Coronavirus disease 19: Difference between revisions

From MEpedia, a crowd-sourced encyclopedia of ME and CFS science and history
m (→‎Disinfecting your home if someone is sick: restore important note containing the additional steps)
(→‎Risk of COVID-19 in patients with ME/CFS: drugs heading, Fludrocortisone, not emphasis)
Line 46: Line 46:
There is a lack of evidence about ME/CFS patients developing COVID-19 illness; but a number of medical advisors have given their expert opinions on this. Immunologist and [[Myalgic encephalomyelitis|ME]] researcher Dr [[Nancy Klimas]] has said she believes people with ME/CFS are at a little higher risk of developing COVID-19 after exposure to the virus;<ref name="Klimas20200313">{{Cite web|url=https://www.youtube.com/watch?v=pkGXiJ1jM14|title=COVID-19 and ME/CFS - Dr Nancy Klimas, Mar 13, 2020|last=Klimas|first=Nancy|date=2020-03-13|work=|access-date=Mar 24, 2020|archive-url=|archive-date=|dead-url=|quote=|author-link=Nancy Klimas}}</ref> Dr [[Nigel Speight]], Dr [[William Weir]] and Dr [[Charles Shepherd]] have said they do not think there is an increased risk.<ref name="SpeightWeirMar20" /><ref name="SpeightMar20" /><ref name="MEA16Mar20" /> Dr [[Lucinda Bateman]] has said this is unknown.<ref name="Bateman20200323QA">{{Cite web |title=COVID-19 and ME/CFS/FM Frequently Asked Questions|last=Bateman|first=Lucinda|author-link=Lucinda Bateman|website=Bateman-Horne Center|date=2020-03-23|url=}}</ref>Klimas, Speight, Weir, Shepherd and Bateman have all advised ME/CFS patients to take additional precautions, and highlighted that there is a risk of ME/CFS becoming significantly worse after viral infections or after COVID-19.<ref name="Klimas20200313" /><ref name="SpeightWeirMar20" /><ref name="SpeightMar20" /><ref name="MEA16Mar20" /><ref name="Bateman20200323QA" />
There is a lack of evidence about ME/CFS patients developing COVID-19 illness; but a number of medical advisors have given their expert opinions on this. Immunologist and [[Myalgic encephalomyelitis|ME]] researcher Dr [[Nancy Klimas]] has said she believes people with ME/CFS are at a little higher risk of developing COVID-19 after exposure to the virus;<ref name="Klimas20200313">{{Cite web|url=https://www.youtube.com/watch?v=pkGXiJ1jM14|title=COVID-19 and ME/CFS - Dr Nancy Klimas, Mar 13, 2020|last=Klimas|first=Nancy|date=2020-03-13|work=|access-date=Mar 24, 2020|archive-url=|archive-date=|dead-url=|quote=|author-link=Nancy Klimas}}</ref> Dr [[Nigel Speight]], Dr [[William Weir]] and Dr [[Charles Shepherd]] have said they do not think there is an increased risk.<ref name="SpeightWeirMar20" /><ref name="SpeightMar20" /><ref name="MEA16Mar20" /> Dr [[Lucinda Bateman]] has said this is unknown.<ref name="Bateman20200323QA">{{Cite web |title=COVID-19 and ME/CFS/FM Frequently Asked Questions|last=Bateman|first=Lucinda|author-link=Lucinda Bateman|website=Bateman-Horne Center|date=2020-03-23|url=}}</ref>Klimas, Speight, Weir, Shepherd and Bateman have all advised ME/CFS patients to take additional precautions, and highlighted that there is a risk of ME/CFS becoming significantly worse after viral infections or after COVID-19.<ref name="Klimas20200313" /><ref name="SpeightWeirMar20" /><ref name="SpeightMar20" /><ref name="MEA16Mar20" /><ref name="Bateman20200323QA" />
      
