COVID-19 | Mount Sinai Today

COVID-19: Coping and Resiliency Skills

Mar 31, 2020 | COVID-19, Mental Health, Psychiatry, Your Health

As the outbreak of COVID-19 spreads throughout the greater New York area, people are adjusting to radical changes in their daily life. Businesses are closed, people are working from home—if they are able to work at all—and kids are trying to learn at home. It’s a stressful time for everybody. Rachel Yehuda, PhD, Professor of Psychiatry and Neuroscience at the Icahn School of Medicine at Mount Sinai, offers this advice about resiliency skills and coping with the COVID-19 crisis.

It’s hard not to get overwhelmed by the news. Should you limit the amount of news you watch?

There’s a part of me that wants to keep up with every update. I try to limit my exposure because much of the news is repetitive and some of it is sensationalized. I was out west in mid-March for a brief trip, and saw pictures on the news of empty shopping shelves here in New York. I was pretty worried until I got home that there might be shortages. Of course when I did return, I realized that the situation wasn’t quite as bad as portrayed. People did panic-shop, but the shelves were also getting restocked. So my worry in that case was exaggerated.

On the other hand, it is a good idea to check in a couple times a day to get the latest reports. Let’s face it, a pandemic is a scary thing to be a part of, and there are important updates that we need in real time. The important news is information about what we can do or should be doing. We need to make sure we get our news from reputable sources, like the World Health Organization. Some news outlets have an agenda that they are trying to promote, and I don’t think that’s helpful or healthy to engage in because it may increase distress. But, even if you’re getting news from reputable sources, you don’t need it 24/7.

It’s hard to avoid if you’re home.

True, but it’s also a time when you can do other things at home other than having the TV on. It’s a time that you can read, write, do something creative, meditate, or try a recipe you’ve wanted to try. You can spend time playing with your children, writing letters, or get organized, even clean out your closet.

Think of something you can do at home that will make you feel productive, and that you’ve accomplished something at the end of the day. Put the focus on enhancing your home experience as opposed to what you can’t do in the outside world.

It’s also a really good time to check in on friends, neighbors and particularly, older folks. Now is the time to catch up with other people, perhaps there’s someone you haven’t had a chance to talk to. Or maybe there’s an older person who’s shut in and isolated and needs help. It’s a healthy and healing thing to think about other people, rather than focus exclusively on yourself.

Some people are reporting that they are learning a new “coronavirus skill or art.” Think about the things you have always wanted to do, but never had the time. Arts and crafts. Watercolors. Play a musical instrument.

Does sticking to a daily routine help keep you on track?

For some people it’s very good. For children, in particular, the structure of a routine is very grounding. But there is also something liberating about a guilty pleasure of going off routine. If you always wake up really early to commute to work, there is nothing wrong with giving yourself a treat of an extra hour of sleep to make up for some of the negative aspects of not being able to go out and do whatever you want. So I wouldn’t rigidly advocate it for everyone. If you feel lost without a structure, like you are wasting the day or failing to be industrious or productive, a schedule can be important. But for people who find themselves over-scheduled, there is something about putting the world on mute and listening to one’s needs that can promote a sense of well-being.

The key is to be mindful about it. We are being given an opportunity to connect with something inside of ourselves that hasn’t been nurtured. We have been given more time. Sleep an extra hour, or skip a meal if you want. Do something you don’t ordinarily get to do. It’s a chance to embrace possibilities outside the box. We’re in a serious situation, but we can try to make the most of it and squeeze something positive out of it.

The people who are going to do the best are those who find special moments, special meaning, and special opportunities during this time. During the past couple days, I’ve gotten texts from people just asking “How are you doing? I’ve been thinking about you.” It’s wonderful to get those messages and connect when, otherwise, we might not have had time. And we’ll come out the other end of this changed in some way—maybe for the better.

Can you talk a bit about resiliency skills?

Optimism is certainly a big resiliency skill. Being able to look at the positive side of things is very important. I believe spiritual mindfulness is key; understanding what is in your control and what is not. And taking whatever control you can take, acting on it, and not feeling victimized. And knowing that this will all pass, and maybe good things will come from it in the future. This is hard to do while people are getting sick and dying, and when people are losing their jobs and faced with economic hardship. Grieving losses in real time is an important key to resilience in the future. Realistically assessing and starting to think about what will need to happen in the weeks to come if one has lost one’s job is also important.

Not feeling helpless, but trying to act is also an important way to build resilience. I am reminded of 9/11. At this time we want to behave in a way that when we look back, we will be proud of what we did during this pandemic—individually and as a society. If you bear that in mind, you won’t have disappointed yourself, and that is an important key to resilience.

