We are writing this document to all of you to provide information and to stop the spread of COVID-19 (coronavirus).

We hope that by the end of this material we will convince you that:

  • this is a serious problem that requires serious actions to prevent a national disaster
  • COVID-19 is not a common flu; it is a virus with a mortality rate of 10-20 times (and sometimes even 30-40 times) higher than normal flu, which requires special attention
  • its spread grows exponentially and a handfull of diagnosed cases in Bulgaria can quickly become an avalanche of new cases, which could lead to higher mortality cases caused by an overwhelmed health care system

We encourage you to follow some basic rules that we believe would reduce the incidence and the consequences of this pandemic. Generally, these rules fall into 3 main classes:

  • social distancing
  • personal hygiene; and
  • maintaining your immune system strong and healthy

What is COVID-19 and how is it transmitted?

This is a large family of viruses. Some coronaviruses infect humans and others animals. Rarely, viruses that infect animals can spread to humans. But this is believed to have been the way of transmission of COVID-19 in province of Hubei, China. MERS (Middle East Respiratory Syndrome) and SARS (Severe Acute Respiratory Syndrome) are two other examples of coronavirus transmitted from animals to humans.

People with severe symptoms are thought to be the most contagious, but transmission can also occur when a person is asymptomatic. The incubation period of the virus in most cases is between 2 and 14 days, with a mean value of about 5 days. This means that one can be infected for 5 days without any symptoms.

The virus may also be transmitted by touching a contaminated surface and then subsequently touching one’s eyes and mouth. According to the World Health Organization, the virus can survive on surfaces from several hours to several days depending on the type of surface, temperature and humidity. Opinions about the survival of the virus on surfaces are not conclusive as there is still very little data.

Some scientists believe that this virus can survive in the air for up to 3 hours, on copper for 4 hours, on cardboard for 24 hours, and on plastic and metal for up to 2-3 days. However, this study was published in medRxiv on March 11 and has not yet been peer reviewed.

Other scientists have concluded that if COVID-19 is similar to other human coronaviruses, such as SARS and MERS, it can remain on surfaces such as metal, glass, and plastic for up to 9 days (the influenza virus only lives for 48 hours). Although COVID-19 is similar to the other two coronaviruses, it is not known whether its behavior is the same on surfaces.

However, there is evidence that a disinfectant containing:

  • 62-71% ethanol
  • 0.5% hydrogen peroxide
  • 0.1% sodium hypochlorite (bleach)

can deactivate the virus for up to 1 minute. The World Health Organization advises that if we suspect that certain surfaces might be infected with the virus, we should use a disinfectant with at least 60% alcohol.

It is believed that the most common mode of transmission is from person to person and that transmission via infected surfaces is less common.

What are the symptoms of COVID-19?

  • Fever
  • Dry cough
  • Shortness of breath

Stuffy or runny nose are not common, which is an important differentiating factor of this virus from the flu.

!!!Seek Medical care if you experience the following symptoms:

  • Shortness of breath
  • Constant pain and chest pressure
  • Confusion and fatigue
  • Blueish lips and face

What is the the current state of the virus spread?

The virus likely started spreading from Hubei in late December. Things were likely covered up until the number of victims with pneumonia significantly increased.

The 830 COVID-19 cases reported on January 23, grew into 10,000 (January 29) in just one week, and by the end of the second week they reached 30,000. In 30 days, the cases exploded from 830 to nearly 80,000. It only took 2 weeks for the cases to increase 12 times, and within 30 days, they increased 96 fold! This exponential growth is depicted by the graph below.

By February 20, things outside China seemed calm. From January 23 to February 13, registered cases outside China increased from 15 to just over 500. In less than a month to this date, however, the cases are already over 45,000, or a 90-fold increase.

It is concerning that nearly 30,000 (or 67%) of all cases outside China come from only 3 countries (Italy = 12,462, Iran = 9,000, and South Korea = 7755). And 90% of all cases worldwide are found in only 4 (China, Italy, Iran and South Korea) of the 125 infected territories. There are around 130,000 cases in these 125 territories.

