Coronavirus & Your Law Practice: Two Leading Authorities Share Actionable Advice

Most respiratory viruses (including other coronaviruses) affect the upper respiratory tract (i.e. nose, sinuses, throat) and cause symptoms of the “common cold” including nasal congestion, sore throat, sinus pressure, nose stuffiness, hoarse voice, and/or ear fullness. Conversely, COVID-19 and influenza viruses specifically affect the lower respiratory tract which results in bronchitis and pneumonia causing symptoms of: 

• Cough (with or without phlegm)
• Fever (>100.4⁰F or >38⁰C)
• Difficult and/or rapid breathing
• Possible gastrointestinal symptoms including diarrhea

Since influenza viruses are far more prevalent than COVID-19 at the current time, not all lower respiratory tract infection symptoms should be immediately suspected as COVID-19, particularly in the absence of risk factors or widespread COVID-19 infections in the community. 

Given the current (March 9, 2020) seasonal prevalence of all respiratory viruses and relatively low current prevalence of COVID-19, most people with respiratory symptoms will not have COVID-19 infection.  Those with isolated upper respiratory symptoms are highly unlikely to have COVID-19, and even those with lower respiratory tract symptoms — in the absence of risk factors for COVID-19 — are at relatively low risk as of today’s date. People with lower respiratory symptoms should be evaluated to rule out influenza, other respiratory viruses, and bacterial pneumonia. Bacterial pneumonia is common as a primary illness but also may occur secondarily as a complication of viral infections.  In fact, bacterial pneumonia must always be considered when viral infections (like influenza) do not stabilize or improve within several days, or when symptoms worsen after initial improvement. 

The CDC’s current recommendation for COVID-19 testing is to call your healthcare professional if you feel sick with fever, cough, or difficulty breathing, and have been in close contact with a person known to have COVID-19, or if you live in or have recently traveled from an area with ongoing spread of COVID-19.  There also may be increased risk for people with recent air, bus, or train travel for more than 2 hours, national or international attendance at a large (>100) indoor events, and/or travel to an area with sustained community spread. Your healthcare professional will work with your state’s public health department and CDC to determine if you need to be tested for COVID-19. People without these risk factors — and people without respiratory symptoms or fever — do not need to pursue COVID-19 testing at this time. If you are sick with a fever (>100.4⁰F or >38⁰C), cough, or difficulty breathing, you should seek medical care. Whenever possible, be sure to call ahead before going to a physician’s office or emergency department, and be sure to tell your doctor about any recent travel and symptoms. Avoid contact with others by maintaining a distance of at least 6 feet.  Patients awaiting test results must self-isolate pending the result.

Current data suggest that the incubation period for COVID-19 is up to 14 days, but most patients show symptoms within four days and some are symptomatic within 48 hours. This is no different from other respiratory viral infections in which patients may not have symptoms for a period of time following infection. The risk of transmitting COVID-19 when asymptomatic is believed to be low. Several countries have taken steps to enforce self-isolation (self-quarantine) to contain undiagnosed spread of disease, but the universal efficacy of these strategies is not well established. Furthermore, availability and accuracy of current testing kits is not 100%, so current testing recommendations are strategic and not universal.

The benefits of self-quarantine are highest when significant risk factors for COVID-19 are present, most notably recent travel to an area with “widespread ongoing community spread”. In other situations, businesses should look to local, regional, and national public health authorities (e.g. CDC) for country-specific recommendations. For example, China, South Korea, and Singapore have enacted strict self- isolation policies while European countries have mixed approaches and the United States favors a state-centered approach. Washington, California, and New York are currently under a “state of emergency” which advocates self-isolation wherever possible. Check CDC updates on travel restrictions.

When self-isolation is pursued, the key is to enforce both “social distancing” and “droplet precautions.” Social distancing generally means staying at home to avoid contact with others. This includes the avoidance of public transportation and crowded public activities. When near other people, try to maintain a distance of at least 6 feet, and avoid people with obvious signs of respiratory infection. Droplet precautions refers to the avoidance of unprotected contact with people who are sneezing or coughing in order to prevent contact with infectious respiratory fluids. While fluids can directly transmit disease by entering the eyes, mouth, and nose, infection can also occur when people touch their own face after touching respiratory fluids.  Meticulous hand washing (soapy water for > 20 seconds) and avoidance of facial touching are two critical steps to avoid infection. The use of standard masks may reduce droplet risk while simultaneously reminding wearers not to touch their face. Hand sanitizers with >60% alcohol are useful when routine handwashing is not available, though benzalkonium chloride, a common active ingredient in some hand sanitizers, is not effective in killing coronavirus.