Doing things for others—altruism—is also key. If you help others, even if there’s a certain amount of risk to yourself, you’ll feel good about yourself when all is said and done. Certainly health care workers on the front lines are expressing altruism each day. People are scared right now. Even people I know who are always positive are worried about getting sick, or even worse, being a carrier and getting someone even more vulnerable at risk. You should be careful if being helpful means posing a risk to yourself or to others. Yet there are many ways to contribute without leaving the house. We can show up each day in our lives—for ourselves and other people—and ask what can we do today to help. That’s resilience.

SARS-CoV2: How a Low-Powered Virus Turns Deadly

Mar 31, 2020 | COVID-19, Featured, Infectious Diseases, Research

File photo of the team from the tenOever Laboratory, from left to right: Kohei Oishi, PhD, Tristan Jordan, PhD, Daniel Blanco-Melo, PhD, Skyler Uhl, PhD candidate, Ben tenOever, PhD, Rasmus Moeller, PhD candidate, Maryline Panis, Lab Manager, Ben Nilsson-Payan, PhD, and Daisy Hoagland, PhD candidate

Early laboratory tests show the SARS-CoV2 virus, which leads to COVID-19, behaves very differently from the flu or common respiratory syncytial virus (RSV) in that it travels under the radar and enters human and animal cells quietly, eliciting a low-powered immune response that tends to fester, according to preliminary research led by Benjamin tenOever, PhD, the Fishberg Professor of Medicine, and Director of the Virus Engineering Center for Therapeutics and Research, at the Icahn School of Medicine at Mount Sinai. The observations, which provide a snapshot of how cells and organisms respond to the SARS-CoV2 virus, were based on studying RNA from live animal models and human cell lines. RSV often occurs in young children with symptoms that mimic the common cold.

“The take-home message of what we found so far is that the immune response to the virus is actually very muted,” says Dr. tenOever. In a typical reaction to the flu or RSV, the body secretes a whole family of proteins or interferons that assemble to take on a variety of functions to prepare for an imminent attack. Some of the interferons directly inhibit the virus. But with the SARS-CoV2 virus, Dr. tenOever says, “We see little to no evidence that the virus-infected cells are secreting these proteins. So a program that should be induced is not launching.” At most, the defense appears to be only 40 percent to 50 percent as strong as it would be for the flu or RSV.

The new virus behaves differently in another way, as well. Whereas the flu is particularly wily in dismantling the innate immune response in several places, SARS-CoV2 does not appear to do so, according to postdoctoral fellow Daniel Blanco Melo, PhD, who was a lead author of the study in Dr. tenOever’s lab. “We may find that the immune response is being blocked by this new virus too, but it won’t be in the same way as the flu,” he says.

According to the scientists, the preliminary findings show that the very stealth nature of SARS-CoV2 may actually account for its lethalness, a hypothesis that complements the virus’s long clinical progression, with many severely ill patients being hospitalized for more than 10 days. The hypothesis also supports the clinical evidence that patients need a strong immune system to fight COVID-19, the disease produced by the SARS-CoV2 virus. Under the leadership of Miriam Merad, MD, PhD, the Mount Sinai Professor in Cancer Immunology and Director of the Precision Immunology Institute, Mount Sinai is working to improve outcomes in critically ill patients who experience an excessive inflammatory response.

“It would almost appear that if you are a healthy individual under the age of 50 and you get this virus your immune system would have no problem tackling it, inhibiting it, and getting rid of it,” says Dr. tenOever. “But in older individuals and those who have comorbidities—those whose immune system is waning—our early data would suggest that their reduced immune system means they’re not aggressively neutralizing this virus, which leaves it to fester in the lungs and keep replicating.” This low-grade inflammation in the body allows the virus to remain under the radar for days as the patient’s lungs become increasingly damaged.

“Maybe what we’re seeing is a slow burn in some people that eventually takes its toll over 10 to 20 days,” says Dr. tenOever. “In the end, the immune system is reacting both to the virus and to the accumulating damage being done to the lungs. So the body goes into this mode of overly trying to repair itself from lungs that are leaking fluid and becoming hypoxic. By the time these patients come to the hospital it is more about controlling the inflammation to the damage induced by the virus than inhibiting the virus itself.”

Is There a Connection Between COVID-19 and IBD?

Mar 27, 2020 | COVID-19, Digestive Diseases, Your Health

COVID-19 is a concern for everyone. But people with inflammatory bowel disease (IBD) may be at increased risk of contracting this virus–or developing a bad case of it. This mostly has to do with medications they may be taking. Ryan Ungaro, MD, Assistant Professor of Gastroenterology at the Susan and Leonard Feinstein Inflammatory Bowel Disease Center, shares information IBD patients need to know about COVID-19.

