ARIZONA COVID CLINIC

Curtis P. Page MD

PREVENTION AND MANAGEMENT OF COVID-19 AT HOME

INFORMATION FOR PATIENTS AND PROVIDERS

This guide was meant to help patients and caregivers with managing COVID-19 at home. This guide is not meant to constitute medical advice as every case is different. It is important that you discuss COVID-19 treatment and monitoring with your medical provider. This protocol is only meant to advise the treatment of unvaccinated adults who have active symptoms related to COVID. Similar strategies may be used to treat vaccinated or previously infected persons who contract acute COVID infection (breakthrough or reinfection), however the timing and treatment strategies of the different stages may vary (breakthrough infections progress through stages more rapidly. For example, someone with a “breakthrough infection” that is high risk might demonstrate hypoxemia (evidence of early inflammatory phase) much earlier.

The key to achieving successful outcomes with COVID-19 is to focus on prevention and early treatment. Nothing is better than receiving a series of vaccinations with either the mRNA vaccines (BioNTech-Pfizer, or Moderna) or an Adenovirus vector vaccine (Astra Zeneca or J & J). Boosters should be provided for at risk populations.

For those that choose not to vaccinate we provide proven methods for prevention and early treatment. THE MOST IMPORTANT THING FOR ANYONE TO KNOW IS THAT EARLY DIAGNOSIS AND TREATMENT IS ESSENTIAL TO PREVENTING POOR OUTCOMES WITH COVID. Since most early treatments must be initiated in the first 5 days of symptoms, it is essential that you purchase and keep in your home early detection COVID-19 antigen test kits. These tests are very accurate during the first week of symptoms. Many people make the mistake of thinking that their allergy symptoms are not due to COVID-19, and they end up in the Emergency Room after 10 days of symptoms when it is likely too late to prevent a poor outcome. Test often and if your test is positive call us IMMEDIATELY so that we can start potential lifesaving treatment.

The first 7-days are a race: a race between the virus and one’s immune system. If one’s immunity is strong, the virus will be destroyed before it can take hold and destroy tissues in the body. After 7 days the virus all but disappears. What we do before infection and in the first 7 days of symptoms make a big difference in many people.

1. Prevention of COVID-19:
   • First and foremost, vaccinate.
   • Wear a mask when in public especially when you cannot socially distance from any person. N95 or KN95 masks are preferred (see Masks below) but there are homemade solutions that may work nearly as well.
   • Practice social distancing whenever possible, maintaining a distance of 6 ft or more from other people.
   • Open windows in your home if possible. See Quarantine and Home Design to prevent COVID transmission below for full guidance on how to design your home to reduce household spread of COVID.
   • Nasopharyngeal washes with 1.1% Saline have proven to reduce the viral loads of people infected with SARS-COV-2.
   • COVID-19 can be very deadly for sedentary people with diabetes, obesity, smoking or heart disease to name a few. Start an exercise program now and start losing weight by eliminating or drastically reducing carbohydrate intake. It is never too late to start.

1. Early Detection and Testing for COVID:
   • Early detection is best accomplished with a home rapid antigen test. This test is most accurate if performed within the first few days of symptoms. Symptoms usually start about 2-3 days after exposure. You are most transmissible before you are asymptomatic and for the first few days of symptoms (this is when the viral loads are the highest (See graph below). By the end of the first few days of symptoms, viral loads drop significantly. Most anti-viral strategies must be initiated in the first 5 days to be most effective.
   • Please buy several home rapid antigen tests and use them frequently after a high-risk exposure or if you have any, even mild, upper respiratory tract symptoms such as headache, sinus congestion, runny nose, cough, or sore throat. If you test positive, please come to the office immediately. PCR tests should be used to confirm infection but do not delay treatment if you have tested positive with an antigen test.

Symptoms: Symptoms may occur 2-14 days (median 5.5) after exposure. Common symptoms include:

1. Runny Nose
2. Headache
3. Sore Throat
4. Diarrhea with or without abdominal pain
5. Fever
6. Muscle aches/Back pain
7. Fatigue
8. Loss of smell or Taste
9. Dry Cough
10. Shortness of Breath

Most unvaccinated people treated conventionally (81%) do not require hospitalization. If you test positive and are asymptomatic, please stay at home for at least 14 days. It is important to self-quarantine. If you would like to be tested for COVID-19 and you are symptomatic, please call our office in advance and we will arrange for you to be tested either in our respiratory unit or we can test you while you wait in your car.

