Dutch building guidelines suggest ventilation systems replace the air in a gym 6 times per hour and in aerobics rooms 8 times per hour. In cycling classes, they suggest air is replaced 10 times per hour.17 It is never more important for facility managers to adhere to current building ventilation standards and system maintenance. Even so, it is suggested that there is no building ventilation research available that is specific to SARS-CoV-2 transmission.16

As of March 15, 2021, almost 13% of Santa Clara County’s residents have been fully vaccinated for COVID-19.22  Vaccination scheduling is currently open to older adults, those with chronic conditions, and those in certain essential-work positions in the county,23 but vaccine availability in Santa Clara and other counties is strained.24 Moderate exercise enhances immune function25  and may positively impact conditions that are linked to severe COVID-19 disease.26 Though no one suggests exercise will inhibit a COVID-19 infection, exercise may be beneficial in reducing COVID-19 severity.27 One researcher thinks that a super-antioxidant is a factor linking exercise to reduced COVID-19 severity.28 Another paper argues that the effects of exercise on the renin-angiotensin-aldosterone system may be a factor influencing COVID-19 severity.29

Clearly it is important to stay physically active as we make efforts to mitigate viral transmission and disperse vaccines.

So how does this inform opening gym doors to once again pound the treadmill, pump iron, and spin away with your favorite instructor? Is it safe? No amount of precaution removes risk, but If you decide to take advantage of gym access as it begins to open in your area, then it is prudent to make sure your facility is adhering to CDC18 and state10 recommendations such as proper exercise facility ventilation and air filtration standards, adherence to social distancing and recommended limits of participation, and enforcing rigorous equipment cleaning and mask wearing. What can you do? Stay quarantined at home if you have a known exposure or symptoms, disinfect equipment before and after use, keep your distance, and wash your hands. And wear a mask!30

Sources:

1 Huffington Post. (2021). 7 Heart-Healthy Activities That Have Nothing to Do with Traditional Cardio. Feb 9. Retrieved from https://www.huffpost.com/entry/heart-healthy-activities-no-cardio_l_602147a1c5b6c56a89a2f2f8

2 Washington Post. (2021). The pandemic’s home-workout revolution may be here to stay. Jan 21. Retrieved from https://www.washingtonpost.com/road-to-recovery/2021/01/07/home-fitness-boom/

3 Amar, A., Brach, M., Trabelsi, K., Chtrourou, H., Boukhris O., Masmoudi, L., Bouaziz, B…..& Hoekelmann, A. (2020). Effects of COVID-19 Home Confinement on Eating Behaviour and Physical Activity: Results of the ECLB-COVID19 International Online Survey. Nutrients. 12:1583. doi:10.3390/nu12061583

4 Britannica. (2021). Jack LaLanne. Jan 19. Retrieved from https://www.britannica.com/biography/Jack-LaLanne#ref1081015

5 Cooper Aerobics. (n.d.). Aerobics. Retrieved from https://www.cooperaerobics.com/About/Our-Story/Aerobics.aspx

6 Jacki’s Aerobic Dancing. (n.d.). About Jacki Sorensen. Retrieved from https://www.aerobicdancing.com.au/index.php/about-jacki-sorensen

7 Jazzercise. (n.d.). About Us. Retrieved from https://www.jazzercise.com/About-Us

8 Kodak Digitizing. (n.d.). History of the VHS Tape. Retrieved from https://kodakdigitizing.com/blogs/news/history-of-the-vhs-tape

9 California State Government. (2021). Industry Guidance to Reduce Risk. Mar 16. Retrieved from https://covid19.ca.gov/industry-guidance/#can-open

10 California Department of Public Health & Cal OSHA. (2020). COVID-19 Industry Guidance: Fitness Facilities. Oct 20. Retrieved from https://files.covid19.ca.gov/pdf/guidance-fitness–en.pdf

11 Jang, S., Han, S.H., & Rhee, J.Y. (2020). Cluster of Coronavirus Disease Associated with  Fitness Dance Classes,  South Korea. Emerging Infectious Diseases. 26(8):1917-1920.

12 Groves, L.M., Usagawa, L., Elm, J., Low, E., Manuzak, A., Quint, J., Center, K.E., Buff, A.M., & Kemble, S.K. (2021). Community Transmission of SARS-CoV-2 at Three Fitness Facilities — Hawaii, June–July 2020. CDC Morbidity and Mortality Weekly Report. 70(9):316-320.

13 Lendacki, F.R., Teran, R.A., Gretch, S., Fricchione, M.J., & Kerins, J.L. (2021). COVID-19 Outbreak Among Attendees of an Exercise Facility — Chicago, Illinois, August–September 2020. CDC Morbidity and Mortality Weekly Report. 70(9);321–325.