Is there a connection between COVID-19 and gastrointestinal conditions?

More and more information suggests that the gastrointestinal (GI) system is involved with COVID-19. We are seeing more reports of GI symptoms among COVID-19 patients. For instance, the very first case in the United States noted nausea, vomiting, and diarrhea. In addition, some reports out of China indicate that there are a significant number of COVID-19 patients experiencing GI symptoms. The virus has several ways to get into the human body. This includes the nasal passages, the airway into the lungs, and through the intestines. It may be that contact surfaces in the bathroom could cause transmission. Scientists have found the virus in the stool of some patients.

Are there any special precautious that IBD patients should take?

Any IBD patients who are taking immunosuppressants–drugs that reduce the body’s immune system–should follow the at-risk population guidelines issued by the Centers for Disease Control and Prevention. Take these standard precautions very seriously. Be vigilant with social distancing and limit the number of people you’re in contact with. Be particularly diligent about hand washing and trying not touch your face. Treat yourself as if you’re part of the high-risk population, like the elderly or people with lung disease.

If you are unsure if the medication you take qualifies as an immunosuppressant, check the Crohn’s and Colitis Foundation’s IBD Medication Guide.

If I’m taking any of these medications, should I stop?

In general, you should stay on your medications now. That includes biologic drugs and immunosuppressants. The one exception I would say is steroids. If you are on oral steroids, you should talk to your doctor to see if it’s possible to taper down to a minimum dose or get off them completely. Everyone’s case is individual and if you have any questions, you should raise them with your physician. You want to stay on your medications because the health system is overburdened or is potentially going to become overburdened. You do not want to have a flare-up that requires a trip to the hospital, where there will be increased risk of exposure. If you do need care, we’re trying to do this by telemedicine visits at the IBD Center, except for the most urgent cases.

Is there any research going on about COVID-19 and IBD?

There are several initiatives taking place. The International Organization for Inflammatory Bowel Disease is developing more nuanced guidance for patients and physicians. That should be out shortly. In addition, we, with collaborators at the University of North Carolina, have launched a registry for cases of COVID-19 in IBD patients called SECURE-IBD. The registry will gather information on confirmed cases; medications the patient was receiving; the activity of the disease; and the outcomes, in terms of hospitalizations and disease severity. The goal is to determine which medications may contribute to the risk of developing COVID-19 or having a more severe response to the virus. Gastroenterologists who have patients with COVID-19 are encouraged to report cases directly on the SECURE-IBD website.

Controlling Extreme Inflammation in Severe Cases of COVID-19 May Help Save Lives

Mar 27, 2020 | COVID-19, Featured, Research

Miriam Merad, MD, PhD, left, Director of the Precision Immunology Institute, with Adeeb Rahman, PhD, Director of the Human Immune Monitoring Center at the Icahn School of Medicine at Mount Sinai.

Immunologists at the Icahn School of Medicine at Mount Sinai are playing a major role in managing the care of severely ill patients with COVID-19, who often experience an excessive inflammatory response to the disease that can ultimately overwhelm them.

Under the leadership of Miriam Merad, MD, PhD, the Mount Sinai Professor in Cancer Immunology and Director of the Precision Immunology Institute, Mount Sinai has created a quick test that monitors a patient’s inflammatory response to COVID-19 and helped launch a clinical trial that uses the drug sarilumab to manage these responses. The drug, manufactured by Regeneron Pharmaceuticals Inc., is typically used to treat rheumatoid arthritis. Dr. Merad says she may also roll out clinical trials that would test drugs used after CAR T cell adaptive therapies.

“Immunologists understand inflammation and know how to control it,” says Dr. Merad. “We developed a test with a three-hour turnaround time that we will repeat many times a day to see what type of inflammation the patient is developing and potentially guide treatment.” By identifying the features of severe immunological reactions in patients quickly, “we can speed the implementation of a cytokine blockade and significantly improve patient outcome.”

Cytokines are small proteins that modulate immunity. In trying to fight the COVID-19 virus the immune system may mount a major response, which can lead to excess inflammation that is also called a ‘cytokine storm.’ This overdrive reaction is happening in a range of COVID-19 patients, from the elderly to some young people with no apparent underlying health conditions.

“You need a strong immune response to fight the virus and this is why some people do well,” says Dr. Merad. “But others develop this storm of cytokines and this is what leads to fatalities. People are not dying from a virus that is running rampant in their bodies and killing tissue. We believe people are dying because of excessive inflammation. If we learn how to prevent this damaging immune response without compromising the fight against the virus we will be able to save many lives while waiting for curative treatment such as an antiviral drug or a vaccine.”