STAGES AND THEIR TREATMENTS FOR COVID 19

Extensive study of COVID-19 infection has revealed that the infection follows a clinical pattern characterized by various stages and physiologic processes. Treatments are directed at the different stages:

1. Incubation Period (Exposed and Pre-symptomatic)
   1. Viral Symptom Phase (Viral Symptoms and reduction of immune system effected by the virus)
   1. Early Inflammatory Phase (Increase in Inflammatory Cytokines)
   1. Secondary Inflammatory Phase (Progression to Cytokine Storm)- characterized by hypoxemia (low oxygen levels).
   1. Multisystem Inflammatory and Thrombotic Phase (Cytokine Storm and Hyper coagulation)
   1. Tail Phase (Recovery and Potential progression to Long COVID symptomatology

Disclaimer and Informed Consent: All established western medical authoritative bodies (FDA, WHO, CDC and NIH), do not recommend the use of Ivermectin for the prevention or treatment of COVID-19 infection. Please consult with your physician before taking Ivermectin.

• VIRAL SYMPTOM PHASE (day 1-7 of symptoms)

This is the stage of illness where symptoms are much like a typical upper respiratory viral infection (flu or cold). 70% of unvaccinated people, will get better without progressing to the inflammatory/cytokine phase.

It is important that you start active treatment at the first onset of symptoms. To confirm your illness, please use a home rapid antigen test, available at many pharmacies. If positive, please start treatment medications and seek immediate medical attention.

Approximately 30% of PCR tests are false negative, so if your PCR test is negative and if there is a high index of suspicion such as altered taste or smell or close contact with a COVID-infected person, please get re-tested and start the viral phase treatment protocol.

1. Vitamin D: 5,000 mg per day. (if patient has never been on Vitamin D supplementation, take 10,000 mg per day for 10 days (Vitamin D loading) and then take 5,000 per day thereafter). Check a vitamin D level every three months until a “steady state” is reached.
   1. Vitamin C: 1,000 mg per day
   1. Elemental Zinc: 30-40 mg per day (not to be confused with non-elemental zinc)
   1. Melatonin: 10 mg per at bedtime
   1. Quercetin 500 mg per day
   1. Famotidine 40 mg every 8 hours
   1. Colchicine 0.6 mg twice a day for 7 days
   1. Loratadine 10 mg/day or any antihistamine
   1. N-Acetyl cysteine: 600 mg once or twice a day
   1. Fluvoxamine 100 mg twice a day for 14 days
   1. Budesonide Inhaler 400 mcg (two puffs), twice a day
   1. Monocolonal Antibody Treatment (see below)

• Additional Alternative and somewhat controversial medications that are not yet recommended by the FDA, CDC or the NIH for use in COVID-19.
  • Ivermectin 0.4 mg/kg once a day until day 7 of symptoms (Controversial at best. Several Anecdotal studies, physician testimonies and some controlled trials support use in early viral stage of disease. Some double-blind placebo-controlled trials have not demonstrated efficacy). Per provider discretion.
  • Micronized Fenofibrate 134 mg once a day (optional- check drug interactions below). This medication may work similar to Fluvoxamine so it might be considered unnecessary.

Treating Fever: Do not use Tylenol or Motrin during the viral phase to treat fever unless > 103 degrees F. There is evidence that fever over 102.2 activates interferon which is essential to fight the virus. SARS-COV-2 interferes with interferon production.

Nasal Rinses: There is emerging data that nasal rinses with Betadine or Hydrogen Peroxide are useful at lowering viral counts in the nasopharynx. There is also good evidence that 1.1% normal saline nasopharyngeal rinses can reduce viral loads. Since we are not yet sure if Betadine or H₂O₂ is toxic to epithelial cells in COVID, we recommend that, as soon as you become ill, start Nasopharyngeal rinses with 1.1% Saline 3-4X per day. The Neti Pot is an ideal way to get a good nasal saline rinse. Nasopharyngeal washes can also be used as prevention up to 4 X per day.

Monoclonal Antibody Treatment: Patients with at least one risk factor: Age over 65, Obesity (BMI over 25/30), HTN, Hyperlipidemia, COPD, Asthma, Diabetes, Cancer on immunosuppression medications, etc should receive early monoclonal antibody treatment. Check your local treatment center(s) for inclusion criteria. Do not delay. This treatment will be most effective if started in the first 5 days of symptoms. If you cannot get in quickly to a treatment center for antibodies, please either go to a local emergency room or urgent care center (call ahead). Monoclonal antibodies are the most accepted, effective treatment we have in the first 7 days. Monoclonal antibody treatment is currently the only early intervention sanctioned by the WHO, CDC, FDA and NIH.

