Coronavirus MERS CoV - symptoms, treatment, routes of infection. The deadly MERS virus continues to tour South Korea

Russians are being urged to avoid traveling to South Korea and the Middle East due to the spread of Middle East respiratory syndrome coronavirus (MERS-CoV) there. Can the infection reach Russia and is there a way to protect against it, AiF.ru told Head physician of KB MEDSI in Botkinsky Proezd Nikita Neverov.

Natalya Kozhina, AiF.ru: Nikita Igorevich, the number of MERS victims is growing almost every day, is it possible to somehow protect yourself from this virus?

Nikita Neverov: Based on the information we have to date, the incubation period for MERS (the time between when a person is exposed to MERS-CoV and when symptoms of the disease appear) is 5 or 6 days, but can range from 2-14 days.

MERS - coronavirus, like other coronaviruses, is released from the respiratory tract of an infected person, for example, when coughing. However, the exact mechanisms of transmission remain to be understood.

Person-to-person transmission of Mers-CoV typically occurs through close contact, such as living together or caring for an infected person. Cases of infection spreading among patients in one hospital have been documented.

Until 2015, all known cases were associated with the Arabian Peninsula region. Most of the infected people either lived there or recently arrived from there. However, recent cases of the disease, such as in South Korea, are the largest outbreak outside of Saudi Arabia. The number of cases in this country is growing every day. A ninth person has been reported to have died from Mers-CoV, bringing the total number of confirmed cases to 108. More than 2,800 people remain in quarantine, either at home or in medical facilities. And more than 2,000 schools remain closed. The first case of the South Korean outbreak was recorded on May 20, the vast majority o cases are associated with patients staying in the same hospital. The virus mainly affected older patients. Fatalities, as expected, occurred in patients with underlying medical conditions.

Due to the lack of accurate data on the modes of transmission of the virus, preventive measures (as for all other respiratory viruses, such as the influenza virus) must include both the airborne route (medical masks) and the contact route (hand treatment and contaminated surfaces).

— What symptoms does an infected person have?

— Most patients with infection caused by Middle East respiratory syndrome coronavirus suffered from severe acute respiratory illness with symptoms of fever, cough, shortness of breath. In some cases, gastrointestinal symptoms were observed, including diarrhea, nausea, and vomiting. Severe complications also developed - pneumonia and kidney failure. 3-4 out of every 10 sick people died. Some infected people had mild cold-like symptoms or no clinical manifestations of the disease at all. Patients with concomitant diseases (diabetes, cancer, chronic diseases of the lungs, heart, and kidneys) are most susceptible to infection and development of a severe form of the disease with a fatal outcome.

— There is no vaccination. There is no specific antiviral drug; treatment includes maintaining the functions of vital organs and systems.

— Is the Middle East respiratory syndrome virus threatening Russia?

— The situation with MERS in the Russian Federation, Europe and the USA represents a very low risk of infection for the general population. For example, in the United States, only two cases of a positive result for MERS coronavirus have been identified, both in May 2014, among more than 500 tests conducted in connection with suspected MERS-CoV. Both cases mentioned were unrelated and were reported in health care workers who lived and worked in Saudi Arabia, where they are believed to have been infected. Both were hospitalized in the United States and then safely discharged due to a full recovery. However, it is impossible to completely reject the possibility of the spread of Merc-CoV in countries outside the Arabian Peninsula region, which is confirmed by the current situation in South Korea. The measures that must be taken to prevent this are standard: increasing laboratories for testing Mers-CoV, creating rapid tests; development of recommendations from health care institutions; control at the border and at airports; study of the virus genome of known clinical cases of Mers-CoV.

In South Korea, there are new cases of infection with the MERS coronavirus, which the media is already calling. Previously, 2 people died from this virus. Now it’s up to 30. To stop the massive spread, schools are being closed across the country. It is believed that a dangerous virus, for which a vaccine has not yet been found, came from the countries of the Middle East. Correspondent Marina Kostyukevich found out what are the symptoms, treatment and prevention of such a serious illness.

From the Middle East to the Far East. Such a long journey has been made by the new virus, which the media has already dubbed “camel virus,” believing that the first human infection occurred from camels. In the language of virologists, the name of the disease sounds like “Middle East respiratory syndrome coronavirus MERS.”