14 Hayashi, M., Yanagi, U., Azuma, K., Kagi, N., Ogata, M., Morimoto, S., Hayama, H., Mori, T., Kikuta, K., Tanabe, S., Kurabuchi, T., Yamada, H., Kobayashi, K., Kim, H., & Kaihara, N. (2020). Measures against COVID-19 concerning Summer Indoor Environment in Japan. Japan Architechtural Review. 3(4):423-434. doi: 10.1002/2475-8876.12183

15 Blocken, B., van Druen, T., Ricci, A., Kang, L., van Hooff, T., Qin, P., Xia, L., Ruiz, C.A., Arts, J.H., Diepens, J.F.L., Maas, G.A., Gillmeier, S.G., Vox, S.B., & Brombacher, A.C. (2021). Ventilation and air cleaning to limit aerosol particle concentrations in a gym during the COVID-19 pandemic. Building and Environment. 193:107659 doi:10.1016/j.buildenv.2021.107659

16 Azuma, K., Yanagi, U., Kagi, N., Kim, H., Ogata, M., & Hayashi, M. (2020). Environmental factors involved in SARSCoV-2 transmission: effect and role of indoor environmental quality in the strategy for COVID-19 infection control.  Environmental Health and Preventive Medicine. 25:66. doi.org/10.1186/s12199-020-00904-2

17 Blocken, B., van Druen, T., van Hooff, T., Verstappen, P.A., Marchal, T., & Marr, L.C. (2020). Can indoor sports centers be allowed to reopen during the COVID-19 pandemic based on a certificate of equivalence? Building and Environment. 180:107022. doi: 10.1016/j.buildenv.2020.107022

18 CDC. (2021). Guidance for Businesses and Employers Responding to Coronavirus Disease 2019 (COVID-19). Mar 8. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/gym-employers.html

19 ASHRAE. (2020). Guidance for Building Operations During the COVID-19 Pandemic. ASHRAE Journal. 62(5):3

20 Grainger. (2020). What Is MERV Rating? Air Filter Rating Chart. Feb 11. Retrieved from https://www.grainger.com/know-how/equipment-information/kh-what-is-merv-rating-air-filter-rating-chart

21 FDA. (2021). UV Lights and Lamps: Ultraviolet-C Radiation, Disinfection, and Coronavirus. Feb 1. Retrieved from https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/uv-lights-and-lamps-ultraviolet-c-radiation-disinfection-and-coronavirus

22 Santa Clara County Public Health Department. (2021). COVID-19 Vaccinations Among County Residents Dashboard. Retrieved from https://www.sccgov.org/sites/covid19/Pages/dashboard-vaccine-CAIR2.aspx

23 Santa Clara County Public Health Department. (2021). COVID-19 Vaccine Information. Retrieved from https://www.sccgov.org/sites/covid19/pages/covid19-vaccine-information-for-public.aspx

24 KTVU. (2021). As eligibility expands, vaccine shortages in California persist. Mar 16. Retrieved from https://www.ktvu.com/news/as-eligibility-expands-vaccine-shortages-in-california-persist

25 Gentil, P., Barbosa de Lira, C.A., Souza, D., Jimenez, A., Mayo, X., Gryshek, A., Pereira, E.G., Alcaraz, P., Bianco, A., Paoli, A., Papeschi, J., Carnevali Jr, L.C. (2020). Resistance Training Safety during and after the SARS-Cov-2 Outbreak: Practical Recommendations. Bio Med Research International.  2020: 3292916. doi:10.1155/2020/3292916

26Med Page Today. (2020). Exercising in the Fight Against COVID-19. Dec 23. Retrieved from https://www.medpagetoday.com/infectiousdisease/covid19/90389

27University of New Orleans. (2020). Physical Activity Could Reduce Severity of COVID-19 Research Suggests. Jul 30. Retrieved from https://www.uno.edu/news/2020-07-30/physical-activity-could-reduce-severity-of-covid-19-research-suggests

28 University of Virginia. (2020). Exercise May Protect Against Deadly COVID-19 Complication, Research Suggests. Apr 15. Retrieved from https://news.virginia.edu/content/exercise-may-protect-against-deadly-covid-19-complication-research-suggests

29 Evagelista, F.S. (2020). Physical Exercise and the Renin Angiotensin System: Prospects in the COVID-19. Frontiers in Physiology. 11: 561403. doi: 10.3389/fphys.2020.561403

30 Almasri, D., Noor, A., Diri, R. (2020). Behavioral Changes in Gym Attending Due to COVID-19 Pandemic: A Descriptive Survey. J Microsc Ultrastruct. 8(4):165-167. doi: 10.4103/JMAU.JMAU_64_20

Freedom Through Interdependence

Photo: Personal Archive, Used with Permission

By Janet von Konsky Miller, MPH

7/4/20

In recent years, my husband and I have often sought out community firework displays on the 4th of July. Whether we find a lookout spot to view the glittering sky show from afar or seek the crowds to experience the soundwaves as each explosive blast bursts a spray of colorful shapes overhead, we have enjoyed contributing to the “oohs” and “ahs” that invariably accompany the annual pyrotechnic shows. Last year we even ventured outside of our local festivities to experience renowned firework displays surrounded by Tahoe’s scenic grandeur. Amidst pandemic conditions, however, the 4th of July festivities this year will look much different. This year’s local firework shows are cancelled to discourage transmission-prone crowds from gathering.