      
ME/CFS includes [[:Category:Immune signs and symptoms|immune symptoms]] including a [[sore throat]], [[swollen lymph nodes]], and [[flu-like symptoms]], but patients are generally not considered to be severely immunocompromised, and immunosuppressant medications are unlikely to be used by most ME/CFS patients. <ref name="Klimas20200313" /> <ref name="canadianconsensus">{{Citation
ME/CFS includes [[:Category:Immune signs and symptoms|immune symptoms]] including a [[sore throat]], [[swollen lymph nodes]], and [[flu-like symptoms]], but patients are generally '''''not''''' considered to be severely immunocompromised, and immunosuppressant medications are unlikely to be used by most ME/CFS patients. <ref name="Klimas20200313" /> <ref name="canadianconsensus">{{Citation
| last1  = Carruthers    | first1 = Bruce M.      | authorlink1 = Bruce Carruthers  
| last1  = Carruthers    | first1 = Bruce M.      | authorlink1 = Bruce Carruthers  
| last2  = Jain          | first2 = Anil Kumar    | authorlink2 = Anil Kumar Jain
| last2  = Jain          | first2 = Anil Kumar    | authorlink2 = Anil Kumar Jain
Line 96: Line 96:
| isbn = 978-0-9739335-3-6
| isbn = 978-0-9739335-3-6
| url = http://www.investinme.org/Documents/Guidelines/Myalgic%20Encephalomyelitis%20International%20Consensus%20Primer%20-2012-11-26.pdf
| url = http://www.investinme.org/Documents/Guidelines/Myalgic%20Encephalomyelitis%20International%20Consensus%20Primer%20-2012-11-26.pdf
}}</ref> This means most ME/CFS patients would not be considered to be at very high risk of COVID-19 illness.<ref name="Klimas20200313" />
}}</ref> This means most ME/CFS patients would '''''not''''' be considered to be at very high risk of COVID-19 illness.<ref name="Klimas20200313" />
 
The unproven [[autoimmune hypothesis]] states that a subtype of ME involves autoimmunity, which is an overactive immune system rather than a weakened immune response.<ref name="OMF2018research">{{Cite web|url=https://www.omf.ngo/2018/02/28/omf-funded-research-t-cells-molecular-immunology/|title=OMF-funded research: T cells and molecular immunology|last=Open Medicine Foundation|first=|authorlink=Open Medicine Foundation|last2=|first2=|authorlink2=|date=Feb 28, 2018|website=Open Medicine Foundation|language=en-US|archive-url=|archive-date=|dead-url=|access-date=2019-07-11}}</ref> Evidence for this theory is limited.
 