It is persistent, easily transmitted through the air, and deadly. Two people in South Korea have already died. Five more have fallen ill in recent days. Three of them were infected, it is believed, from a roommate. This infection was brought to the country by a 68-year-old man who returned from a trip to the United Arab Emirates, Saudi Arabia and Bahrain. He went to the hospital with a cough and high fever. It is possible that there are still sick people trying to treat themselves. This is where the high mortality rate comes from: almost 40%. This is a serious danger, says an immunologist, doctor of medical sciences, a specialist in especially dangerous infections Vladislav Zhemchugov.

“This is a very high (mortality rate - ed.). Our usual autumn flu is 1-2%. For the first time, the virus was found in a person from the UAE. It causes pneumonia and death in humans, especially in the elderly.”

Virologists classify the MERS virus as a member of the same family of coronaviruses, which are usually accompanied by pneumonia. These also include atypical pneumonia. And this is a serious test for the immune system, says the secretary of the environmental commission of the Russian Geographical Society, candidate of biological sciences Valery Shmunk.

“It’s scary because it’s poorly studied. It entered the arena relatively recently - in the fall of 2012. In the Middle East. It’s not very clear what its clinical cycle is. After all, the name that stuck to it in the media is “camel flu” " - not entirely correct. There is no reliable data. It is not very clear who is infecting whom. It is too early to draw conclusions."

One thing is absolutely clear: almost no one is immune from infection during summer travel. Therefore, if you suspect MERS, you must act immediately. As in any other cases of viral infections of unknown nature, says Vladislav Zhemchugov.

“At the first signs of a severe viral infection - and they are the same for everyone, this is a high temperature, headache, shortness of breath, especially if pneumonia begins, pain in the muscles, bones - you need to take serious anti-inflammatory pills, such as aspirin, analgin, together. 3 times a day. And it’s better to add suparstin to them - until you get to the doctor.”

Treatment here can only be prescribed by a doctor. And it doesn’t matter what kind of virus. Anything that is accompanied by high fever and heavy breathing requires a mandatory examination by a doctor, and, if necessary, additional studies, hospitalization and specific therapy. As a preventative measure, strengthen the immune system and maintain basic hygiene.

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RG answered the most common questions about coronavirus

Text: Oleg Kiryanov (Busan)

Recently, many have learned about the new coronavirus MERS (Middle East Respiratory Syndrome), which has already spread to South Korea and has begun to actively spread there. The concern is that those who contract the virus have high mortality rates and there is still no vaccine for it. At the same time, rumors and speculation began to circulate that exaggerated the danger from what some of the more impressionable people called “the new plague of the 21st century.” Rossiyskaya Gazeta decided to clarify the situation by summarizing the answers to the most frequently asked questions about the MERS coronavirus, and at the same time talking about the current state of affairs with the spread of the disease. Separately, we will talk about South Korea, which, due to the virus, is attracting a lot of attention and has become the forefront of the fight against the new infection.

What is this coronavirus MERS?

MERS is an abbreviation of the English name of the disease - Middle East respiratory syndrome, which translates to “Middle East Respiratory Syndrome.” Sometimes the word “coronavirus” is added to the name and abbreviation. Then a longer name appears - MERS-CoV. In the Russian media you can also often find the Russian-language abbreviated name, which is the translation of MERS-CoV into Russian - MERS-CoV.

MERS is part of the coronavirus family, which includes many other viruses, both those that cause the common cold and severe acute respiratory syndrome SARS.

Where does it get the “crown” in its name?

The family of viruses received such a “beautiful” name because the villi on the virus shell are shaped like a spectacular solar corona.

Where did he come from?

There is controversy over the “original” reservoirs of the new coronavirus. It is possible that a mutation has occurred in one of the existing viruses. But MERS began to be transmitted to humans from animals, for reasons that are also unclear, breaking the interspecies barrier. According to some reports, camels were carriers of the virus at the very beginning (that’s why MERS is sometimes called “camel flu”), according to other experts, the virus began to be transmitted from bats. Recently, experts from the World Health Organization (WHO) have been leaning towards the version of the “camel” origin of the virus.

The first human case of MERS was recorded in the summer of 2012 in Saudi Arabia. This was the start of the spread of infection among people.

How many people are sick in the world, which countries? MERS already touched on?