Concerning Drug interactions: Taking Fenofibrate or Statin drugs with Colchicine may cause muscle cramping or muscle injury; if you develop muscle aches while on these medications stop the Colchicine or consult with your physician. Fluvoxamine can cause nausea and lethargy. Fluvoxamine is an SSRI and should not be taken with MAO inhibitors, other SSRI medications or if someone has a history of Bipolar Mania.  Each medication has side effects and contraindications that are too numerous to list here. Please consult with your physician and/or pharmacist before taking any new medication.

Labs: LDH, CRP, Ferritin and D-Dimer every 48 hours. Mobile labs can be sent to the home if patient cannot come to the office. IL-6 may also be used to monitor inflammation. Ferritin may help determine which patients would benefit from early and aggressive anticoagulation with low molecular weight heparin (Enoxaparin) and higher doses of steroids.

If you start to feel better on or before day 7, most likely you will not need further treatment. For 70% of people, symptoms resolve without progression. For many people, however this is the calm before the storm (read below) and occasionally people can start to feel better and then suddenly become very short of breath or develop extreme fatigue (signs that they have entered the cytokine phase).

If you are not getting better after the first 6-7 days of symptoms, then you will need to start preparing for the inflammatory/cytokine phase. Many people also start to feel better currently. Most will be OK, but some will suddenly enter the cytokine or inflammatory phase after feeling better on day 5-7.  The cytokine storm for many people is often characterized by sudden shortness of breath or difficulty breathing and the resumption of fevers. Additional signs of cytokine storm with the Delta Variant include sudden loss of taste or smell, sudden onset of significant new low back pain or muscle aches and/or sudden profound fatigue. Most of the time, the cytokine storm starts at day 8 give or take a day. 

It is important that you purchase a pulse oximeter to monitor your oxygenation before the cytokine storm hits, so if you are not feeling better by day 6/7 purchase a pulse oximeter. Monitoring oxygenation is the most important indicator that doctors use to determine the severity of illness and whether we need to escalate to more potent treatments.

IT IS VERY IMPORTANT THAT YOU SEEK IMMEDIATE MEDICAL ATTENTION IF YOU EXPERIENCE SYMPTOMS OF SERIOUS LUNG INFLAMMATION ALSO KNOWN AS THE CYTOKINE STORM.

COVID-19 should be thought of as 2 sequential diseases (First, Viral and subsequently Inflammatory/Thrombotic). In unvaccinated/never infected people, the cytokine storm (Inflammatory phase) typically starts on or about day 8 (7-9) of symptoms. It is extremely important that you do not delay care if you are in the storm. You need to be immediately started on a different set of treatments. Once the body enters the inflammatory phase, the virus is no longer very infective, and any anti-viral treatments deployed after day 7 should have little to no effect. In those that experience disease progression, the disease process that exists after day 8 is not from the virus, but from your body’s own hyperactive immune system attacking the lungs and other organs.  The medications we use to calm down the overactivated immune system are very different from those that we use in the initial viral phase. The disease can be infinitely more dangerous if it progresses past day 7. We will need daily contact with you if you do not immediately improve with our treatments past day 8 so that we may modify or increase your medication until the inflammatory process is sufficiently treated.  You will need to have your labs drawn every 24-48 hours to monitor your progress. You will need to come to the office for a Chest X-ray from time to time or upon request. If you respond and normalize then we will need to taper down your steroids daily and quickly. High dose steroids may cause serious side effects if taken for an extended period. It is essential that once the storm breaks (breathing easier with rising oxygen saturations) with the use of high dose steroids, we need to know and be able to rapidly taper down the steroid dose. In contrast, if you do not respond or immediately improve with the initial steroid dose, we will need to increase your steroid dose until we reach the desired effect. During this time, we need constant monitoring of vital signs and constant communication with our providers to keep you safe. At times, a person will need to be in the hospital. Only with constant communication and reporting of vital signs and symptoms can we help you determine if or when you need to be in the hospital.