The data so far demonstrates that any country can be threatened by this exponential explosion. Although Bulgaria has only 23 registered cases at this stage, their potential exponential growth is concerning. This week we just started with 2 cases, which grew to 7, then to 16, and today they are already 23.
Due to the large number of infected countries and the rapid transmission of the virus, on March 11 the World Health Organization classified COVID-19 as pandemic.

What is the mortality rate and what are the risk groups?

Of the 130,000 cases, we have about 4,700 deaths, or a mortality rate of 3.6% (about 3-4 people die per 100 people). Mortality is 30-40 times higher than that for the normal flu (0.1% or 1 in 1000 people). This is a significantly higher rate than the 2% mortality initially reported by China. The World Health Organization believes that each country may have a different mortality rate, depending on how well their health system works.

In terms of how many new deaths we observe per day, we have 2 peaks – one around mid-February (the peak in China) and a second in the last few days, mainly accounted by the rapid increase of cases from countries outside China (most notably Italy and Iran) and the inability of the healthcare system to absorb the large number of patients.

In terms of risk groups, we have information only from China. In view of the rapid development of the virus and the heterogeneous group of countries outside China, this information may have changed. Unfortunately, this is the only information we were able to find at this stage.

The first table shows that the most vulnerable groups are people who are over 60 and who have pre-existing conditions such as cardiovascular disease, diabetes, chronic respiratory diseases, hypertension and cancer. It is also important to note that there are no registered deaths for children, but they can be carriers without significant symptoms. This also applies to age groups with a lower risk of mortality (those between 10 and 50). It is therefore extremely important that less-at-risk groups (such as children and young people without pre-existing conditions) protect those at higher risk by limiting face time, especially if they have symptoms, they have recently travelled, or they have been in large groups for the last 14 days.

What can we learn from other countries, such as Italy and China?

The experience of other countries, such as China and Italy, demonstrates that if the exponential growth of new cases is not stopped at the beginning, it can have catastrophic consequences. Because the virus has a long incubation period (between 0 and 14 days), hospital beds fill up very quickly but are emptied very slowly. Severe cases, which are about 4%-5% of all cases, require intubation as they cause pulmonary complications. 15% of cases are serious and require the supply of additional oxygen. The remaining 80% of cases occur with mild symptoms and do not require hospitalization.

According to BurgasInfo, which is unofficial information but the only information we found at this stage, our country has the following hospital facilities and protective gear:

Based on this data, we can see that there are 740 COVID-19 beds for use. It is not clear how many beds can be provided by the other 3 clinics that are currently being reorganized. If each establishment has 50 beds, the total number of COVID-19 beds available at the moment is around 1000.

In one form or another, we have 2,147 respirators. It is not known how many of these respirators are occupied by current patients. At best, all respirators can be used for COVID-19 critical cases that require intubation. If we assume that 5% of all cases are critical, which is equal to the 2,147 respirators (that will be used for critical cases, then our medical system will be at capacity with 42,940 COVID-19 cases. Unfortunately, there are only 1463 respirators for hospital use, which means that the total number of COVID-19 patients that can be serviced by the medical system is 29,260.

This hospital capacity is not insignificant in ordinary non-infectious diseases. In view of the exponential growth rate of the virus and the long incubation period, this capacity may be insufficient if the spread is not suppressed. This is the situation in Italy, where patients are treated in corridors and doctors choose to treat only patients who have higher chance to survive. The rest are left to deal with the disease alone.

How to protect and prevent the exponential growth of the virus?

The World Health Organization considers that social distancing and complete isolation for those:

  • with symptoms
  • who have travelled abroad
  • who have been in contact with infected people,

coupled with mass screening, tracking and isolating of all contact people, are some of the most important measures to reduce the exponential growth we see in other countries.

The impact of social distancing was observed during the 1918 flu pandemic. There is a significant difference between the deaths rates of St. Louis and Philadelphia. In Philadelphia, the first cases of the disease appeared on September 17, 1918, but the government downplayed their significance and allowed a large city parade to be held on September 28. Schools only closed on October 3, when social gatherings were also banned. Unfortunately, by that time the disease had begun to spread and had already surpassed the city’s medical resources.