===Drug related risks===
The following drugs may be used for some ME/CFS symptoms and are a possible concern
* '''<span id="ibuprofen">[[Ibuprofen]]</span>''' - Ibuprofen drugs (Nurofen, Bruprofen, Advil, Midol, Motrin, Motrin) are anti-inflammatories commonly used for cold/flu symptoms and for ME/CFS. There have been some reports that ibuprofen taken for COVID-19 may prolong the illness and increase it's severity. Several countries including the UK and France now recommend that people with suspected or confirmed COVID-19 avoid ibuprofen and '''use paracetamol / acetaminophen''' (e.g., Tylenol) instead, although the evidence for this is relatively limited.<ref name="MEA16Mar20" /><ref name="Day20200317">{{Cite journal|last=Day|first=Michael|date=2020-03-17|title=Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists|url=https://www.bmj.com/content/368/bmj.m1086|journal=BMJ|language=en|volume=368|doi=10.1136/bmj.m1086|issn=1756-1833|pmid=32184201}}</ref><ref>{{Cite web|url=https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-advice/|title=Stay at home advice - Coronavirus (COVID-19)|last=National Health Service|first=|authorlink=National Health Service|last2=|first2=|authorlink2=|date=2020-02-28|website=nhs.uk|language=en|archive-url=|archive-date=|dead-url=|access-date=2020-03-23}}</ref> There is no suggestion that ibuprofen affects the risk of catching COVID-19.
* '''<span id="ibuprofen">[[Ibuprofen]]</span>''' - Ibuprofen drugs (Nurofen, Bruprofen, Advil, Midol, Motrin, Motrin) are anti-inflammatories commonly used for cold/flu symptoms and for ME/CFS. There have been some reports that ibuprofen taken for COVID-19 may prolong the illness and increase it's severity. Several countries including the UK and France now recommend that people with suspected or confirmed COVID-19 avoid ibuprofen and '''use paracetamol / acetaminophen''' (e.g., Tylenol) instead, although the evidence for this is relatively limited.<ref name="MEA16Mar20" /><ref name="Day20200317">{{Cite journal|last=Day|first=Michael|date=2020-03-17|title=Covid-19: ibuprofen should not be used for managing symptoms, say doctors and scientists|url=https://www.bmj.com/content/368/bmj.m1086|journal=BMJ|language=en|volume=368|doi=10.1136/bmj.m1086|issn=1756-1833|pmid=32184201}}</ref><ref>{{Cite web|url=https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-advice/|title=Stay at home advice - Coronavirus (COVID-19)|last=National Health Service|first=|authorlink=National Health Service|last2=|first2=|authorlink2=|date=2020-02-28|website=nhs.uk|language=en|archive-url=|archive-date=|dead-url=|access-date=2020-03-23}}</ref> There is no suggestion that ibuprofen affects the risk of catching COVID-19.
* '''[[Rituximab]]''' - The MS Society has stated that taking rituximab, which has been used in clinical trials for ME/CFS, may affect the risk of catching COVID-19.<ref name="Covid-19-MS">{{Cite web|url=https://www.mssociety.org.uk/about-ms/treatments-and-therapies/disease-modifying-therapies/covid-19-coronavirus-and-ms|title=COVID-19 coronavirus and MS|last=MS Society|first=|authorlink=|last2=|first2=|authorlink2=|date=|website=www.mssociety.org.uk|language=en|archive-url=|archive-date=|dead-url=|access-date=2020-03-23}}</ref><ref>{{Cite web|url=https://renal.org/wp-content/uploads/2020/03/BAPN-COVID-19-patient-info-for-HD.PD_.Immunosuppression-17March20.pdf|title=Coronavirus (SARS-CoV-2) and its associated illness (COVID-19) {{!}} Information and Guidance for Children on Haemodialysis, Peritoneal Dialysis and Immune suppression (including Renal Transplants)|last=Renal Association|first=|authorlink=|last2=|first2=|authorlink2=|date=2020-03-17|website=renal.org|archive-url=|archive-date=|dead-url=|access-date=2020-03-23}}</ref>
* '''[[Rituximab]]''' - The MS Society has stated that taking rituximab, which has been used in clinical trials for ME/CFS, may affect the risk of catching COVID-19.<ref name="Covid-19-MS">{{Cite web|url=https://www.mssociety.org.uk/about-ms/treatments-and-therapies/disease-modifying-therapies/covid-19-coronavirus-and-ms|title=COVID-19 coronavirus and MS|last=MS Society|first=|authorlink=|last2=|first2=|authorlink2=|date=|website=www.mssociety.org.uk|language=en|archive-url=|archive-date=|dead-url=|access-date=2020-03-23}}</ref><ref>{{Cite web|url=https://renal.org/wp-content/uploads/2020/03/BAPN-COVID-19-patient-info-for-HD.PD_.Immunosuppression-17March20.pdf|title=Coronavirus (SARS-CoV-2) and its associated illness (COVID-19) {{!}} Information and Guidance for Children on Haemodialysis, Peritoneal Dialysis and Immune suppression (including Renal Transplants)|last=Renal Association|first=|authorlink=|last2=|first2=|authorlink2=|date=2020-03-17|website=renal.org|archive-url=|archive-date=|dead-url=|access-date=2020-03-23}}</ref>
* '''[[Ampligen]]''' - Ampligen or ''rintatolimod'' is sometimes used by ME/CFS patients, it is an [[antiviral]] immunostimulant rather than immunosuppressing drug, and is being tested for the treatment of COVID-19 illness in Japan.<ref>{{Cite web|url=https://adisinsight.springer.com/drugs/800001203|title=Rintatolimod - AIM ImmunoTech - AdisInsight|website=adisinsight.springer.com|access-date=2020-03-23}}</ref> There is no information about whether it may help prevent COVID-19 in ME/CFS patients.
* '''[[Ampligen]]''' - Ampligen or ''rintatolimod'' is sometimes used by ME/CFS patients, it is an [[antiviral]] immunostimulant rather than immunosuppressing drug, and is being tested for the treatment of COVID-19 illness in Japan.<ref>{{Cite web|url=https://adisinsight.springer.com/drugs/800001203|title=Rintatolimod - AIM ImmunoTech - AdisInsight|website=adisinsight.springer.com|access-date=2020-03-23}}</ref> There is no information about whether it may help prevent COVID-19 in ME/CFS patients.
*The unproven [[autoimmune hypothesis]] states that a subtype of ME involves autoimmunity, which is an overactive immune system rather than a weakened immune response.<ref name="OMF2018research">{{Cite web|url=https://www.omf.ngo/2018/02/28/omf-funded-research-t-cells-molecular-immunology/|title=OMF-funded research: T cells and molecular immunology|last=Open Medicine Foundation|first=|authorlink=Open Medicine Foundation|last2=|first2=|authorlink2=|date=Feb 28, 2018|website=Open Medicine Foundation|language=en-US|archive-url=|archive-date=|dead-url=|access-date=2019-07-11}}</ref>
*[[Fludrocortisone]], a [[corticosteroid]] (steroid) - brand names include Florinef. This may be used by patients with [[POTS]], which is common in ME/CFS patients.<ref name="Fludrocortisone-Drugbank">https://www.drugbank.ca/drugs/DB00687</ref >
  {{Quote box|I have now reached the conclusion that people with pre-existing health conditions that make them more vulnerable to lung complications (which may or may not be the case with ME/CFS – at this stage we just don’t know), or have a condition like ME/CFS where an infection such as this will almost certainly cause a relapse, or significant exacerbation of symptoms, need to be doing far more to protect themselves, and to socially distance themselves from other people, than official NHS guidance indicates.
  {{Quote box|I have now reached the conclusion that people with pre-existing health conditions that make them more vulnerable to lung complications (which may or may not be the case with ME/CFS – at this stage we just don’t know), or have a condition like ME/CFS where an infection such as this will almost certainly cause a relapse, or significant exacerbation of symptoms, need to be doing far more to protect themselves, and to socially distance themselves from other people, than official NHS guidance indicates.