Disclaimer and Informed Consent: All established western medical authoritative bodies (FDA, WHO, CDC and NIH), do not recommend the use of steroids outside of the hospital setting. These recommendations have been made because steroid use has not yet been studied in the outpatient setting and because steroid use without the presence of lung inflammation (hypoxia, shortness of breath, abnormal chest X-Ray) typically before day 8, is associated with a WORSE OUTCOME (We need an active immune system to fight the virus during the early phase of the disease- steroids inhibit the immune system, so DO NOT TAKE STEROIDS IN THE FIRST 7 DAYS OF SYMPTOMS.Exceptions might include those persons with symptoms of a COPD or asthma flare. Consult with your provider under these circumstances. A lot of urgent care or other providers that do not understand the pathophysiology of the disease might prescribe steroids too early, so please beware. Do not take them. If you are not short of breath, have a pulse oximeter reading greater than 94% or have a normal chest X-Ray, you likely do not have enough inflammation to warrant the use of steroids which again can be harmful if given during the early viral phase of the illness.

• Supplements and medications for mid-range symptomatic treatment (day 7/8/9-13 of symptoms) CYTOKINE STORM/INFLAMATORY PHASE

1. Vitamin D: 5,000 mg per day.
   1. Vitamin C: 1,000 mg per day
   1. Quercetin 500 mg per day
   1. Famotidine 40 mg every 8 hours
   1. N-Acetyl cysteine: 600-1200 mg per day
   1. L-Arginine 1.6 mg twice a day (optional)
   1. Cyproheptadine 8 mg three times a day
   1. Montelukast 10 mg daily
   1. Clopidogrel 75 mg per day
   1. Continue Fluvoxamine 100 mg twice a day for a total of 10 days ((If does not tolerate Fluvoxamine (fatigue, confusion) substitute with Fluoxetine 30 mg/day))
   1. Prednisone 40-240 mg per day or Methylprednisolone 40-240 mg per day or Dexamethasone 6-20 mg per day (dose depends on multiple factors including severity of disease and risk).

Consider adding Ipratropium Bromide and/or Albuterol nebulizers and/or Budesonide via SVN for Asthmatics or those with COPD/smoking history or those with significant respiratory symptoms.

Consider adding Low Molecular Weight Heparin (Enoxaparin 40 mg twice a day or 1mg/kg twice a day). LMWH should be added if the D-Dimer is above 1,500 or escalating rapidly with hypoxemia and infiltrates seen on Chest X-Ray.  If Ferritin is >1,300, consider adding therapeutic dose LMWH (1 mg/kg twice a day), if not in the hospital intensive care unit. Once in the ICU lower the dose of LMWH to 40 mg once or twice a day.

Labs: CBC, CMP, LDH, CRP, and D-Dimer every 24-48 hours. Consider checking IL-6 and Ferritin levels. Mobile labs may be sent to the home if the patient cannot come to the office. Consider checking stool occult blood test early to determine the safety of using anticoagulant therapy. Consider adding Protonix 40 mg daily to prevent stress gastritis in high-risk patients.

Although not advisable, for those patients that are adamant about not going to the hospital, consider purchasing a Portable Oxygen Concentrator and Nebulizer if you would like to stay home for your care.  If you need to be on supplemental oxygen, you are best served in the hospital, however you may want to purchase a portable oxygen concentrator or portable oxygen tank for home use in case of a sudden decline in oxygenation (rare).

Steroid Use: High dose steroids are essential at this stage. It is important to start high and taper down rapidly once effect has been achieved. If you start on a dose and effect has not been achieved keep doubling the dose until hypoxemia resolves. It is essential that you take caution to treat, hyperglycemia, stress gastritis and potential steroid psychosis should they become evident.  Steroids may also lead to secondary infections such as bacterial or fungal pneumonia. We suggest that a respiratory procalcitonin lab test is drawn whenever there is evidence for a secondary infection such as new onset fevers, a sudden rise in CRP or a new and elevated neutrophil count. Consider initiating antibiotics or testing for a fungal infection as well. Secondary infections are very rare in the outpatient setting and are mainly seen in the hospital and almost always with critical COVID managed in the ICU.

• Supplements and medications for late symptomatic treatment (after day 12-14) THROMBOTIC PHASE

1. Vitamin D: 5,000 mg per day.
   1. Vitamin C: 1,000 mg per day
   1. Elemental Zinc: 30-40 mg per day
   1. Melatonin: 10 mg per day
   1. Cyproheptadine 8 mg three times a day
   1. Quercetin 500 mg per day
   1. Famotidine 40 mg three times a day
   1. L-Arginine 1.6 mg twice a day (optional)
   1. N-Acetyl cysteine: 600 mg per day
   1. Montelukast 10 mg daily for 14 days
   1. Clopidogrel 75 mg per day for 14 days
      1. Consider substituting with Enoxaparin 1mg/kg BID for signs of thrombosis
         1. Elevated D-Dimer >1500 or trending up
            1. The trend up is most important
         1. Ferritin > 1,300.
         1. Diffuse patchy infiltrates on CXR/CT scan
         1. Hypoxemia with oxygen saturation < 94%.
   1. Steroids under advisement of provider
   1. Hospitalized patients should be treated with either Barcintinimib or Tocilizumab (initiate early in course of disease to ameliorate the cytokine storm).