News reports of COVID-19 spikes in cases throughout the US have been reported the week before the Independence Day holiday. As of July 2, the US has 2,732,531 cases1 and those numbers are increasing by an average of over 40,000 cases daily.2 Nine percent of all COVID-19 tests are currently positive in the US.3 California along with Arizona, Texas, and Florida comprise half of the nation’s new COVID 19 cases.2 As of July 2, 6.4% of California COVID-19 tests are positive, which has increased from 4.5% positivity on June 4.4 While Santa Clara County fares better than the state-wide positivity rates, these county rates are increasing as well (2.62% positive tests on July 2 up from 1.39% on June 4 in Santa Clara Couny).5

This July 4th marks 244 years since the Declaration of Independence was signed, a document declaring colonial independence from Great Britain. This document symbolizes the values of freedom and independence deeply rooted in American culture. This year’s anniversary calls Americans to conceptualize their freedom and independence from a pandemic perspective.

To explore freedom and independence within a pandemic, we must first understand the virus behind the pandemic. The SARS coV 2 virus causing COVID-19 is a new virus in humans. Over the past 6 months, scientists have examined past viruses that are similar to SARS coV 2 and have studied how this new virus affects human physiology. If we as community members better understand its effects, we might be better able to embrace the importance of following recommendations meant to slow transmission.

When exposed to the SARS coV 2 virus, the virus binds ACE2 receptors.6 These receptors are found in many places throughout the body, including the lungs. While over 40% of those exposed may not experience symptoms,7 symptoms will occur 4 to 5 days after exposure on average in symptomatic individuals.8 In more moderate forms of the disease, local inflammation will resolve as healthy immune systems attack and kill the virus. In severe disease, however, an inflammatory response called a “cytokine storm” ensues.8, 9, 10 A dysfunctional immune system that is unable to conquer the virus coupled with inflammation may lead to lung tissue damage, low oxygen levels, risk of opportunistic infection such as pneumonia, organ failure, and possible death.6, 8 Those who suffer severe disease and recover may be inflicted with post recovery health issues from lung damage.23, 25

An immune dysfunction associated with the severe COVID-19 cases is characterized by low levels of an immune cell called “T cells.”10, 11, 12, 13, 14 T cell levels decline with age and may contribute to the increased risk of severe COVID-19 with advancing age.8, 14 In Santa Clara County, only 12.5% of the COVID-19 cases but 68% of the deaths have occurred in individuals who are 70 years of age or older.15 In the same county, 34.5% of cases and 2.5% of deaths occur in individuals who are between 20 and 39 years of age.15

T cell levels also decline with malnutrition.16,17 Therefore, it may be possible that those who do not have access to adequate nutrition could be at risk of severe COVID 19 disease. National food insecurity rates are estimated to be twice the pre-pandemic rates.18 California food bank demands have soared 73% in 1 year.18

Obesity may promote T cell dysfunction and this may not be reversible with weight loss.19 The Centers for Disease Control and Prevention (CDC) report that over 42 out of every 100 US adults are obese.20 Factors influencing obesity include diet, exercise, and sedentary lifestyles, and obesity risk may increase with chemical exposures and gut dysbiosis.21 Obesity is a risk factor for severe COVID-19 disease.22

Personal freedom and community responsibility are not mutually exclusive. It is estimated that masks may cut SARS coV 2 transmission in half.24 It may save someone from severe disease, post recovery health issues, and death. If we all cooperate with transmission mitigation efforts, businesses will open sooner, lasting health effects will be reduced, the pandemic health care impact will be eased, and loved ones will be able to hug again. It only takes properly wearing a mask when in public. It only takes a 6-foot distance when in contact with others. It only takes regular hand washing and cleaning of frequently touched surfaces. By embracing these behavior choices, we help each other and we commit to end this global pandemic. This is freedom. This is community. Through interdependence we may experience independence.