Revision as of 17:58, April 6, 2020

Coronavirus disease 19, commonly known as COVID-19, is the infectious respiratory illness caused by the novel (new) Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), previously known as n-2019-nCoV.[1][2][3][4]

Computer-aided identification of lesions on the lungs of COVID-19 patients.
COVID-19 can cause lesions on lungs, and pneumonia.
Author: Shen et al. 2020. Journal of Pharmaceutical Analysis. Copyright: CC-BY-NC-ND-4.0

COVID-19 was first identified in Wuhan, China, in December 2019,[1] and can infect babies, children, and adults of any age.[5] It spread globally, resulting in the 2019-2020 coronavirus pandemic.[6][7]

Symptoms[edit | edit source]

Symptoms are usually mild and begin gradually, although around 1 in 6 people with COVID-19 need medical help.[1] Some people become infected but don't develop any symptoms and don't feel unwell.[8] These symptoms may appear 1-14 days after exposure; most commonly around five days.[8][9]

Common Symptoms[edit | edit source]

Most patients only have one or two of the common symptoms.[8][11][12]

Other Symptoms[edit | edit source]

Emergency Warning Signs*[edit | edit source]

*This list is not all inclusive. Consult your medical provider for any other symptoms that are severe or concerning.[9]

Additionally, there are reports that patients have lost or have a reduced sense of smell, or lost or distorted of taste, but are otherwise asymptomatic.[13]

The American Academy of Otolaryngology on Sunday posted information on its website[14] saying that mounting anecdotal evidence indicates that lost or reduced sense of smell and loss of taste are significant symptoms associated with Covid-19, and that they have been seen in patients who ultimately tested positive with no other symptoms.[13]

The symptoms, in the absence of allergies or sinusitis, should alert doctors to screen patients for the virus and “warrant serious consideration for self isolation and testing of these individuals,” the academy said.[13]

Asymptomatic carriers[edit | edit source]

The SARS-CoV-2 virus causes COVID-19.
Author: CDC

A number of studies have found that some people who test positive for COVID-19 do not have any symptoms of illness or a raised temperature, and have normal blood test results, but are able to infect others, some of whom developed severe COVID-19 pneumonia as a result of COVID-19.[15][16][17] Some asymptomatic carriers have abnormal chest CT scans, and some do not. False negative tests have also been reported.[15][16]