• Recovery:
  • Once you have recovered, stop all medications except:
    • Colchicine 0.6 mg daily for 14 days (In high-risk individuals, if prescribed early and have not progressed to severe COVID/inflammatory phase) after recovery. Not necessary in low risk recovered individuals.
    • Plavix 75 mg/d for 30 days from onset of illness (optional use) in high-risk individuals that did not progress to severe infection. Not necessary in low-risk individuals that never progressed through inflammatory phase of illness.
      • Blood clots: Strokes, heart attacks or pulmonary embolism have been seen up to 90 days after illness.
    • Supplements and Vitamins: Vitamin D, NAC, Vitamin C, Zinc, and Quercetin.

• Disclaimer and Informed Consent: All established western medical authoritative bodies (FDA, WHO, CDC and NIH), do not recommend the use of therapeutic doses of LMWH/ Enoxaparin (1 mg/kg BID) outside of the hospital setting. These recommendations have been made because such use has not yet been studied in the outpatient setting. Use of therapeutic dose LMWH has been associated with severe and life-threatening bleeding which may include, intracerebral hemorrhage and gastrointestinal bleeding. If you have ever experienced life threatening bleeding or currently suffer from gastritis or peptic ulcer disease, please inform your provider before taking therapeutic dose LMWH/Enoxaparin.

1. If at any time after initiating home therapy, you do not feel comfortable or you feel that you should be in the hospital, do not hesitate to call 911 or have someone drive you to the hospital if you are stable. If your oxygen saturations remain above 90% during this treatment you can feel comfortable that you are improving. If your oxygen saturations drop below 90% that is sustained, you are best managed in the hospital setting. Walking, deep breathing and Proning (see below) are the best methods to raise your oxygen saturations. Keep in constant contact with your medical provider. Report symptoms and vital signs frequently. Should you experience, sudden shortness of breath, severe chest pain, significant bleeding or acute neurologic deficit please call 911 and proceed to your nearest emergency room.

Guidelines for home treatment of COVID-19

1. Monitoring
   1. Check temperature frequently about every 8 hours
   1. Monitor signs and symptoms and seek immediate medical attention if there are Emergency Signs and Symptoms (see above)
   1. For patients with shortness of breath monitor pulse oximetry (see “Equipment” below)
   1. If you progress (disease not mild and self-limited) your provider may need labs and a chest X-Ray to monitor the severity of your disease and to make decisions on when it might be necessary to escalate care.

Emergency Signs and Symptoms that require immediate medical attention.

1. Difficulty breathing
2. Persistent chest pain
3. Confusion or unarousable
4. Bluish lips, fingers, or face

Visit the CDC for additional information: www.cdc.gov/coronavirus/2019

1. Quarantine and Home Design to prevent COVID transmission (COVID-19 viral particles spread via droplets and aerosolization)
   1. Make sure effected person stays in a room separate from others.
   1. Make sure that there is good air circulation to and from the outside world. Keep a window open if possible and blow air from the inside to the outside.
   1. Make sure the patient wears a mask even when in isolation. Note: if the patient is actively coughing, viral particles can escape into the room even if they are wearing a mask.
   1. Your home should have Minimum Efficiency Reporting Value (MERV) 13 (or higher) filters in your HVAC.
   1. Use portable air cleaners/purifiers with a HEPA Filter. Ionizers or UV light do not work as well as a HEPA filter.
   1. The goal is to circulate your homes air 4-6 X per hour. Most homes circulate air 0.5 X per hour. To calculate your air changes per hour, use the following formula:  CADR (CFM) X 60 (Minutes)/ (divided by) the volume of the room in square ft (LXWXH).  Your air purifier should have the CADR listed on the label. Measure the cubic feet of the space that you want to evaluate and plug into the formula.
   1. Caregiver should avoid entering the room whenever possible. If this cannot be avoided, caregiver must wear a mask in the room and perform hand hygiene after leaving the room. Note: surgical masks only provide partial protection. We advise that caregivers not enter the room of an actively coughing or sneezing person as there are likely many viral particles in the air for up to 3 hours. These particles can get into the eyes and through or around most homemade or surgical masks.
   1. Patients should have a separate bathroom. Nobody else should use that bathroom. If this cannot be done, it is important to disinfect the bathroom after each use with diluted bleach https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/disinfecting-your-home.html. If the bathroom is shared make sure all toiletries, towels and toilet paper are taken in and removed after each use by the patient.
   1. The patient should eat alone in their room. Use disposable cutlery and plates. Any non-disposable utensils, plates or cups should be disinfected after use with bleach.
   1. If you live in a dry environment,