The number of people infected with this virus is gradually growing, although we cannot talk about explosive spread. Currently, the number of infected people is about 1,200 people in the world. MERS has affected 25 countries so far: in the Near and Middle East - Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, UAE, Yemen; in Europe - Austria, France, Germany, Greece, Italy, the Netherlands, Türkiye, Great Britain; in Asia - China, the Philippines, South Korea, in America - the USA.

The undisputed record holder for the number of infected people is Saudi Arabia - more than 1,000 people. That's where most of the dead are. In general, the majority of cases are in the Middle East region. But recently, quite unexpectedly, South Korea came into second place in the number of infections and deaths - 145 infected and 14 deaths.

How contagious is it and how is it transmitted?

Again, due to lack of research, there is no definitive answer, but MERS is thought to have limited transmissibility. That is, it is not so easily transmitted, otherwise there would be much more sick people in the world. There is no evidence yet that it is transmitted through airborne droplets. For transmission, you need close and fairly long contact with an infected person, for example, through a handshake, if a person sneezes and particles of saliva fall on you, etc. The vast majority of infected people appeared in hospitals, where their friends, acquaintances, relatives, doctors, as well as strangers spent a long time with the infected people. In any case, as doctors now believe, transmission requires close and direct contact with the patient. The virus itself cannot exist outside the body for long and dies within a maximum of a few days. It is also easily destroyed by conventional disinfectants.

It is often called “deadly” and other scary epithets. Is he really that dangerous? Who should be afraid first?

If you look at the “naked statistics” of mortality, the numbers are really quite serious. There is no vaccine for this type of coronavirus yet. Globally, the mortality rate from MERS is 39%. But here the following should be taken into account: a very large number of deaths are elderly people (over 60, and more often over 70 years old), whose bodies were weakened by a large number of other diseases. MERS, in fact, became the “final” blow for those when the usual serious cold could lead to death. For example, in South Korea, the youngest of the dead was 58 years old, but most of the victims were over 70 years old and had previously had “bouquets” of other diseases: cancer, pneumonia, diabetes, etc.

Although the origins and essence of the coronavirus are not yet completely clear, doctors believe that the main risk group is older people with a weakened immune system and serious health problems (diabetes, cancer, etc.). There is also evidence that those with serious respiratory conditions are particularly vulnerable. MERS often causes difficulty breathing, which, coupled with previous problems, can lead to death in some people. In general, the main risk group is older people with serious illnesses.

If there is no vaccine, does everyone end up dying? Are there those to whom the virus is not transmitted?

It is worth recognizing that many media tried and created fear, significantly exaggerating the danger. Many people eventually recover; the body simply overcomes the disease itself. In Korea, 10 people have already been discharged; after being ill, they recovered and are now living their old lives again. Due to the lack of a vaccine, the main task of doctors now is to help the body overcome it on its own and support it at key moments. As a result, we repeat, the body of people with normal immunity copes on its own. There is also data that suggests that often the virus simply does not “stick” to healthy people. Most likely, the immune system kicks in and repels the virus. So there is no need to stir up fears; this is by no means a terrible infection that came from another planet and that can “mow out” all of humanity. Many people compare MERS with the general symptoms and course of the disease to the flu, albeit quite severe.

There is one feature that may allow parents to calm down at least a little. For reasons that are still unclear, MERS is extremely rarely transmitted to children. According to statistics, only 3% of all cases worldwide were children under 14 years of age. This is significantly less than in other age groups. In South Korea, for example, no one under the age of 14 got sick, the youngest of those infected is 16 years old and, as doctors note, a teenager suffers from the infection much more easily than others. In general, the virus is transmitted much more easily to children than to adults.

What are the symptoms?

Very similar to a common cold: fever, fever, cough, sneezing, often difficulty breathing, sometimes diarrhea, general malaise. Please note that symptoms do not appear immediately. The incubation period ranges from seven to 14 days, which is why quarantine measures are important. A person may not feel anything, but carry a virus within himself that has just begun to develop.

How to understand what I have: MERS or a common cold?