Estimates of the number of asymptomatic carriers vary wildly. Mizumoto et al. (2020) estimated that asymptomatic carriers accounted for 17.9% of the COVID-19 positive people on the Diamond Princess cruise ship, which was quarantined for 14 day after a previous passenger developed the illness.[11]

Recovered patients testing positive[edit | edit source]

Lan et al (2020) identified a group of 4 recovered patients who continued to test positive for COVID-19 after recovery; suggesting that they may still be infectious.[12] It is not known whether patients who have recovered may be reinfected later, or whether those who later needed treatment actually relapsed, or if recovered patients who later test positive do so because of issues with the diagnostic test's accuracy.[18] Another study found group of 5 recovered patients were found to have reactivated COVID-19.[19]

ME/CFS[edit | edit source]

EmbedVideo received a list of URL arguments that contained malformed data or blank arguments.


Risk of COVID-19 in patients with ME/CFS[edit | edit source]

There is a lack of evidence about ME/CFS patients developing COVID-19 illness; but a number of medical advisors have given their expert opinions on this. Immunologist and ME researcher Dr Nancy Klimas has said she believes people with ME/CFS are at a little higher risk of developing COVID-19 after exposure to the virus;[20] Dr Nigel Speight, Dr William Weir and Dr Charles Shepherd have said they do not think there is an increased risk.[21][22][23] Dr Lucinda Bateman has said this is unknown.[24]Klimas, Speight, Weir, Shepherd and Bateman have all advised ME/CFS patients to take additional precautions, and highlighted that there is a risk of ME/CFS becoming significantly worse after viral infections or after COVID-19.[20][21][22][23][24]

ME/CFS includes immune symptoms including a sore throat, swollen lymph nodes, and flu-like symptoms, but patients are generally not considered to be severely immunocompromised, and immunosuppressant medications are unlikely to be used by most ME/CFS patients. [20] [25][26] This means most ME/CFS patients would not be considered to be at very high risk of COVID-19 illness.[20]

The unproven autoimmune hypothesis states that a subtype of ME involves autoimmunity, which is an overactive immune system rather than a weakened immune response.[27] Evidence for this theory is limited.

Drug related risks[edit | edit source]

The following drugs may be used for some ME/CFS symptoms and are a possible concern

  • Ibuprofen - Ibuprofen drugs (Nurofen, Bruprofen, Advil, Midol, Motrin, Motrin) are anti-inflammatories commonly used for cold/flu symptoms and for ME/CFS. There have been some reports that ibuprofen taken for COVID-19 may prolong the illness and increase it's severity. Several countries including the UK and France now recommend that people with suspected or confirmed COVID-19 avoid ibuprofen and use paracetamol / acetaminophen (e.g., Tylenol) instead, although the evidence for this is relatively limited.[23][28][29] There is no suggestion that ibuprofen affects the risk of catching COVID-19.
  • Rituximab - The MS Society has stated that taking rituximab, which has been used in clinical trials for ME/CFS, may affect the risk of catching COVID-19.[30][31]
  • Ampligen - Ampligen or rintatolimod is sometimes used by ME/CFS patients, it is an antiviral immunostimulant rather than immunosuppressing drug, and is being tested for the treatment of COVID-19 illness in Japan.[32] There is no information about whether it may help prevent COVID-19 in ME/CFS patients.
  • Fludrocortisone, a corticosteroid (steroid) - brand names include Florinef. This may be used by patients with POTS, which is common in ME/CFS patients.[33]
Advice from the UK's ME Association

I have now reached the conclusion that people with pre-existing health conditions that make them more vulnerable to lung complications (which may or may not be the case with ME/CFS – at this stage we just don’t know), or have a condition like ME/CFS where an infection such as this will almost certainly cause a relapse, or significant exacerbation of symptoms, need to be doing far more to protect themselves, and to socially distance themselves from other people, than official NHS guidance indicates.

In particular, for those who are not housebound, this applies to social mobility and what you can do (and cannot do) if you decide to leave your home.[23]

Charles Shepherd, ME Association


Risk of death or serious complications in ME/CFS patients[edit | edit source]

25% ME Group for Severe ME

Although ME is a "chronic condition" my gut feeling is that they are not actually at greater risk of dying from the virus itself than healthy people. The conditions which put people at extra risk would be things like severe asthma or COPD, or immunosuppressed people eg those on chemotherapy for cancer.