1. Personal Hygiene and Cleaning
   1. Caregiver and patient should wash hands frequently with soap and water for 20 seconds and caregiver should avoid touching face.
   1. Wash clothing and bed sheets regularly in hot water (90^o C) and bleach.
   1. Use disposable gloves and a mask when entering a patient’s room to clean.
   1. Use disposable gloves to handle and dispose of trash.

1. Mental Health
   1. Continue to communicate with the patient. Schedule video conferences or phone calls with family and friends.
   1. Meditation and Exercise are helpful ways to manage depression or anxiety.
   1. Seek professional help if there are significant signs of emotional distress.
   1. Stress reduction and good sleep are extremely important to combat any infection. If depression or the stress of your illness is interfering with your sleep, please seek medical attention immediately.

1. Accidental Exposure to body fluids
   1. If body fluids fall on a intact skin, wash with soap and water for at least 20 seconds. You can also disinfect with 70% alcohol for 3 minutes.
   1. If body fluids fall on mucous membranes or an open wound. Immediately leave the room and flush the wound or mucous membrane with saline (salt water). Isolate for 14 days and observe for symptoms.
   1. If you are impaled or cut with a sharp object that was contaminated, squeeze any blood out from the bottom to the top and then flush the wound with running water for 5 minutes. Isolate for 14 days and observe for symptoms.
   1. If an infected person coughs or sneezes directly on an unprotected caregiver, gargle with salt water. Wash face and surrounding skin with soap and water. Dip a cotton swab in 70% isopropyl alcohol or 75% alcohol and swab the inside of your nose. Isolate for 14 days and observe for symptoms.

1. Mask Use
   1. N-95 masks are the most effective way to prevent transmission of COVID-19.  Make sure the N-95 is well fit, to not allow for air to enter your mouth and nose from around the edges of the mask.
   1. Surgical Masks: Wash your hands or disinfect your hands with sanitizer before you put on your mask. When you put on a surgical mask, the colored side faces out. Use the metal bar on the top of the mask to mold the mask to the bridge of your nose and upper cheeks. Extend the bottom of the mask around your chin. Beards should be shaved off during this time as beards will allow viral particles to enter through gaps in the mask-face interface. To improve the effectiveness of a surgical mask, wear a snug-fitting cloth mask over the surgical mask (this forces air to enter through the mask and not around the sides). This double masking technique is 91% effective at filtering particles the size of SARS COV2 and nearly approaches the effectiveness of an N95.
   1. Never touch the front of your mask. The mask is an air filter. Particles suspended in the air will trap on the surface of the mask when you breath. The surface of the mask is potentially contaminated. Always handle the mask from the straps on the back of the mask. If you need to adjust the mask or scratch your face, try using a tissue.
   1. If you inadvertently touch the front of your mask wash your hands with soap and water for 20 seconds or use hand sanitizer with 70% alcohol.
   1. Cloth Masks: The CDC recommends that all persons wear a cloth face mask when out in public especially when social distancing of at least 6 ft cannot be maintained.
      1. Single layer cloth masks are better than nothing.
      1. Multilayer cloth masks are better than single. High thread-count and certain synthetic materials that are less porous are better.  Quilter’s cotton filters even better than surgical masks.
      1. Double layer cloth masks can be made with a central compartment that can be used to insert a filter strip. Some people use HEPA filters (MERV 12 or greater) or non-fiberglass vacuum bag filters. Elastic around the edges of the cloth mask is preferred. You can have the best filter in the world but if the mask does not fit closely to the skin, every time you breath in, the air will take the path of least resistance which is around the gaps in the sides, top and bottom of the mask.
      1. Remember cloth masks are only partially effective. People can easily sneeze virus particles through a cloth or surgical mask. Keep away from people coughing or sneezing in a mask. Keep 6 ft between you and any person and continue to practice good hand hygiene.   
      1. If you can get your hands on N95 or non-counterfeit KN95 masks this is preferrable. If properly fit these masks filter 95% of all viral particles.
2. Mask sterilization: Surgical masks should be used once and discarded. If you do not have access to home-made cloth masks or multiple surgical masks and need to reuse your surgical masks, the best option is to put 7 masks in 7 brown paper bags and label each paper bag with a day of the week.  At the end of each day return your mask to the appropriate bag and then it can be reused in a week.
   1. UVC light can be used to sterilize a mask. About 60 minutes of sterilization is effective.
   1. Masks can be sterilized in hot air ovens at 70⁰ C for 30 minutes.  
   1. Masks can be sterilized three times with these methods and then should be discarded.