Sources:

1CDC. (2020). Cases in the US. July 3. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

2NBC News. (2020). Fauci: COVID-19 cases could swell to 100,000 a day if U.S. doesn’t control virus. June 30. Retrieved from https://www.nbcnews.com/health/health-news/fauci-covid-19-cases-could-swell-100-000-day-if-n1232526

3CDC. (2020). Testing Data in the US. July 2. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/testing-in-us.html

4California State Government. (2020). COVID-19 State-wide Update: How are COVID-19 cases progressing? July 3. Retrieved from https://update.covid19.ca.gov/

5Santa Clara County Public Health Department. (2020). Novel Coronavirus (COVID-19): COVID-19 Testing Dashboard. July 2. Retrieved from https://www.sccgov.org/sites/covid19/Pages/dashboard-testing.aspx

6 Zabetakis, I., Lordan, R., Norton, C., Tsoupras, A. (2020). COVID-19: The inflammation link and the role of nutrition in potential mitigation. Nutrients. 12(5): 1466. doi: 10.3390/nu12051466

7 Lavezzo, E., Franchin, E., Ciavarella, C., Cuomo-Dannenberg, G., Barzon, L, Del Vecchio, C., Rossi, L., Manganelli, R., Loregian, A., Navarin, N., Abate, D., Sciro, M., Merigliano, S., De Canale, E., Vanuzzo, M.C., Besutti, V., Saluzzo, F., Onelia, F., Pacenti, M., Parisi, S., Carretta, G., Donato, D., Flor, L., Cocchio, S., Masi, G., Sperduti, A., Cattarino, L., Salvador, R., Nicoletti, M., Caldart, F., Castelli, G., Nieddu E., Labella, B., Fava, L., Drigo, M., Gaythorpe, K.A.M., Imperial College COVID-19 Response Team, Brazzale, A.R., Toppo, S., Trevisan, M., Baldo, V., Donnelly, C.A., Ferguson, N.M., Dorigatti, I., & Crisant, A. (2020). Suppression of a SARS-CoV-2 outbreak in the Italian municipality of Vo’. Nature. Jun 30. doi: 10.1038/s41586-020-2488-1

8 Tay, M.Z., Poh, Z.M., Renia, L., MacAry, P.A., & Ng, L.F.P. (2020). The trinity of COVID-19: immunity, inflammation and intervention. Nature Reviews Immunology. 20: 363–374. doi: 10.1038/s41577-020-0311-8

9 Ye, Q., Wang, B., & Mao, J. (2020). The pathogenesis and treatment of the ‘Cytokine Storm’ in COVID-19. Journal of Infection. 80: 607-613. doi: 10.1016/j.jinf.2020.03.037

10Diao, B., Wang, C., Tan, Y., Chen, X., Liu, Y., Ning, L., Chen, L., Li, M., Liu, Y., Wang, G., Yuan, Z., Feng, Z., Wu, Y., & Chen, Y. (2020). Reduction and functional exhaustion of T cells in patients with coronavirus disease 2019 (COVID-19). Front. Immunol. May 1. https://doi.org/10.3389/fimmu.2020.00827

11Ganjia, A., Farahania, I., Khansarinejada, B., Ghazavib, A., Mosayebia, G. (2020). Increased expression of CD8 marker on T-cells in COVID-19 patients. Blood, Cells, Molecules and Diseases. 83: 102437. doi: 10.1016/j.bcmd.2020.102437

12Qin, C., Zhou, L., Hu, Z., Zhang, S., Yang, S., Tao, Y., Xie, C., Ma, K., Shang, K., Wang, W., & Tian, D.S. (2020). Dysregulation of immune response in patients with COVID-19 in Wuhan, China.  Clin Infect Dis. ciaa248. doi: 10.1093/cid/ciaa248

13Wang, F., Hou, H., Lui, Y., Tank, G., Wu, S., Huang, M., Liu, W., Zhu, Y., Lin, Q., Mao, L, Fang, M., Zhang, H., Sun, Z. (2020). The laboratory tests and host immunity of COVID-19 patients with different severity of illness. JCI Insight. 5(10):e137799. Doi:10.1172/jck.insight.137799

14Liu, Y., Pang, Y., Hu, Z., Wu, M., Wang, C., Feng, Z., Mao, C., Tan, Y., Liu, Y., Chen, L., Wang, G., Yuan, Z., Diao, B., Wu, Y., & Chen, Y. (2020). Thymosin alpha 1 (Tα1) reduces the mortality of severe COVID-19 by restoration of lymphocytopenia and reversion of exhausted T cells. Clin Infect Dis. ciaa630. doi: 10.1093/cid/ciaa630

15Santa Clara County Public Health Department. (2020). Novel Coronavirus (COVID-19): Demographics of Cases and Deaths. July 3. Retrieved from https://www.sccgov.org/sites/covid19/Pages/dashboard-demographics-of-cases-and-deaths.aspx

16Alwarawrah, Y., Kiernan, K., MacIver, N.J. (2018). Changes in nutritional status impact immune cell metabolism and function. Front Immunol. 9:1055. doi: 10.3389/fimmu.2018.01055

17Cohen, S., Danzaki, K., & MacIver N.J. (2017). Nutritional effects on T-cell immunometabolism. Eur J Immunol. 47(2): 225–235. doi:10.1002/eji.201646423

18 NY Times. (2020). As Hunger Spreads with Pandemic, Government Takes Timid Steps. May 13. Retrieved from https://www.nytimes.com/2020/05/13/us/politics/coronavirus-hunger-food-banks.html?