The biggest worry therefore for ME sufferers is that catching the virus will make their ME much worse, and of course people in the 25% group do not have much leeway.

It might even be that worsening of their already severe ME could be a bigger threat to life than the virus itself.[22]


Risk of developing ME/CFS after COVID-19[edit | edit source]

ME/CFS has been linked to many different viruses, but it is not known what the likelihood is of developing ME/CFS after COVID-19 illness.

ME/CFS charity medical advisors' COVID-19 statements[edit | edit source]

Research on ME/CFS and COVID-19[edit | edit source]

COVID-19 is a new illness and research on the effects on ME/CFS patients has not been published yet. Patient surveys in progress include:

A Dutch patient organization survey to assess if the risk of contracting COVID-19 is higher for those with ME/CFS, and if symptoms are more severe in ME/CFS patients.[35][36] The European ME Alliance is suggesting that non-Dutch speakers use an online translation tool to complete it.[35]

Prevention[edit | edit source]

image of Coronavirus Disease 2019 (COVID-19)
Image author: CDC


The SARS-CoV-2 coronavirus is an enveloped virus, which means it is easier to kill outside the body than non-enveloped viruses like Coxsackievirus, or Poliovirus.[37][38]

CDC advice[edit | edit source]

  • Know How it Spreads
  • Clean your hands often
  • Avoid close contact
  • Stay home if you're sick (may have the virus)
  • Cover coughs and sneezes
  • Wear a face mask if you are sick (may have the virus)
  • Clean and disinfect

High touch surfaces: disinfect daily[edit | edit source]

High-touch surfaces: disinfect daily. Tables, doorknobs, light switches, countertops, handles, desks, phones keyboards, remote controls, toilets, faucets, sinks, hard-backed chairs. Source: Coronavirus disease 19 Prevention - CDC, March 2020. Public domain image.


The CDC currently recommends people clean AND disinfect frequently touched surfaces daily:

  • tables
  • doorknobs
  • light switches
  • countertops
  • handles
  • desks
  • phones
  • keyboards
  • remote controls
  • toilets
  • faucets
  • sinks
  • hard-backed chairs[39][40]


To clean use:
  • Detergent or soap and water prior to disinfection. [39]
To disinfect use:
  • Disinfectants used against SARS-CoV-2 (list)
  • Most common EPA-registered household disinfectants will work, or
  • Diluted household bleach (mix: 5 tablespoons bleach per gallon of water, OR 4 teaspoons bleach per quart of water), or
  • Alcohol solutions with at least 70% alcohol
Follow manufacturer’s instructions for application and proper ventilation. Check the product is not past its expiration date. (Updated Mar 18, 2020)[39]
Check for updates:

Suspected or confirmed COVID-19 cases:
If possible the sick person should also clean:

  • soiled items and surfaces (as needed)
  • if a separate bathroom is not available, the bathroom should be cleaned and disinfected after each use by an ill person
  • provide personal cleaning and disinfectant supplies in ill person's room (unless unsafe, e.g. they are a young child) - include tissues, paper towels, cleaners and EPA-registered disinfectants[39][40]

Coronavirus transmission from surfaces[edit | edit source]

The new coronavirus can survive on different surfaces for hours or days:

  • small, airborne virus particles (aerosols) - 3 hours
  • copper - 4 hours
  • cardboard - 24 hours
  • stainless steel - 2 to 3 days
  • plastic - 2 to 3 days[41][42]

This means direct contact with an infected person is not needed to contact the illness.[41] Surgical face masks have not been effective against aerosols in previous influenza outbreaks like swine flu, but N95 respirators have been effective.[42]

Disinfecting your home if someone is sick[edit | edit source]

The following is an abbreviated bullet-point list from the Centers for Disease Control and Prevention (CDC) article "Everyday Steps and Extra Steps When Someone Is Sick"[43]


Suspected or confirmed COVID-19 cases:


If possible the sick person should also clean:

  • soiled items and surfaces (as needed)
  • if a separate bathroom is not available, the bathroom should be cleaned and disinfected after each use by an ill person
  • provide personal cleaning and disinfectant supplies in ill person's room (unless unsafe, e.g. they are a young child) - include tissues, paper towels, cleaners and EPA-registered disinfectants[39][40][44]