1. Equipment:
   1. We recommend that anyone with shortness of breath acquire a pulse oximeter to monitor oxygenation. It is important to keep your oxygen saturations between 92 and 94%. If your oxygenation starts to drop, please seek medical attention. If your oxygen saturation drops below 90% you should seek immediate medical attention as you may need to be hospitalized.
      1. Lying in the prone position (face down) can help with breathing and improve oxygenation (see below)
      1. Using an incentive spirometer every hour or blowing up balloons may improve oxygenation.
   1. Some people might prefer to manage low oxygen levels at home with an oxygen concentrator or portable oxygen, however some patients may get worse quickly so this must be done under close medical supervision and with monitoring by an capable caregiver/family member.

1. Diet: It is important for anyone that is ill to keep up with their calories. Fighting the infection and fever will require you to eat a lot.
   1. Foods that improve immunity include citrus, watermelon, berries, spinach, wheat germ, yoghurt, garlic, ginger and chicken soup.
   1. If patient is fatigued, eating may be difficult. Try soups, broths or soft foods. Avoid Meat as the intestines have a difficult time digesting meat.
   1. Drink plenty of water- about 8-10 glasses a day. Exceptions would be if you have a history of congestive heart failure or kidney problems. Consult with your medical
   1. provider if you have one of these conditions. If your urine is dark or amber, you are likely dehydrated. Drink more water. Urine should be light yellow. If your ankles swell or you get short of breath seek medical attention and cut back on your liquids.

• Exercise:
  • It is important that you maintain exercise if possible. Deep breathing exercises are very important. It is important to that you expand your lung. If you have a moderate to severe case of COVID, characterized by shortness of breath when walking or at rest, we suggest that you walk for at least an hour every 3 hours. Set your alarm clock to wake you up every 3 hours. It is important that you keep moving to keep your blood from clotting. When you are not walking you should be lying in the prone position.
  • An incentive spirometer the best way to expand your lungs. You can also blow up balloons.
  • Consult your doctor for guidance on an appropriate home exercise program.
  • Patients with Long COVID tend to experience a worsening of symptoms. So if you have Long COVID, refrain from vigorous exercise.

• Proning:

Anyone that develops hypoxemia should start to prone on a regular basis. This technique increases oxygenation and reduces the work of breathing. This technique can be lifesaving and keep people off the ventilator.

• References (not complete- work in progress):