You cannot determine this yourself; this requires rather complex clinical tests, and sometimes a whole series. In any case, we advise you not to panic or be overly nervous if your temperature suddenly rises and you start coughing. There is a much greater chance that it is a common cold or a banal flu, which, by the way, has not been canceled, but which everyone “forgot” about amid the discussion of MERS. The new coronavirus is rather exotic, and it does not spread so easily. In any case, if there are signs of a severe cold, just go to the doctor and talk about the symptoms. True, if the day before you visited countries where MERS is quite widespread (Saudi Arabia especially, as well as other countries in the Middle East, South Korea), then you will need to immediately tell your doctor about this.

How to protect yourself from possible infection with coronavirus in countries where it is widespread?

Just like regular flu. Wash your hands more often, if possible, avoid visiting places with large crowds of people; it is also better not to go to hospitals, since they are the main breeding grounds for infection. You can also wear a mask. If you suddenly want to sneeze, but there is no mask, then we sneeze, covering ourselves with our sleeve. Contact with sick people should be avoided.

Doctors also categorically advise against touching animals infected with MERS and not consuming camel meat and camel milk that has not undergone sufficient heat treatment. Although such recommendations are more likely to make Russians smile. This is more relevant for those located in the Middle East.

However, just in case, the Koreans also checked their camels in zoos. It turned out that all camels in Korea are virus-free. But here it is rather logical: “Korean” camels were either born in Korea or brought from Australia, and not from the Middle East, as it happened for the zoos of the Land of Morning Freshness.

Are there any foods that, when consumed, will help the body prevent the virus from entering?

There are no clear recommendations on this matter either. In general, you should eat something that will help strengthen your immune system in general, that is, what you are advised to eat and drink when there is a flu epidemic in the country. Recently, by the way, the South Korean media came across a list of 10 products that should “help repel MERS.” Doctors I know, looking at the list, shrugged their shoulders and said: “It definitely won’t get worse, but we’ll find out how effective it really is later.” But since “it can’t get worse,” here’s this list, just in case. But it is worth remembering that this is not a guarantee against MERS, but rather a small help for immunity at best. These products are: garlic, broccoli, animal protein, yogurt, oysters and fish oil, mushrooms, black tea, barley, sweet potatoes, cactus.

How did the coronavirus get from the Middle East to South Korea, far from that region?

It was brought in in the second half of May 2015 by an elderly Korean man who has his own farm in Saudi Arabia. He visited several countries in the region, including Saudi Arabia, Kuwait, Bahrain and Qatar. Most likely, MERS was “caught” somewhere there. Then he came to a Korean clinic complaining of a cold and the disease began to spread throughout the country, quite quickly compared to the rate in other countries.

What is the situation with MERS in South Korea?

As of June 14, 2015, a total of 145 cases of virus infection have been reported. Of these, 14 people died (9.7%), 10 fully recovered and were discharged. That is, physically there are now 121 confirmed patients in the country (excluding those who died and recovered), the condition of 16 of whom is assessed as “unstable.” More than four thousand people are in quarantine, but most of them are quarantined at home. At the same time, more than 1,900 people have already been released from the quarantine regime. In the country, more than 10% of kindergartens, schools and universities went on forced holidays. The main centers of the spread of the disease are several clinics in Seoul and Gyeonggi Province. In other regions there are only a few confirmed infected people.

Why did the coronavirus spread so quickly in a country like South Korea, which is famous for high technology and has modern medicine and healthcare?

Let us immediately emphasize that in many ways the hype around the disease is inflated. The country has a population of 50 million and 145 sick people. This is not an epidemic; people now get the common cold more often, but they talk about it much less, having quickly learned the unfamiliar abbreviation MERS.

But indeed, compared to other countries, the spread is faster in Korea. This was influenced by a number of different factors. The country has a very high population density. 50 million people live in an area of ​​500 by 300 km. Transport is very well developed, the economy is active, people are used to moving around the country a lot, many large-scale events are constantly taking place in the country, and therefore all this unwittingly contributes to the spread of infection.

There is also an opinion that the Korean climate is somehow “suitable” for the new coronavirus.

However, WHO experts have a cooler and more professional point of view on this matter. Recently, WHO Assistant Director General for Health Security Keiji Fukuda voiced the following reasons. Firstly, local doctors and the healthcare system were not ready to “receive” the new coronavirus. At best, they only heard about him distantly and did not expect that he would make his way from the Middle East to the country. Therefore, at first they did not take the measures necessary for quarantine of patients and disinfection, which provoked an outbreak.

