March 23, 2020, Update to the Joint Statement

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As cases of the virus surge in countries around the world, with Italy being particularly hard hit, many nations are taking extreme steps to mitigate the outbreak, including whole country lockdowns. Here in the United States, the President declared a national emergency on March 13, 2020. Several states have declared shelter-in-place to minimize non-essential activities and mitigate transmission. President Trump has declared California, New York State, and Washington State to be major disaster areas.

In this week’s update, we discuss the following topics related to COVID-19:

Origin of SARS-CoV-2

SARS-CoV-2 is the seventh coronavirus known to infect humans. SARS-CoV, MERS-CoV, and SARS-CoV-2 can cause severe disease, whereas HKU1, NL63, OC43, and 229E are associated with mild symptoms. There has been a lot of speculation on the origin of SARS-CoV-2. Scientists have now sequenced the genetic material of the virus isolated from different patients. These sequencing results clearly establish that SARS-CoV-2 is not a genetically engineered virus, meaning it is not manmade.1

The researchers provide two scenarios for the origin of SARS-CoV-2. In one scenario, the virus evolved to its current pathogenic (disease-causing) state through natural selection in a non-human host and then jumped to humans. This is how previous coronavirus outbreaks have emerged, with humans contracting the virus after direct exposure to civets (SARS) and camels (MERS). The researchers proposed bats as the most likely reservoir for SARS-CoV-2 as it is very similar to a bat coronavirus. In the other proposed scenario, a non-pathogenic version of the virus jumped from an animal host into humans and then evolved to its current pathogenic state within the human population. For instance, some coronaviruses from pangolins, armadillo-like mammals found in Asia and Africa, have similarities to SARS-CoV-2. A coronavirus from a pangolin could possibly have been transmitted to a human, either directly or through an intermediary host such as civets or ferrets.

Which age groups have severe responses to COVID-19?

Initial data on COVID-19 suggested that when stratified by age, the elderly were the most likely to develop a more severe form of COVID-19. Recent data released by the CDC demonstrated that this is not the case anymore.  As shown in the figure below, almost all age groups are susceptible to a serious form of COVID-19 that requires hospitalization.2

COVID-19 severity by age group

This is especially important to keep in mind given that younger people have been more resistant to social distancing.

How long does SARS-CoV-2 survive outside the body?

A recent study found that the SARS-CoV-2 virus (which causes COVID-19) can survive up to four hours on copper, up to 24 hours on cardboard, and up to two to three days on plastic and stainless steel. The researchers also found that this virus can hang out as droplets in the air for up to three hours before they fall. But most often they will fall more quickly.3

The researchers were able to detect viable viral particles for at least 72 hours on the four surfaces studied. This suggests that transmission of SARS-Cov-2 is possible through aerosols and fomites (solid objects and surfaces that are able to carry pathogens and transmit infections).

We recommend that after you bring articles into your home, you do the following:

  • Wash your hands after carrying delivered items into your home.
  • After accepting a package that’s in a cardboard container, put it aside or in the garage and let it sit for a day or two before opening (if possible).
  • After opening a package, wipe down all articles that have solid surfaces with chlorine wipes or disinfect with an alcohol-based solution.
  • At this time, there is no guidance on how to disinfect edible items such as fruits and vegetables.
  • Follow cleaning and disinfecting procedures listed on the website

Community transmission of SARS-CoV-2 by asymptomatic individuals

Data from initial cases of COVID-19 suggested that most transmissions were occurring through individuals who showed signs and symptoms of COVID-19. This is, however, not the case. It is now estimated that as many as 31% of new COVID-19 infections are being caused as a result of transmission through asymptomatic individuals—those who have been infected with SARS-CoV-2 but don’t shown signs and symptoms of the disease.4 This is an especially important aspect of SARS-CoV-2 transmission and reinforces why we need to practice stringent social distancing to flatten the curve.

COVID-19 patients may present with non-respiratory symptoms even before they have respiratory symptoms

Individuals infected with SARS-CoV-2 may present with gastrointestinal symptoms such as anorexia (83.8%), diarrhea (29.3%), vomiting (0.8%), and abdominal pain (0.4%).5 These gastrointestinal symptoms may show up even before respiratory symptoms of COVID-19. Furthermore, a small sample of patients presented with only gastrointestinal symptoms. If you have unexplained gastrointestinal issues, we suggest that you talk to your doctor promptly.  Also, conjunctivitis may be present in a small subset of patients as well. 6

Prepare your legal documents

Given the uncertainty over availability of medical care during the COVID-19 emergency, we suggest everyone review their legal documents and ensure they have a current Durable Power of Attorney and Advance Directive. This virus can progress very rapidly and seriously interfere with breathing, which means you cannot be certain that you will be able to make your wishes known verbally if you get severely ill. Discuss your wishes with your family and ensure everyone knows where to find these important documents.

If you haven’t completed these legal documents, some estate planning attorneys may be willing to help prepare and witness them via video conferencing so that you do not have to leave your home.

If you are not sure how to get started, please review the resources available at

Can I take ibuprofen when I have COVID-19?

Short answer: yes.  Long answer: we’re not sure.

On March 18, the World Health Organization (WHO) posted an article suggesting that patients who have COVID-19 avoid taking ibuprofen, based on observations of patients in France.7 However, later the same day, WHO changed their stance and said patients who have COVID-19 should not avoid taking ibuprofen.8

This is a good example of how quickly information is evolving during this pandemic. It’s difficult for doctors to know whether to act on information that is based on the experience of only a few (or even one) patient.

Resources and websites:

  1. The National Cancer Institute has a special website for COVID-19 and emergency preparedness. Coronavirus: What People with Cancer Should Know -
  2. We are following updates provided by the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC), which can be found here:
  3. Johns Hopkins Coronavirus Resource Center is one of the best places to get current updates.
  4. Interactive map of US COVID-19 cases by state -
  5. The One-Two Punch: Cancer And Coronavirus (an important perspective for cancer patients) -
  6. You can find information specific to your state or city or town on your health department’s website.
  7. The American Medical Association is also maintaining a resource website for healthcare providers. You can find more information here:
  8. If you cannot avoid air travel, check out this handy article on “Dirtiest Places on Airplanes: How to Avoid Germs


  1. Anderson K, Rambaut A, Lipkin W, Holmes E, Garry R. The proximal origin of SARS-CoV-2. Nature Medicine. 2020.
  2. CDC. Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep. 2020.
  3. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020.
  4. Nishiura H, Kobayashi T, Suzuki A, et al. Estimation of the asymptomatic ratio of novel coronavirus infections (COVID-19). Int J Infect Dis. 2020.
  5. Pan L, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. American Journal of Gastroenterology. 2020.
  6. AAO. Alert: Important coronavirus updates for ophthalmologists. Published 2020. Accessed March 23, 2020.
  7. Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med. 2020.
  8. ScienceAlert. Updated: WHO Now Doesn't Recommend Avoiding Ibuprofen For COVID-19 Symptoms. Published 2020. Accessed March 23, 2020.

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