March 20, 2020

COVID-19

#99 – Peter Hotez, M.D., Ph.D.: Continuing the conversation on COVID-19

“If we have large numbers of healthcare workers sickened by the virus and in ICUs, it's 'lights out' and our whole healthcare system collapses." —Peter Hotez, M.D., Ph.D.

Read Time 4 minutes

In this episode, Dr. Peter Hotez M.D., Ph.D., Dean for the National School of Tropical Medicine Baylor College of Medicine, returns to continue the conversation on COVID-19. Dr. Hotez informs us on how we can gauge the number of infected people, behaviors to reduce the probability of becoming infected, and the inconsistency of hospitalizations among young adults between different countries. Dr. Hotez underscores the continued uncertainty in many virus-related developments, but ends with some points of optimism.

Disclaimer: This is information accurate as of March 19, 2020, when it was recorded.

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We discuss:

  • How to gauge true number of infected people [5:45];
  • Reducing the probability of getting infected [22:45];
  • Inconsistency by country in infected young people [27:15];
  • Conferred immunity, seasonality, and repurposed therapeutics [30:30];
  • Vaccine development [39:30]; 
  • Practical behaviors to reduce risk of transmission [46:00];
  • Mental health resource and funding [51:00];
  • Points of optimism [56:00]; and
  • More.

Show Notes

How to gauge true number of infected people [5:45]

  • ~13k cases confirmed in US as of midafternoon time of recording PST on March 19 2020

How does that translate to an estimate of actual people infected?

  • Every day there is a large increase because there is testing underway 
  • We don’t have a real sense of % population infected and we are just beginning to pick up existing transmission 
  • Physicians in major hospitals are seeing a lot of cases and feeling overwhelmed meaning: 
    • Despite number of tested cases, there is still a ramp increase 
    • Creates concerned for system threshold to care for the sick

Distribution of total U.S. cases is where we should focus concern

  • The distribution of absolute case numbers in the US is more insight-producing rather than total case numbers

Evaluating confirmed infected case multiplier (estimation): 

    • Takes into consideration: 
  1. What is the assumed number of days to a fatality 
  2. What is the assumed fatality rate?

The status of U.S. healthcare delivery

  • Unclear how CDC made decisions around testing
  • Peter has deflected these questions because there were missteps made and a committee will have to retrospectively evaluate to make sure the same mistakes are not made in the future
  • It is a matter of figuring out how we rapidly fix the problem around hospital system stress 

Rate limiting step in healthcare delivery 

  • New York City as a case example ….
    • Doctors and nurses are demoralized: initial breakdown of trust 
    • Seeing colleagues get sick and inadequate support and preparation 
    • Disconnect between state and federal government management

 No longer a disease of young adults

  • Destabilizing for young physicians 
  • Front line healthcare workers are getting sick

What is the solution for staff workers getting sick?

  • Heavily-hit Covid19 areas are likely experiencing understaffed medical support
  • The whole healthcare system was fragile to begin with due to high demand on physicians 
  • There is no clear solution

Could we expand the U.S. public health service? 

  • Bring in individuals to train as medics who are currently under Furlow?

Reducing the probability of getting infected [22:45]

How much insight do we have about transmissibility?

  • There is not a lot of new information about virus survival time on various surfaces 
  • We know that it can live on cardboard but how relevant is that?
    • CDC came out with guidelines that loosened criteria of exposure 
    • A desperate move to have people remain in the workforce 
    • Convalescent serum could help people remain in the workforce as a form of prophylaxis 
  • White House came out with press report to create convalescent serum 
  • The recent study of blood type and susceptibility: not clear how relevant it is yet 
    • Study out of china showing that type O blood type had reduced risk 
    • Protective antibodies but not immunity like a convalescent serum

Inconsistency by country in infected young people [27:15]

  • Younger age group in Italy getting ill but not seen in China  
  • High number of hospitalized people between 20-40 years old, accounting for ~33% of hospitalizations in the U.S.
  • ~50% in the U.S. are under the age of 54 years old – very different than what was observed in China 
    • Individuals aren’t dying at as high rates as older population groups but they are still hospitalized 
    • Could this be due to vaping?
  • Require good epidemiology on young patients to identify differences 

Conferred immunity, seasonality, and repurposed therapeutics [30:30]

  • Non-human primates show that once exposed, the infection should confer immunity 
  • The federal government thinks that the pandemic should last 18 months
    • Operating under the assumption that the virus comes back in the fall
    • Or could be anticipating that there is a vaccine in 17 months, but Peter does not think this is realistic
    • Peter hopes that the model is not dependent on vaccine development

Repurposed drugs…

  • Published Kaletra paper interpretation: drugs administered when viral progression is too far gone is not helpful 
  • Didier Raoul preliminary work has looked at hydroxychloroquine (HCQ) 
    • Small study reveals HCQ potential but has yet to be rigorously tested

We are on a steep learning curve around ARB and mechanistic action …

  • ARBs have the ability to block viral entry but on the other hand, it may upregulate ACE2 receptor
  • They may have anti-inflammatory effects
  • Preliminary look on camostat out of Japan seems promising

Vaccine development [39:30] 

Should we be considering a universal coronavirus vaccine rather than SARS or Covid-19 specific?

