TWiV (This Week in Virology) #635, recorded July 5
These are my notes of Dr. Griffin's talk, so I can't guarantee they're accurate. If you have questions, go listen to the podcast.
Today was the first time since this started that he entered his hospital and had no covid positive cases. (or did he mean no new ones?)
Testing. Still problems getting adequate tests, which are needed for contact tracing. Antibody testing: About 20% of infected people don’t produce measurable antibodies, especially those who had milder cases. And if you look 2 months out, antibody levels go down. So limited value to antibody tests.
Covid parties. The idea of intentionally contracting covid is absurd, because of our ignorance about how long immunity lasts, whether one can get reinfected, and possible long-term effects.
Possible reinfection. With some other viruses, a second bout is worse than the first. Earlier in the epidemic, cases that were initially thought to be reinfections were probably just two phases of a single infection. But we’re still not sure if it was reinfection, or how quickly reinfection would occur.
With some other viruses, a second reinfection is often more severe. Dr. Griffin himself caught dengue in China in the 1980s, easily recovered, then got it again in Zimbabwe. He was so sick the second time that his parents were told “We’ll let you know if he’s still here in the morning.” Well, obviously he recovered, but we don’t know what will happen with covid, so it’s foolhardy to assume that reinfection would be mild when it could potentially lead to tragic consequences.
A listener asked about his 54-year old patient who had recovered from mild COVID in early April, and had two negative PCR tests (but no antibody test). Two months later, his son got covid. The following week, the father again had a positive covid test, with increasingly severe symptoms, and O2 sat of 83. Was this a reinfection? Dr. Griffin answered that it's concerning, but thought it’s possible that it’s the same infection, and the tests in April were too insensitive to measure the virus. Or it might be a different strain of the virus. Or it might be a re-infection with the same virus. If it’s re-infection, this would imply that immunity is very short-lasting, perhaps even too short for effective herd immunity or effective vaccines. However, he thought it’s too early to get too depressed about this. We need to see if more such cases develop.
He noted that there had been a recent account of a mutated virus that is more transmissible, but he wanted to point out that it’s not more pathogenic. It’s easier to catch, but not more likely to kill you.
Lingering effects. Many reports of people still sick, months later. Several support groups, one has 4000 people. Need to study how often this occurs, and to educate those doctors who are unaware of it and assume it’s not real, that patients are malingering.
Football players are concerned about restarting to play because of the close contact with possibly asymptomatic teammates. What if they get covid and get late-onset muscle weakness, fatigue? To threaten your future life and a career you dreamed of? We just don’t know the long-term impact of this disease.
Patients may describe a chest heaviness, skin feels like had sunburn, persistent fatigue, brain fog, weakness, little exercise tolerance, depression, anxiousness. Most people say they feel worst in the morning, get better throughout the day, then at 1-2 in the afternoon they feel like they’re dying. Some doctors suggest that these are more common in young women, and say “the older men die, the younger women suffer”. But he sees men and women, and all ages with these lingering symptoms.
Recent study of patients 30 days after they were discharged from hospital showed that about half still had suboptimal lung function: respiratory muscles were weak, gas didn’t diffuse as readily into the lungs, and abnormalities were seen via lung imaging. Published in Respiratory Research but there’s a summary here:
https://www.cidrap.umn.edu/news-perspective/2020/06/study-finds-lung-impairment-recovering-covid-19-patients TreatmentSome patients say that Mucomyst, prescribed to break up their mucus, made them feel better overall. Maybe it also acts as an anti-oxidant or anti-inflammatory. He’s not recommending this, just mentioning it.
NSAIDS were opposed early on, based on a single French study, but there have been 70 studies now that show no evidence of problems, so there may be no justification for avoiding ibuprofen, aleve, or aspirin.
Not using HCQ, famotidine, azithromycin. There’s now a price of $3120 for a 5 day treatment with remdesivir, which might affect its use. Steroids and anticoagulation is being discussed more, need guidance on what to recommend for those at home.
Patients who were hospitalized have been studied most intensively, and we need more information on those who recovered at home. Recent MMWR says outpatients tend to be younger, fewer underlying conditions, more likely lower socioeconomic status, and 2-3 weeks after symptoms, one-third say I’m still sick.
First trial of convalescent serum didn’t show benefits, and in fact, those treated late in the disease developed more clotting complications. It seems possible that antibodies play more of a role in the early response to the virus, and T cells are important later, in which case convalescent serum would be expected to benefit those in earlier stages of the disease. We need more studies of this.
School reopening. The American Academy of Pediatrics strongly recommends that kids should be physically present in school this fall. Dr Griffin agrees, says “Open schools, not bars”, especially since not every kid has a great home environment. But need to open in the right way and accurate, frequent testing is critical for that, and we don’t have ability for frequent testing. If you can’t afford to test students frequently, then you can’t afford to open schools. Kids need to be kept in small groups, plastic separations. He doesn’t think many states will run it properly. Some have said students don’t need to wear masks when they sit down… and he sees that as a problem. Even if not 100% effective, masks act as a reminder to be careful. States and federal government should financially help local school districts.
True, that young people much less likely to get covid, but MSI has been found in 200 kids in NYS, and he thinks its underreported. Also, recent studies showed viral load in children is similar to adult, so they may be as likely to transmit infection. On the other hand, one study showed very little viral shedding from kids. And epidemiological data doesn’t show schools playing a role in spread of covid, as occurs with most respiratory diseases, though this could be because schools that stayed open in March were already taking precautions. Just don’t know yet.
Airplanes. HEPA filters clean the air, although if someone sick is sitting right next to you, the filters don’t protect you. So airplanes are not low risk, but are safer than being in a bar or at a party. The greater risk is not from the flight, but the fight you get into over why your neighbor isn’t wearing a mask! So try to move, if that happens.
Masks: Don’t have good data on comparing different kinds, or knowing value of plastic shields. Homemade cloth masks are fine for catching droplets, and are important to prevent spread from an infected person. Nobody can wear it 24/7, but think about time and dose: The more you wear it, and the better you cover your nose and mouth, the better you will be protected and protect others. The more you fiddle around with it, the greater risk of spread, so put it on and leave it there. If you have long hair, tie it back, so it doesn’t hit the mask. If you wear hearing aids, tuck the bands under the hearing aids. Here are some other tips for wearing a mask with hearing aids:
https://www.hearingloss.org/wp-content/uploads/Wearing_mask_and_hearingaids.jpgSome can’t wear a mask for good medical reasons, but that’s fine. Like herd immunity, we don’t need to get to 100%, but if enough people wear one, it will cut transmission.