Benjamin K. Chen, MD, PhD

Dr. Merad adds, “There is urgency in learning how to best block the fatal inflammatory response.” To that end, she and other researchers are using the leading technology platform that she helped build in Mount Sinai’s Human Immune Monitoring Center, which allows them to “map with unprecedented depth the immune response to the virus in our patients.”

Benjamin K. Chen, MD, PhD, the Irene and Dr. Arthur M. Fishberg Professor of Medicine, and Vice Chair for Research in the Department of Medicine (Infectious Diseases), has been supporting the evolution of many proposed clinical trials with the help of leaders throughout the Mount Sinai Health System. Dr. Chen says there is limited but encouraging data to support cytokine blockers. Dr. Merad’s lab and the Human Immune Monitoring Center are uniquely capable of mapping out the “cytokine release profile,” he says. “With these trials we have the opportunity to measure those changes very carefully and decide what other trials or studies might be best to use for coronavirus. We are doing everything we can to support promising developments against COVID-19.”

Dr. Chen is working with Linda Rogers, MD, Associate Professor of Medicine (Pulmonary, Critical Care and Sleep Medicine), and Michele Cohen, Clinical Research Program Director in the Department of Medicine, who have been coordinating several major COVID-19 clinical trials at the Mount Sinai Health System. Judith A. Aberg, MD, the Dr. George Baehr Professor of Clinical Medicine and Chief of the Division of Infectious Diseases, Department of Medicine, is leading key clinical trials, including one for the antiviral drug remdesivir, made by Gilead Sciences. Remdesivir has shown promise in treating patients with COVID-19 and was developed in response to the Ebola crisis.

What Older Adults and Their Families Need to Know About COVID-19

Mar 26, 2020 | COVID-19, Geriatrics, Your Health

A leader in geriatric medicine, R. Sean Morrison, MD, the Ellen and Howard C. Katz Chair of the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, shares information that older people and their loved ones need to know about physical distancing in the time of COVID-19.

Are there any special steps that older people should take?

Because COVID-19 is so contagious–carried in droplets in the air and lingering on surfaces–we should all practice physical distancing. This is the term the World Health Organization (WHO) now wants us to use instead of “social distancing.” The idea is that we want to maintain a physical distance of at least six from the nearest person, to avoid infection. But we also want to maintain social and emotional closeness with friends and family, because that is also crucial to our well-being.

Distancing means that older adults should limit the number of visitors who come into their home or apartment, and this can be particularly hard. It means that children, grandchildren, even young adults, should not be visiting.

And it means that older adults should go out only when they can be assured that they can practice physical distancing and, if at all possible, should avoid going to grocery stores, riding public transportation, or going out for meals or religious services.

What about the emotional toll of this kind of self-isolation?

One of the things that many people worry about, including me, is the risk of depression. What can we do to prevent that from happening? First of all, if an older friend or relative is self-isolating in their home, call them frequently, and don’t just talk about COVID-19, talk about normal things.

Have different people call, so it’s not always the same person. Use video calls whenever possible, so grandparents can see their grandchildren and talk to their grandchildren–hear what’s going on in their lives.

What can older adults do to protect their mental well-being?

Stream movies, and watch TV, but try not to focus on the news. When we are exposed to minute-by-minute coverage of COVID-19, it can really increase our anxiety. Check in a couple times a day as to what’s happening in the United States, your community, and the world, but then turn to something else. Nothing is going to happen that you’re going to need to respond to immediately and that won’t still be there when you turn the television on again in say six or eight hours.

Are there any signs of depression to watch out for?

It’s important to realize that depression presents differently in older adults. Older adults may not experience it as sadness. What they may experience is loss of appetite, weight loss, difficulty sleeping, tiredness and fatigue, and sometimes memory problems. These are the things that both adult children and their parents should be watching for and self-monitoring, and if any of these develop, that’s the time to call your doctor right away so an intervention can be made, and treatment can be started before things progress.

What can I do to boost my immunity to COVID-19?

Unfortunately there is no magic pill that can rapidly boost your immune system. However there are things that you can do: Make sure you’re getting enough rest and sleep. Eat well. Stay well-hydrated. Exercise. This becomes hard in a setting of physical distancing, but there are things you can do. Use a stationary bike or a treadmill if you have them in your home or apartment. Go out for long walks in the community, or out in the park, at a time when few people are around, and make sure you stay six feet away from the nearest person.