1. Short term, high-dose vitamin D supplementation for COVID-19 disease: a randomized, placebo-controlled, study (SHADE study) Ashu Rastogi,1 Anil Bhansali,1 Niranjan Khare,2 Vikas Suri,2 Narayana Yaddanapudi,3 Naresh Sachdeva,1 G D Puri,3 Pankaj Malhotra 2
2. Quercetin: Antiviral Significance and Possible COVID-19 Integrative Considerations Pawan K. Agrawal1 , Chandan Agrawal1 , and Gerald Blunden2
3. N-Acetylcysteine to Combat COVID-19: An Evidence Review
4. Inhaled budesonide in the treatment of early COVID-19 (STOIC): a phase 2, open-label, randomised controlled trial Sanjay Ramakrishnan*, Dan V Nicolau Jr*, Beverly Langford, Mahdi Mahdi, Helen Jeffers, Christine Mwasuku, Karolina Krassowska, Robin Fox, Ian Binnian, Victoria Glover, Stephen Bright, Christopher Butler, Jennifer L Cane, Andreas Halner, Philippa C Matthews, Louise E Donnelly, Jodie L Simpson, Jonathan R Baker, Nabil T Fadai, Stefan Peterson, Thomas Bengtsson, Peter J Barnes, Richard E K Russell, Mona Bafadhel
5. Inhaled budesonide for COVID-19 in people at higher risk of adverse outcomes in the community: interim analyses from the PRINCIPLE trial PRINCIPLE Collaborative Group*
6. Lopes MI et al Beneficial effects of colchicine for moderate to severe COVID-19: a randomized, double-blinded, placebo controlled clinical trial, Rheumatic and Musculoskeletal Diseases (RMD) Open 2021; 7:e001455.dol:10.1136/RMD open-2020-001455
7. Inhibition of Severe Acute Respiratory Syndrome Coronavirus 2 Replication by Hypertonic Saline Solution in Lung and Kidney Epithelial Cells; The Journal of Physical Chemistry Letters  2020, 11, 24, 10446-10453
8. Review of the use of nasal and oral antiseptics during a global pandemic Christopher Stathis1 , Nikolas Victoria1 , Kristin Loomis1, Shaun A Nguyen2, Maren Eggers3, Edward Septimus4 & Nasia Safdar*,5
9. Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19; August 4, 2021, at NEJM.org. DOI: 10.1056/NEJMoa2105911
10. Colchicine for community-treated patients with COVID-19 (COLCORONA): a phase 3, randomized, double-blinded, adaptive, placebo-controlled, multicentre trial; Lancet Respir Med 2021; 9: 924–32 Published Online May 27, 2021 https://doi.org/10.1016/ S2213-2600(21)00222-8
11. The importance of understanding the stages of COVID-19 in Treatment and Trials Daniel O. Griffin, et al. AIDS Reviews Vol 23, No. 1 January-March 2021
12. Rainwater-Lovett K, Redd JT, Stewart MA, Calles NE, Cluff T, Fang M, Panaggio MJ, Lambrou AS, Thornhill JK, Bradburne C, Imbriale S, Freeman JD, Anderson M, Kadlec RP. Real-world Effect of Monoclonal Antibody Treatment in COVID-19 Patients in a Diverse Population in the United States. Open Forum Infect Dis. 2021 Jul 24;8(8):ofab398. doi: 10.1093/ofid/ofab398. PMID: 34409125; PMCID: PMC8364980.
13. Marconi, Vincent & Ramanan, Athimalaipet & Bono, Stephanie & Kartman, Cynthia & Krishnan, Venkatesh & Liao, Ran & Piruzeli, Maria & Goldman, Jason & Alatorre Alexander, Jorge & Pellegrini, Rita & Estrada, Vicente & Som, Mousumi & Cardoso, Anabela & Chakladar, Sujatro & Crowe, Brenda & Reis, Paulo & Zhang, Xin & Adams, David & Ely, E & Zirpe, . Kapil. (2021). Efficacy and safety of baricitinib for the treatment of hospitalized adults with COVID-19 (COV-BARRIER): a randomized, double-blind, parallel-group, placebo-controlled phase 3 trial. The Lancet Respiratory Medicine. 10.1016/S2213-2600(21)00331-3.
14. dr_chetty_8th_day_therapy_may_12_2021 (emlct.com)
15. Papamanoli A, Kalogeropoulos AP, Hotelling J, Yoo J, Grewal P, Predun W, Jacob RP, Cao K, Marcos LA, Skopicki HA. Association of Serum Ferritin Levels and Methylprednisolone Treatment With Outcomes in Nonintubated Patients With Severe COVID-19 Pneumonia. JAMA Netw Open. 2021 Oct 1;4(10):e2127172. doi: 10.1001/jamanetworkopen.2021.27172. PMID: 34605919; PMCID: PMC8491101.
16. Theoharides TC. Potential association of mast cells with coronavirus disease 2019. Ann Allergy Asthma Immunol. 2021;126(3):217-218. doi:10.1016/j.anai.2020.11.003
17. Yadav H, Kor DJ. Platelets in the pathogenesis of acute respiratory distress syndrome. Am J Physiol Lung Cell Mol Physiol. 2015 Nov 1;309(9):L915-23. doi: 10.1152/ajplung.00266.2015. Epub 2015 Aug 28. PMID: 26320157; PMCID: PMC4628982.
18. SARS-CoV-2 infects human adipose tissue and elicits an inflammatory response consistent with severe COVID-19 Giovanny J. Martínez- Colon et al, doi: https://doi.org/10.1101/2021.10.24.465626
19. Jalali, Farid and Rezaie, Salim and Rola, Philippe and Kyle-Sidell, Cameron, COVID-19 Pathophysiology: Are Platelets and Serotonin Hiding in Plain Sight? (February 5, 2021). Available at SSRN: https://ssrn.com/abstract=3800402 or http://dx.doi.org/10.2139/ssrn.3800402
20. Inhibition of Severe Acute Respiratory Syndrome Coronavirus 2 Replication by Hypertonic Saline Solution in Lung and Kidney Epithelial Cells Rafael R. G. Machado, et al  ACS Pharmacology & Translational Science 2021 4 (5), 1514-1527 DOI: 10.1021/acsptsci.1c00080