19Rebeles, J., Green, W.D., Alwarawrah, Y., Nichols, A.G., Eisner, W., Danzaki, K., MacIver, N.J., Beck, M.A. (2019). Obesity-induced changes in T-cell metabolism are associated with impaired memory T-cell response to influenza and are not reversed with weight loss. J Infect Dis. 219(10): 1652–1661. doi: 10.1093/infdis/jiy700

20CDC. (2020). Adult Obesity Facts. June 29. Retrieved from https://www.cdc.gov/obesity/data/adult.html

21CDC. (2020). Adult Obesity Causes and Consequences. June 11. Retrieved from https://www.cdc.gov/obesity/adult/causes.html

22CDC. (2020). CDC Updates, Expands List of People at Risk of Severe COVID-19 Illness . June 25. Retrieved from  https://www.cdc.gov/media/releases/2020/p0625-update-expands-covid-19.html

23Science News. (2020). Some Patients Who Survive COVID-19 May Suffer Lasting Lung Damage. April 27. Retrieved from https://www.sciencenews.org/article/coronavirus-covid-19-some-patients-may-suffer-lasting-lung-damage

24CNN. (2020). Pelosi Says Federal Mandate on Masks Is ‘Long Overdue.’ June 28. Retrieved from https://www.cnn.com/2020/06/28/politics/pelosi-masks-federal-mandate/index.html

25Spagnolo, P., Balestro, E., Aliberti, S., Cocconcelli, E., Biondini, D., Della Casa, G., Sverzellati, N., Maher, T.M. (2020). Pulmonary fibrosis secondary to COVID-19: a call to arms? The Lancet. May 15. doi: 10.1016/ S2213-2600(20)30222-8

Pandemic Coping Tool Box

By Janet von Konsky Miller, MPH

4/21/20

I took a virtual yoga class a week ago. In the week before this class, I had noticed that maintaining my lockdown morale had become more of an effort. As lockdown wore on, I had noticed others expressing likewise morale challenge. During class, the virtual yoga instructor voiced these same observations. As we begin week 6 of social distancing and SCC’s shelter in place mandate, we might fill the pandemic-coping tool box with healthy strategies to maintain morale and weather this traumatic storm.

I have attended many webinars while social distancing, especially in the first few weeks of the SCC shelter in place mandate. One of the webinars presented by the National Academy of Medicine (NAM) and the American Public Health Association (APHA) was a 2-part webinar on Social Distancing. One presenter, Dr. Sandro Galea, identified the COVID-19 pandemic as meeting the criteria for a traumatic event. He said that traumatic events are associated with increased stress behaviors and mental health issues. Experiencing multiple stressors can exacerbate the consequences of trauma on mental health. Some examples of multiple stressors people may be experiencing during the pandemic may include care of a high-risk loved one, economic burdens, among others. The more stressors, the greater the trauma’s effect, especially if these added stressors endure over time.1

While the presenter suggested solutions at a system-wide level, what can we do ourselves to mitigate the stress from the pandemic and subsequent isolation during lockdown? One article suggests that connection with others, healthy eating, adequate sleep, and exercise, in addition to other coping tools, may benefit mental health during this pandemic.2 A Harvard Medical School article suggests that through physical activity we can reduce anxiety and depression and increase well-being.  When working out with others, even if it is remote, the synchronized movement may contribute to increased self-esteem and cooperation.3 Laughter,4 gardening,5, 6 viewing nature,7 and music8, 9, 10 are other strategies that have been shown to impact the stress response.

Including emotional “normalcy” as a tool to remember during this anything-but-normal time may go a long way in coping with the trauma of the pandemic.1 Anxious? Sad? Grief-stricken? Irritable? Perhaps it may be comforting to know that experiencing a myriad of feelings during this crisis may be “normal.” Remember to be kind and compassionate to self as well as others during this crisis. Include reaching out to each other in that coping tool box because together we will get through this traumatic event.*

(*Note: If experiencing overwhelming emotional and mental distress, reach out to a mental health professional)

Sources:

1NAM & APHA. (2020). The Science of Social Distancing, Part 2 [webinar]. COVID-19 Conversations. April 1. Retrieved from https://www.covid19conversations.org/webinars/science-of-social-distancing-2

2Psycology Today. (2020). Trauma of Pandemic Proportions. March 14. Retrieved from https://www.psychologytoday.com/us/blog/lifting-the-veil-trauma/202003/trauma-pandemic-proportions