Practical behaviors to reduce risk of transmission  [46:00]

  • Peter Hotez does not believe receiving mail to be an issue 
  • Real risk is close, personal contact with someone infected 

Mental health resource and funding [51:00]

“The psychological devastation on the United States […] is going to be almost as big as the damage of the infection.” —Peter Hotez, M.D., Ph.D.

Points of optimism [56:00]

  • We are seeing scientists put at higher esteem
  • At times of stress, people are looking to scientists and in leadership roles
  • Science communication and data sharing has improved

“The heroism we are seeing of physicians of nurses… there is going to be a new awakening behind the medical community…” —Peter Hotez, M.D., Ph.D.

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36 Comments

  1. This is more of a comment than a question, but as far as public health policy goes, it will be interesting to see the impact of different social distancing policies and quarantine policies in their effectiveness in slowing the growth of cases.

    Looking at it graphically, I can’t see a specific change in trend where a state implemented a policy and it had an impact, but there are no doubt delays in the effects and any change in trajectory is difficult to see in an exponential function.

    This will surely be a topic of study when the epidemic is over, but it seems like we could start doing some of this data analysis now and over the next month or two (or longer).

    On its face, social distancing seems to work, but what does the analysis tell us?

  2. So, perhaps this is a complicated scenario and question with a lot to consider.

    For a patient is in a state of ketosis, COVID-19 positive, and exhibiting severe symptoms to a point where treatment requires ventilation and parenteral nutrition, considering that dextrose is used in the parenteral nutrition and that dextrose may be highly inflammatory for a patient in ketosis, would you be concerned for the outcome of such a patient?

  3. Peter & Team,
    Question around treatment options and steps to take if one thinks one is infected. Here is my case:
    1) 34 year old male, eat healthy mostly (unprocessed) and exercises 4-7 times a week (4x strength trainining, if possible 3x zone 2 60 mins).
    2) Isolated at home with my wife, my 2 year old and 25 year old male relative since March 13th. My wife is 38 weeks pregnant, we have C-section scheduled for March 30th. We live in the Atlanta, GA metropolitan area.
    3) On Friday (March 20th) I started feeling warm, with heart palpitations & loss of appetite. These heart palpitations are quite strong, especially at night, making it hard to fall asleep. No diarrhea, only other GI symptom could be explained as tingling? I have been monitoring my temperature and no fever (temp around 98.4-98.6 F so far), no cough so far.
    4) My family believes this is just anxiety (which would make sense), since we haven’t left the house since the 13th and the symptoms aren’t the usual narrative you read everywhere else(fever, cough, etc.), and most symptoms other than the feeling of warmth, match with a diagnosis of anxiety.
    5) In reading, I am concerned I might have the GI pathway variety of Covid-19 with a movement to the heart, which would explain the strong heart palpitations and slightly elevated (80-90 bpm) average heart rate during the day.

    What would you recommend for someone in my situation? This is not intended as medical advice, to be honest I am just concerned about any potential implications to myself by just staying home unless/until I need to go to the ER, and implications to my pregnant wife, son and other family member. I want to ensure I take the best steps given my situation, any help or guidance is truly appreciated.

  4. Woke up thinking about some of our biggest tech companies could get in the fight by re-purposing software to aid in modeling and notifications. Here’s what I came up with. Everyone has a cell phone. GPS based apps like strava can measure coordinate location in intervals down to seconds to measure location and could flag contact interactions. For cities where GPS is unavailable bluetooth apps like Tile can record when a person is within range of another device. If an app was developed to use a combination of these data sets you could target testing and possibly help more precisely enact quarantine measures. A/B testing to get the notifications right. I realize the privacy component but desperate times. Not sure this is the right forum but felt like an outside the box idea that may serve to help next time.

  5. Perhaps the number of young patients is just a result of them getting infected first. Although states were slow to sound the warnings, I know the people in my age group (47+) started modifying our behavior weeks ago, but young people in our neighborhood were still out partying on St. Patrick’s Day.

    My guess is we’ll see more older patients in a few weeks, when the kids on the beaches in Florida and in the house parties and pubs on St. Patrick’s Day go home.

  6. Can you recommend a preemptive immunity-system-strengthening strategy to dampen the effects of a SARS-CoV-2 invasion to an individual?

    • Has there been any news yet on whether the very high rates of pneumonia seen in Wuhan and Lombardy amongst those with the disease are being seen elsewhere? The pneumonia rates in those two areas may have been exacerbated by local smog issues, together with high rates of smoking in China and Italy having Europe’s oldest population. As John Ioannidis has said, the case for drastic action stands or falls by the pneumonia rate. The Italian death figures include deaths in people who happen to test positive for coronavirus rather than just people who died of it https://www.telegraph.co.uk/global-health/science-and-disease/have-many-coronavirus-patients-died-italy/ . Here in the UK, the National Health Service has indeed been overwhelmed over the last month, as far as I can tell by the general response to the pandemic rather than all the coronavirus patients they are treating; the published numbers here are still small, with just 20 patients listed as severe/critical.

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