In contrast, the first cases of the diseases among civilians in St. Louis were reported on October 5, and local authorities moved rapidly to introduce a broad sets of measures designed to promote social distancing, implementing these on October 7. The difference in mortality rates between the two cities is striking and is illustrated by the graph below.

In Denver, measures were initially imposed, subsequently relaxed and reintroduced later. This caused two consecutive peaks in mortality rates.

At this point, the virus is already here. The only thing we can do is to reduce its exponential growth by social distancing and strict hygiene protocol. Some suggest that social distancing reduces the number of new cases by 40% in just 1 day, although it is unclear from the article how this conclusion was extrapolated from the existing data in China.

If we can flatten the steep transmission curve, the medical resources we have might be sufficient to provide adequate treatment for all patients and reduce the mortality rate caused by shortages of consumables, apparatus and medical professionals. We need to avoid the situation in Italy, where people are treated in corridors, doctors are infected and exhausted from long shifts, and they are forced to choose between patients.

What can we do to protect ourselves and others?

  • Wear your face with masks and goggles in public places and when meeting with people
  • You can clean the masks we have given you by washing them with water and soap and letting them dry. Be careful they might be infested with viruses on their surface. Washing should be done very carefully. Unfortunately, masks are in short supply and they must be reused periodically
  • If you decide to discard the mask without washing it, please carefully remove it from your face and put it in a plastic bag. Tie the bag and then throw it in the trash. Wash your hands well!
  • Avoid mass events and group gatherings – choose an online format
  • Avoid travelling and the public transit
  • Protect those at higher risk (those over 60 and those with pre-existing conditions) by reducing your visits; do not visit them if you are experiencing any symptoms
  • Wash your hands with soap and water for at least 20 seconds, especially after coughing, sneezing and blowing your nose; after going to the bathroom and before and after food preparation
  • Disinfectants are not substitutes for hand washing, but if necessary use only those with at least 60% alcohol
  • Avoid touching your face and especially your eyes, nose and mouth
  • Stay at home when you have symptoms
  • Sneeze into a towel and flush it in the toilet.
  • Do not touch anything around you until you wash your hands
  • When you get home, wash your hands immediately without touching anything around; take your shoes, coat, hat, gloves, etc to the balcony and wash your hands immediately after. Change into indoor clothes and take your clothes to the balcony or wash them.
  • Before bringing an outside packages to your home – wash them well, disinfect them or leave them on the balcony overnight; metal and plastic surfaces need to be disinfected
  • Be sure to air your room every hour
  • Clean/ disinfect frequently used items (phone, glasses, computer)
  • Clean/ disinfect surfaces that are used often and are subject to contamination – e.g. the floor in front and around external doors, door knobs/handles and light switches, kitchen counters, etc.
  • Use only relevant and reliable information

You can find daily statistics and other information about the virus here: bda7594740fd40299423467b48e9ecf6

How to strengthen our immune system?

Whether a person will become seriously ill and develop complications depends on the state of his or her immune system. Since lung and respiratory complications are frequent among critically ill patients, we propose the following supplement intake for children and adults:

For adults:

For school-age children:

For children under 6 years of age:

Drink warm water or tea every 10-15 minutes. In addition, whenever possible, choose fresh, wholesome and varied food.

Reduce stress. We must adhere strictly to the above-mentioned rules regarding social distancing and hygiene, but there is no room for panic. Stress lowers our immune system and puts us at greater risk of being infected due to frantic and irrational behaviour.

For people with pre-existing conditions, it is paramount that they keep them under control to avoid unnecessary stress on their body. For example, if you are diabetic, keep your blood sugar in the normal range; similarly, those with high blood pressure should keep it in the normal range.


There is no room for panic, but that does not mean we should underestimate the severity of the situation. The virus is already in Bulgaria and requires adequate and timely actions. Let’s fight it together!
If you have any questions, please contact Borola Medical Crisis Team!

Sources used:

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