3Harvard Health Publishing. (2016). How simply moving benefits your mental health. March 28. Retrieved from https://www.health.harvard.edu/blog/how-simply-moving-benefits-your-mental-health-201603289350

4Yim, J.E. (2016). Therapeutic Benefits of Laughter in Mental Health: A Theoretical Review [abstract]. Tohoku J Exp Med. 239(3):243-9. doi: 10.1620/tjem.239.243

5University of Colorado Boulder. (2018). Why Dirt May Be Nature’s Original Stress Buster. Retrieved from https://www.colorado.edu/today/2019/05/09/natures-original-stress-buster

6Soga, et al. (2017). Gardening is beneficial for health: A meta-analysis. Preventive Medicine Reports. 5: 92-99. doi: http://dx.doi.org/10.1016/j.pmedr.2016.11.007

7Van den Berg, et al. (2015). Autonomic nervous system responses to viewing green and built settings: Differentiating between sympathetic and parasympathetic activity. Int J Environ Res Public Health. 12(12):15680-15874. doi: 10.3390/ijerph121215026

8Jolij, J. & Meurs, M. (2011). Music Alters Visual Perception. PLoSONE. 6(4): e18861. https://doi.org/10.1371/journal.pone.0018861 

9Harvard Medical School. (2011). Music and Health. Retrieved from https://www.health.harvard.edu/staying-hea…/music-and-health

10UC Berkeley, Greater Good Science Center. (2015). Five Ways Music Can Make You Healthier.  Retrieved from https://greatergood.berkeley.edu/article/item/five_ways_music_can_make_you_healthier

Face Masks

By Janet von Konsky Miller, MPH

4/5/20

As the week-3 SIP closes amidst changing guidelines for wearing face masks during essential outings, it was delightful to see my SIP-mate dive into the art and craft of face mask making yesterday. He experimented with scarfs and shop towels.

While he was busy creating, I dove into learning more about the science behind effective face masks. Here is what I found:

N95 masks are 95% effective as a barrier against particles that are 0.3 microns in size.1, 2  This compares to surgical masks which are effective only up to 65%.3  Whereas the surgical masks are a loosely worn barrier, the NIOSH certified N95 masks fit snugly against the face.1 As we reserve the N95 and surgical masks for the health care work force, we must turn to creatively repurposing home items for home-made face masks.

For the home-made face mask, different fabrics offer different amounts of protection. While T-shirt type fabric may be too thin to be very helpful, two layers of tightly woven fabric offers pretty good protection, according to a North Carolina anesthesiologist who tested different fabrics for effectiveness. The report suggests that if you don’t have fabric with a 180-thread count, use a less tightly woven fabric along with a flannel layer.3

A Los Angeles based clothing manufacturer (Suay Sew Shop) experimented with fabric masks lined with shop towels. This organization tested masks against 0.3 micron sized particles and found that cotton masks were up to 60% effective at blocking particles, and cotton masks lined with shop towels were 93% effective.4, 5 

When studying the effectiveness of 2-layer cotton face masks compared to medical masks in a healthcare setting, researchers found that cloth masks were less effective than the medical masks in preventing rhinovirus infection when worn continuously. Though there were challenges with the control group in the study design, the researchers hypothesized that moisture content and tightness of weave may be factors influencing the effectiveness of cloth masks.6

It is important to remember that the face mask recommendation does not diminish the importance of social distancing during this pandemic, but may be helpful in reducing transmission when participating in essential outside activity. 

It is also important to understand how to properly use the face masks:7

  • Wash hands before putting on a face mask
  • Make sure both the nose and mouth are covered (I saw someone yesterday who just covered the mouth!)
  • Don’t touch the mask
  • If it is wet, replace it
  • Remove a mask from the straps, not the body of the mask
  • Wash hands after removing the mask

Home-made fabric masks may be laundered after use, but adding harsh chemicals to the wash is not recommended.3

Guidelines are updated as more is learned about the SARS Cov 2 virus that causes COVID-19. The virus is currently believed to be airborne which means it can remain in the air even if the infected person is not close by.8 It can take up to 2 weeks for symptoms to appear after exposure.9  Not only are asymptomatic infected people contagious, those who have had the virus may continue to be contagious from 8 days to 37 days after recovery.10, 11  Wearing a face mask may reduce viral transmission when worn by infected individuals.12 Due to asymptomatic transmissions, wearing a face mask during essential activity away from home may help stop the spread of the virus.

So much has changed in the last month for everyone, and while it may be difficult to embrace ever-changing guidelines, it can be an opportunity for some creative SIP mask-making activity!