Secondly, the features of the Korean healthcare system. The approach common in the Korean healthcare system is vulnerable from an epidemiological point of view: patients engage in so-called “medical shopping,” when, in search of better conditions, they undergo the same treatment in different clinics, spreading the disease. In addition, patients in Korea are constantly visited by a large number of relatives and friends; patients themselves go wherever and whenever they want, no one restricts them. The waiting rooms are overcrowded, no one is isolated. Thirdly, ineffective actions of the authorities at the initial stage. They did not disclose the situation about the outbreaks of infection, which did not allow it to be localized quickly. As a result: people continued to visit infected clinics, where, moreover, anti-epidemiological measures had not yet been taken. Fourthly, the indecisive actions of the authorities to control the sick and potentially infected. Many of those infected continued to live their normal lives, not following the recommendations to remain in home quarantine. Fifthly, there is a lack of qualified epidemiologists, equipment, experience, and research centers in this area in Korea. The combination of these very different factors has led to the fact that in the world the number of infected people is now second only to Saudi Arabia.

What is the general atmosphere in South Korea? How do people react to it?

There is very wide coverage of this topic in the media. On the one hand, this is understandable, on the other, it provokes nervousness. There are fewer people on the streets, you can see people wearing masks much more often, reminders about MERS and infection prevention measures are everywhere. Many planned public events are canceled or postponed: festivals, symposiums, concerts, etc. But in general, life goes on. The country is by no means extinct, there are still enough people, everything is working as before, and not all public events have been cancelled. In general, much is exaggerated in foreign media. There is a certain impact of the coronavirus outbreak, but it should not be exaggerated; the country continues to live.

Are there any special features in the situation with MERS in Korea, which surprise experts or allow them to say that the virus has become stronger?

WHO experts, having analyzed the “Korean” modification of the coronavirus, confirmed that it has not mutated and is practically the same as in the Middle East. That is, he is already more or less familiar and so far there are fewer surprises from him. One of the features is an increased (compared to other countries) rate of spread, but at the same time the mortality rate is significantly lower than in the world as a whole. If in the world on average 39% of those infected die from MERS, then in Korea the figure fluctuates around 10%. Moreover, all deaths were recorded exclusively in elderly people who previously had serious health problems.

The presence of “super spreaders” is also noted, that is, individuals from whom the disease was transmitted to a significant number of other people. What is the reason for the appearance of such “super spreaders” (there are currently three or four people) - doctors cannot yet answer.

Further prospects for the development of the situation? When will this epidemic end?

Let us emphasize once again that this cannot be called an epidemic. There is much more hype, but the scale of distribution, as statistics show, is still very modest. But, as experts admit, in any case, new patients will continue to appear. The virus will not disappear overnight. Most likely, the rate of spread will decrease. The authorities took into account the omissions at the first stage, began to act more decisively, international experts also provided assistance, and the level of development of medicine in Korea is very high. We can expect that the virus will gradually disappear, but this will take more time.

Another question is that mutations of the coronavirus cannot be ruled out, including towards a higher degree of spread among people. But so far there is no evidence to support this. Doctors are constantly monitoring the situation, active work is underway to create a vaccine, but so far they have not yielded results.

I was planning on going to see South Korea on vacation, but now I’m thinking about it. Do you think I should return my tickets and cancel my trip?

The concern is understandable. According to recently released data from the Korea Tourism Organization, more than 100 thousand foreign tourists, mainly from China, Hong Kong, Taiwan and Japan, have already canceled tours to Korea. The Federal Tourism Agency also recommended refraining from visiting South Korea unless absolutely necessary. On the other hand, WHO emphasized that it does not yet consider it necessary to introduce travel restrictions. Therefore, everyone must make decisions themselves. In our subjective opinion, if you are an elderly person with serious illnesses, then, perhaps, it is better not to risk it. And the rest should just wash their hands more often, maybe wear a mask, avoid contact with sick people, not get too carried away with being in crowded places, and then, perhaps, you can be calm in Korea too. But in general, taking into account the above, it’s worth weighing everything yourself, although South Korea as a whole continues to live its normal life.

The official and generally accepted name of the coronavirus is “Middle East respiratory syndrome Coronavirinae” (MERS-CoV, in Russian abbreviation MERS-CoV). This new and almost unstudied type of the Betacoronavirus virus has excited not only epidemiologists in recent weeks, more and more people in different parts of the world have begun to become interested in the symptoms and methods of treatment for the MERS CoV coronavirus, because according to leading media reports, MERS CoV leaves very little chance of survival infected.