Although COVID-19 may survive for a period of hours on surfaces, and in some cases remains detectable for several days, it is not known whether the virus particles are infectious or capable of transmitting disease. Prudent recommendations for hygiene include periodic surface decontamination with appropriate cleaners (the EPA has a list of recommended products) wherever known contamination occurs or where there is heavy human traffic in communities affected by active COVID-19 transmission. 

Awareness of the overall low risk of COVID-19 is key. While data are still evolving, current estimates are that this outbreak will be similar to seasonal influenza and better than past outbreaks of SARS and MERS coronaviruses. However, many countries are advocating self-isolation (self-quarantine) wherever possible to enhance overall containment. It is important to be thoughtful and measured when responding to this disease.  For example:

• If this was an outbreak of a new variant of influenzavirus, as opposed to coronavirus, would your business respond similarly or differently?

• How did your business respond to the SARS outbreak of 2002, the H1N1 influenza outbreak of 2009, and the MERS epidemic of 2012? What lessons did your business learn from those experiences?

In addition, it would be important to consider the following: 

• Practice strategic, rather than indiscriminate, use of self-isolation (self-quarantine) in alignment with local, regional, national, international public health expert recommendations (e.g. CDC, WHO).

• Consider the limitations of frequent news updates while data are still in flux. Just as stock market volatility can complicate understanding of true economic health, receiving constant news cycle updates may complicate day-to-day operational decision-making. Given an ongoing lack of clarity about true risk, reliance on expert opinion and public health authorities is essential to avoid overreaction.

• Given the pervasiveness of social and news media, be mindful of inadvertent secondary effects such as workplace discrimination against those with nonspecific symptoms, recent travel, or specific ethnic backgrounds. Business managers should consider the financial impact to individuals who engage in self-isolation (quarantine) without adequate sick pay coverage. Regardless of origin, uncertainty often leads to anxiety which may damage productivity and workplace harmony.

• Now is the time to test the power of remote work and telepresence, particularly before quarantine measures may be instituted. For healthcare professional in particular, Congress recently passed an $8.3 billion supplemental funding package to waive telehealth restrictions under Medicare during the coronavirus outbreak.

All ill employees should stay at home and not report to the office. Anyone with a fever (≥100.4) or symptoms and signs of respiratory illness (cough, sneezing) should self-quarantine until symptoms have resolved. HR and payroll policies should be reviewed and/or developed to reinforce this simple measure and to avoid overtly or inadvertently discouraging employees from self-quarantine.  Decisions about working from home for large groups of employees may be limited by IT capabilities as well as unique continuity requirements unique to each office or business. The importance of working from home might also depend on the office structure, level of crowding, and social interaction. Typically working from home emerges as a recommendation in locations where there is active community transmission occurring. In the U.S. currently, this is occurring in a few “hotspots” but will likely continue to spread. Public health authorities such as the CDC will continue to update the public on the status of the COVID-19 epidemic and issue guidance for escalation of social distancing as the situation evolves.

The best response to this question is probably in the context of general disaster preparedness. There is little evidence from the current COVID-19 epidemic that suggests people need to stockpile large supplies of home products, such as masks or gloves. In fact health authorities recommend against this since it might hamper supply chain distribution to health care workers and others who actually need supplies of protective equipment. Although many people are stocking up on hand sanitizer, washing with soap and water is still the most effective method for cleaning hands. 

 It is generally good advice for everyone to keep sufficient supplies of essentials to prepare for a wide variety of disasters, such as severe weather events or other natural disasters. Some items to consider: canned and nonperishable food and a supply of water that is adequate for at least three days for each family member; sufficient medication, flashlights and batteries, clothing, and first aid supplies. See CDC family emergency kit checklist for a more comprehensive list. 

Public health authorities, including the CDC and WHO, are monitoring the COVID-19 situation very carefully and are updating the public with any new developments. Important milestones that will inform decision making may include the following: 

• When we learn the case fatality rate (dangerousness of the disease) through widespread testing.
• When the total incident rate (number of new cases) begins to plateau and decline.
• When we identify the true spectrum of disease and the number of mild or asymptomatic cases.

Currently these answers are unknown, but data from additional testing over the next few weeks may provide clarity.  In the best-case scenario, the data will reveal disease severity similar to seasonal influenza in which case businesses will have less operational anxiety.