Sources:

1FDA. (2020). N95 Respirators and Surgical Masks (Face Masks). Retrieved from https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-and-surgical-masks-face-masks

2CDC. (2009). N95 Respirators and Surgical Masks. Retrieved from https://blogs.cdc.gov/niosh-science-blog/2009/10/14/n95/

3NBC News. (2020). Making your own face mask? Some fabrics work better than others, study finds. Retrieved from https://www.nbcnews.com/health/health-news/making-your-own-face-mask-some-fabrics-work-better-others-n1175966

4Business Insider. (n.d.). Using blue shop towels in homemade face masks can filter particles 2x to 3x better than cotton, 3 clothing designers discover after testing dozens of fabrics. Retrieved from https://www.businessinsider.com/homemade-mask-using-hydro-knit-shop-towel-filters-better-2020-4

5Daily Mail. (2020). Designers find that layering two blue shop towels inside cotton face masks makes the most effective homemade PPEs. Retrieved from https://www.dailymail.co.uk/news/article-8187603/Designers-say-layers-blue-shop-towels-inside-cotton-masks-help-effectiveness-homemade-PPEs.html

6 MacIntyre, C.R., Seale, H., Dung, T.C., Hien, N.T., Nga, P.T., Chughtai, A.A., Rahman, B., Dwyer, D.E., & Wang, Q. (2015). A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJOpen. 5:e006577. doi:10.1136/bmjopen-2014-006577

7WHO. (n.d.) Coronavirus disease (COVID-19) advice for the public: When and how to use masks. Retrieved from https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks

8Johns Hopkins Medicine. (n.d.). Coronavirus Disease 2019 vs. the Flu. Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-disease-2019-vs-the-flu

9Yale Medicine. (2020). 5 Things Everyone Should Know About the Coronavirus Outbreak. Retrieved from https://www.yalemedicine.org/stories/2019-novel-coronavirus/

10Chang et al. (2020). Time Kinetics of Viral Clearance and Resolution of Symptoms in Novel Coronavirus Infection. American Thoracic Society. March 23: 1-12. doi: 10.1164/rccm.202003-0524LE. https://www.atsjournals.org/doi/pdf/10.1164/rccm.202003-0524LE

11Zhou, et al. (2020). Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. 395( 10229):P1054-1062. doi: https://doi.org/10.1016/S0140-6736(20)30566-3

12Leung, N.H.L., Chu, D.K.W., Shiu, E.Y.C., Chan, K.H., McDevitt, J.J., Hau, B.J.P., Yen, H.L., Li, Y., Ip, D.K.M., Peiris, J.S.M., Seto, W.H., Leung, G.M., Milton, D.K., & Cowling, B.J. (2020). Respiratory virus  shedding in exhaled breath and efficacy of face masks. Nature Medicine. 26: 676–680. doi.org/10.1038/s41591-020-0843-2

Last Updated 5/21/20

To Hike or Not to Hike

By Janet von Konsky Miller, MPH

3/24/20               

Today begins week 2 of the COVID-19 shelter in place mandate in Santa Clara County. When I started week 1, I was grateful that the mandate allowed me to hike. Getting out into nature using local trails was a welcome coping strategy to all of the changes the mandate influenced: work, social contact, economics, habits and routines. It is my happy place.

I quickly found that social distancing was difficult to commit to on the trail, however. Many other residents were also taking advantage of the ability to hike the local trails and staying 6 feet apart from other hikers on a narrow trail is at times impossible. What is an avid hiker to do?!

I heard some people are traveling to remote wilderness locations to get their nature and physical activity fix. While tempting, it warrants caution. Hikers who don’t know they have the virus risk exposing rural areas to the virus. Keep in mind the rural population tends to be older and has a reduced access to hospitals (seven percent of rural hospitals have closed in the past decade).1

While California open space and many parks remain open, this is subject to change.2 Traveling distances to get a nature fix may cause further closures of nature access. For instance, hikers have been urged to get off the PCT (access to supplies has been interrupted and risk of contaminating rural areas is a concern).3 Taking cue from other states, Montana locals are requesting Yellowstone be closed.4

“ ‘Ultimately, social distancing doesn’t mean traveling all over the place while making sure you’re six feet away from people.’ “.3

Remember, infected droplets from respiration can stay in the air for 3 hours. Smaller droplets stay in the air longer than large droplets, and smaller droplets are more likely to gain access to lung tissue. The larger droplets may dehydrate and become smaller droplets. Don’t forget that eyes are also a virus access point. And staying 6 feet away doesn’t mean you haven’t come into contact with the virus, but that there is less concentrations of the virus in the air which influences infection.5

Though remote hiking may pose less of a risk to hikers due to fewer people on the trail, it potentially brings the virus in to rural communities. Let’s take the “stay home” motto to heart. Find nature’s beauty in small things – the trees are beginning to blossom, and the bulbs are blooming. Get exercise at home. Stay active, stay local. Just for now. We can do this.