Should we really be afraid of coronavirus? Russian scientists and doctors are already asking themselves these questions.

The first cases of MERS CoV coronavirus infection

These types of viruses, discovered back in the 60s, received their original “crown” name because of the villi on their shell. Their shape exactly follows the outline of the solar corona during an eclipse. It is these coronaviruses that cause many respiratory infections in animals and humans.

The MERS-CoV coronavirus was first identified several years ago, and the first diagnosed human infection caused death; doctors first recorded infection and death from the MERS coronavirus in 2012 in Saudi Arabia - then a 60-year-old man became a victim of the virus. The next place where we encountered a new type of virus was Qatar, where similar symptoms were confirmed in a 49-year-old patient. This time, the research was carried out on a larger scale - special laboratories belonging to the Public Health Protection Agency in North London were involved. The World Health Organization sounded the alarm when it became clear that scientists had encountered a new strain of the virus. This infection has never been identified in either animals or humans.

WHO Director-General Dr. Margaret Chan has raised concerns that the new coronavirus has the ability to spread faster than capabilities and effective methods can be found to combat it. According to the latest data, as of the summer of 2015, 64 cases of infection with Middle East respiratory coronavirus syndrome have already been laboratory confirmed. Of these, 38 deaths were recorded. Residents of Germany, Saudi Arabia, France, Italy, Tunisia, UAE, Great Britain, Jordan, and Qatar were infected. As you can see, the mortality rate from MERS CoV is quite high.

Possible routes of infection with the MERS CoV virus

The main danger is the fact that the new virus has the ability to be transmitted by airborne droplets, that is, like a normal one. The possibility of infection is quite high when, even during ordinary close communication over a long period of time, the infection can be transmitted to an opponent. If the infected person just coughs and sneezes, that will be enough. However, there are no vaccination options against coronavirus exposure yet.

The incubation period lasts one to two weeks. Employees of the Agency for the Protection of Public Health express the opinion that the transmission of the virus is limited. Otherwise, the area covered and the number of cases would be presented in completely different figures - more globally.

Infectious disease specialist and microbiologist S. Wiles, representing the University of Auckland, noted in an interview with the Guardian newspaper that most infections occurred in hospitals where infected patients were subsequently treated for completely different diseases, as, for example, happened in France. From here we can draw a parallel and find diseases that can make a person more vulnerable to a new type of virus.

Symptoms of MERS coronavirus in humans

Experts do not yet have complete information about the real symptoms and risks of infection. In almost all recorded cases, patients experience the following symptoms: high fever, shortness of breath, difficulty breathing, and increasing cough. But these symptoms have not been fully studied as a typical reflection of an infectious disease.

Unfortunately, it is still too early to talk about a proven treatment method in this case. Initially, it is important to place maximum emphasis on treating the respiratory tract and quickly restoring its functions. According to information provided by the chief state sanitary doctor of the Russian Federation, medications used in the treatment of hepatitis C and other extensive viral infections have a clear therapeutic effect on coronavirus.

Quite often, the newest type of infection is compared with SARS, which is also caused by the presence of coronavirus in the body. And although some similarities can indeed be observed, this point has not yet been proven in laboratory studies.

The danger of infection with the MERS coronavirus in Russia

There has been talk for a long time that the coronavirus may well penetrate into Russian territory. In this regard, employees of Rospotrebnadzor are carrying out a list of anti-epidemic measures, the action of which is aimed at preventing the spread of infection to us. The regions of Primorye and Sakhalin - places of intense air traffic with South Korea and population migration - are the most worrying.

In addition, if you wish or need to visit the countries of the Middle East, doctors advise adhering to at least basic rules of hygiene. On such trips it is important:

• use soap or disinfectant wipes when washing your hands;
• if you suspect exposure to diseases, reduce communication with these people;
• If possible, avoid places with large crowds of people.

Moreover, if you experience a feeling of malaise, poor health, or symptoms of ARVI, you must contact a specialist as soon as possible for examination and testing. In addition, it is important at this time to use handkerchiefs, respiratory masks and try to communicate with others as little as possible.