Finally do everything you can to minimize your stress and anxiety in this very worrisome time. Steps you can take are limiting your time on social media, particularly the time you’re focusing on COVID-19 on social media. There is a lot of misinformation out there, and there are a lot of very, very scary posts. Instead, keep up-to-date by looking at the data. Look at the websites of the Centers for Disease Control and Prevention, WHO, your state and local health departments, and Mount Sinai, and also your local newspaper and one of the reputable national newspapers or news television shows.

What kind of supplies should I have on hand?

I would recommend that older adults have a 30-day supply of food, medicine, and other essential items. That’s a 30-day supply, not a six-month supply, of toilet paper.

Any more thoughts on the COVID-19 crisis?

We as a community, we as a country, and we as the world have not gone through a global humanitarian crisis like this in our lifetime. But we will get through this. We know what to do to control COVID-19. If we wash our hands thoroughly and often, disinfect high-contact surfaces, and rigorously practice physical distancing, we will get through this, and we will get through this well.

How Should Pregnant People Protect Themselves From COVID-19?

Mar 26, 2020 | COVID-19, OB/GYN, Your Health

The rapidly changing health advisories surrounding COVID-19, the novel coronavirus causing a pandemic, can be confusing. While the elderly and those with severe respiratory illness have been highlighted as high risk populations, the question remains as to whether pregnant people are also at risk.

Frederick Friedman, Jr., MD, Associate Professor of Obstetrics, Gynecology and Reproductive Science, at the Icahn School of Medicine at Mount Sinai, explains what we know about COVID-19 and pregnancy and how pregnant people can protect themselves.

I am pregnant. Am I high risk for COVID-19?

We don’t have a lot of data about coronavirus and pregnancy. There were two studies released about 18 pregnant individuals from China. Sixteen delivered by caesarean section, all delivered at term, and none of the children was affected. As a result of that very small study, it appears that as long as mom is healthy, the baby is likely to be healthy.

As far as we know the coronavirus does not cause problems for the fetus in cases of pregnant women who are exposed in the first trimester. However, it’s important to remember that we do not have much data that will confirm this. That being said, the general philosophy is that once the baby is formed, any virus that might cause birth defects would not have that effect. Whether or not COVID-19 causes developmental problems similarly is not yet known. But, as is the case with prior coronavirus infections, it does not seem to have any damaging effect on the baby.

Unfortunately, there are not enough data to say with certainty what effect the virus has on pregnancy and similarly what effect pregnancy has on progression of the disease. Due to the immune system changes in pregnancy and based on historic data from other viral infections, pregnancy might make women more susceptible to infection. In addition, they might have a more serious response to the virus. However, I emphasize that this is conjecture at present.

Should I put off trying to conceive?

At present, there are no recommendations to delay conception efforts. However, it is important to understand that our knowledge base will continue to expand. Also, it is critical that if one’s partner is ill, safe distances be maintained to prevent spread of the virus; that might delay conception efforts.

What if I have a pre-existing condition? Should I be particularly worried?

Anything that poses a severe risk to the mother—that is if the mom has a severe response to the virus that—could have harmful effects on the entire pregnancy, not just the baby. Such illness would place the mother at risk for preterm labor.

COVID-19 seems to affect most severely those individuals who are over 60, especially those over 80, which would not involve most of our pregnant patients. However, anyone with underlying respiratory ailments or chronic cardiovascular disease, as well as those who are immunocompromised have been affected more severely.

Are there particular precautions I should take after delivery? What about when I return home?

As much as birth is a social event, it’s also one that involves a baby who has a very poorly developed immune system and is highly susceptible to any types of infections. Any individual that handles the newborn should be free of any evidence of upper respiratory tract infection. No coughing, no runny nose, no sneezing, no fever.

Presently, most hospitals have visitation limits to the labor and postpartum floors. Due to the changing nature of the virus, each hospital’s visitation policy is in flux. Be sure to confirm the policy at your birthing location beforehand.

Additionally, while breastfeeding is generally encouraged, mothers who are suspected of having COVID-19 should keep distance from the baby when not feeding. Allow other caregivers to care for the baby and wear a mask while breastfeeding. The good news is that there have been no severe cases of coronavirus in individuals under nine years of age. But, discretion is the better part of valor.

Ultimately, we don’t know with certainty that pregnant or postpartum women are at greater risk for contracting the virus or having a more severe infection. Should they contract it, as is the case with influenza, these women tend to have a much higher risk of serious disorders. I would recommend the same universal precautions: avoidance of individuals with evidence of respiratory ailments like coughing, sneezing, and a runny nose; careful hand washing with soap and water or hand sanitizer; and avoidance of large crowds. Social distancing is difficult for some individuals, but prudent given our current situation.

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