References:

1Forbes. (2020). How The COVID-19 Coronavirus Pandemic Is Impacting Rural America. Retrieved from https://www.forbes.com/sites/claryestes/2020/03/17/coronavirus-and-rural-america/#50b4973de108

2Mercury News. (2020). Coronavirus parks closures in the Bay Area: Five things to know. Mar 23. Retrieved from https://www.mercurynews.com/2020/03/23/coronavirus-parks-closures-in-the-bay-area-five-things-to-know/

3LAist. (2020). Coronavirus Is Forcing Hikers To Quit The Pacific Crest Trail. Retrieved from https://laist.com/2020/03/23/coronavirus-pacific-crest-trail-pct-hikers-cancel.php

4Montana Free Press. (2020). Neighboring counties ask Yellowstone National Park to close. Retrieved from https://montanafreepress.org/2020/03/22/park-gallatin-counties-ask-yellowstone-national-park-to-close/

5UMN, Center for Infectious Disease Research and Policy. (2020). COVID-19 transmission messages should hinge on science. Retrieved from http://www.cidrap.umn.edu/news-perspective/2020/03/commentary-covid-19-transmission-messages-should-hinge-science

You Tube Video Pitch for Team #personalfaceofscience

ACS #FlattenTheCurveHack hackathon Pitch Video for Team #personalfaceofscience

This post contains a short pitch video that was produced by Team #personalfaceofscience as part of the Australian Computer Society (ACS) #flattenthecurvehack Hackathon in April 2020.

The video outlines:

  • The goals of our project;
  • The project’s alignment with the Health Belief Model (HBM) to empower users without science backgrounds to take empowering and informed action to safeguard themselves and their families; and
  • A demonstration of our minimum viable produce.

Business Plan for Team #personalfaceofscience for the ACS Flatten The Curve Hackathon

The primary author of this post was Fang (Elena) Li from Team #personalfaceofscience, with additional contributions by her team mates.

Vision

In the face of the COVID-19 pandemic, following social distancing standards have become crucial to how effectively we can control the spread of the virus and minimize its negative impact on people’s well-being. While people are encouraged to limit face-to-face interaction, we find it also important that people feel empowered in what they can do to combat the pandemic and take charge of their own actions according to the knowledge they have.

Problem

However, two problems that exist are the prevalent misinformation and people’s lack of understanding on how various behaviors can lead to different development patterns of COVID-19. As most people access information about COVID-19 through social media, TV news and digital journals, it is also a fact that a lot of the information being circulated is false and misleading. Even information from authorities is sometimes inconsistent. For example, the claims regarding whether it is necessary to wear masks in public.

In order to empower people to make better decisions, in their personal contexts, about what they can do during the pandemic, we are building an online educational website to tackle these two problems.

Solution

Firstly, we want to make sure people have access to the right information by presenting them with a data visualization of how various personal behaviors can affect the ways the pandemic develops. Having people play with the data visualization game, we are making the mathematical science behind COVID-19’s spreading pattern accessible to people without science background, helping them clearly understand the scientific facts and predictions in an intuitive way, therefore they can make informed decisions that guide their behaviors. Another function our website features is that we share a series of personal stories of what actions other people have taken to help relieve the pandemic so people can relate their personal situations to these stories and be inspired on what they can do themselves at this moment. In addition, our users can also post their own stories on the website and motivate each other who share a similar context.

Sustainability (How we are different)

The online educational website we build functions as a decision-making engine for people to make empowered and informed decisions. Even after the pandemic, the data visualization models and contents on our website can be adjusted to reach different types of target users in various decision-making contexts. For example, how driving less and biking more can help reduce the carbon emission and what actions people have taken to protect the environment. Designed this way, our website has a broad range of potential use and it is a sustainable project that can constantly deliver values in the long-term.

Value

With this online educational website, we aim to achieve below benefits:

  • Have the complicated science behind how COVID-19 spreads accessible to non-science people.
  • Empower people with the right information and inspire people to better decide what actions they can take in their own contexts.
  • Influence people’s decision-making process and guide their behaviors to follow social distancing norms.
  • Assist the decision-making process of various users in different scenarios with the adjustable visualization models and contents.
  • An interesting tool to play with and have some fun in the learning process.

Marketing Plan

In reaching out to the market, we plan to introduce our website by launching social media campaigns on popular platforms like Facebook and Twitter, where users are presented with the link to our website and can share this content to other users in their social media network by inviting more people to join the campaign.

Another way of marketing our product is to collaborate with educational institutions, corporations and residential communities where they can send out emails containing the web links and introduction of our website to their students, employees, and community residents as an effort to improve people’s awareness of how COVID-19’s spreading pattern can vary in accordance to the different actions they take.

Tentative Plan

Below are a few designs we would consider to build in the next phase:

  • Design the product into a game that is more interactive and fun for users to play with
  • Build applications for mobile and tablets so users can access via multiple platforms
  • Make the visualization models and contents on our platforms adjustable to assist people in their decision-making processes in different scenarios.