COVID-19 Update 10/21: Vaccines, Rising Cases, Transmission Risk, and More

On this week's COVID-19 update, Dr. Steven Bishop talked about vaccine development and how an eventual vaccine should be rolled out, the threat of rising cases in some parts of the country, various risk levels for transmission, and more. He also answered many questions from the audience. Watch the video below and read on for a full transcript. 

Vaccines Under Development

So first things first is let's just talk about the good news first. So good news is we have 11 vaccines that are now in Phase III trials. So that means they're being actively tested on large numbers of people to try to figure out A, whether they work, and B, whether they are safe.

So that is good news. The more vaccines in the Phase III trial area, the better, because the more we have going on, the more likely we are to find a candidate that works and is safe. So that's really good news. If you're following along with the New York Times COVID vaccine tracker, which is what I've been using, because it's a nice visualization, so there are 11 in the Phase III section, there is actually 33 in Phase I and 15 in Phase II. So we've got a lot of vaccine candidates. So this is all really good news. Three in phase three. It's kind of progressing more or less the way most of us expected. They're still enrolling people. There's still data coming in. I don't really think we're going to have a clear indication of which of these vaccines is gonna really be safe and effective until probably toward the end of the calendar year.

Maybe even beginning of January. There are six vaccines that are listed as approved for limited use. Those vaccines...that can be a little confusing. If you're using the New York Times tracker, don't be too misled about that. They're not approved here in the U.S. or in Europe. Those are six vaccines that are approved in China and in Russia. And they have a little bit of a different process than we do. And some of their vaccines they've gone ahead and are releasing them to the public prior to what we will consider to be a Phase III study with lots of good data. So they just a different country, different process. We're not going to follow that process, I don't think, and I hope that we don't, because I don't think it's ideal.

We have our phases set up the way we do for a reason to make sure things are safe and effective. But that being said, despite the fact that it's a little slower, I think it'll get us to a better answer in a better way. So again, 11 vaccines in Phase III. That's great news, lots of good stuff. So I think we'll have more good information to come here in the next couple of months.

Plans for Distributing a Vaccine

Let's talk about the next thing about vaccines. Some of which was in the news this past week. So some states are submitting plans to the CDC and such about how they would roll out vaccine administration when vaccines are available. Virginia and Maryland issued their plans and made them public. Not every place has done that yet. But essentially what Virginia and Maryland are saying is that we're going to give the vaccine to elderly people and to healthcare workers first and in particular health care workers that are working with people who have COVID, which makes quite a lot of good sense on a number for a number of reasons, namely that older people are the ones that are at higher risk from doing poorly with the virus.

So those in nursing homes and rehab facilities and the elder general elderly populations, they really should get the vaccine first. They're likely they're the most likely to benefit from the vaccine given what we know about the virus at this point, following that group, other high risk people, healthcare workers who are being exposed on a constant basis, that makes quite a bit of sense. And then I think over time as we get more and more comfortable with the vaccine as a population, we see that it's safe, we'll roll it out to more and more groups probably in decreasing order of risk risk for the virus in terms of bad outcomes. So I think that's good. It's a good way to approach it. I think hopefully we'll continue to follow sort of a phased voluntary approach to these things.

I think that makes the most sense and is the most most appropriate way to handle the vaccine rollout.

Rising Case Numbers

Now let's talk about numbers. This continues to be an area of lots and lots of consternation and controversy. And I'm going to say what I've been saying since March and April, when we started talking about flatten the curve, which is that the two numbers I care about most are hospitalizations and deaths. Those matter more than anything else, case numbers can be very misleading. They can vary widely and not everyone who's getting tested and who has a positive test has symptoms. Many, many are not symptomatic. That is good news. This should be celebrated. Okay. That is very good news. So when we see in the news, like we've seen last few weeks, Oh, okay. The cases are going up, the cases are going up.

Well, first of all, it's not true everywhere. Cases are not going up everywhere. Cases are going up in some places. Overall, numbers across the U.S., They are up a little bit, but that is raw numbers. Right? Okay. What are the real most important indicators that we really need to know? It's hospitalizations. How many people are really sick and how many people are dying? Those numbers have stayed roughly similar across the country and in particular, Virginia in this area, they've stayed very similar, very you know, trended down from their peak back in the summer or early May, June, and they have stayed pretty stably low, hospitalizations and deaths in particular. Hospitalizations seem to be trending in Virginia, at least cause they have one of the best dashboards, it seems to be, let's see it switch over to the toggle over here to the hospitalizations.

So it's about 10 to 20 people being reported in the hospital each day, which has stayed consistent through the fall and summer. It's actually trending down, which is good. Deaths are the same...about single digits. So things are stable/improving in many places in terms of hospitalizations and deaths. Again, this is good news. I think it's reassuring that as we continue to open things up slowly, but that's a good approach, A, to do it slowly, and, B, to keep moving forward because it means that it's not making things worse, which is good and opening up the economy has a lot of good effects on a lot of people, which is going to also save lives. So we can't forget that that opening the economy, opening schools, these things also keep people alive and healthy.

So let's not lose that side of that while we think about these things. So, yeah, that's a good news, lots of good news in a lot of quarters, even though the main news sites would help you believe otherwise. And that being said across the country, we still have a problem, right? We still have roughly a thousand people dying a day across all 50 states from the virus, and that's still grossly unacceptable, which is why we've got to have a vaccine. My personal thought and opinion given how widespread the virus is at this point and how easily it does spread, I think that that is probably going to continue and stay stable until we have a vaccine, which is why the finding a safe and effective vaccine is really the critical next step that we need to do.

There are other things we need to keep doing too, right? We need to keep doing all the things we've been talking about since March. Being reasonable about things. Be sensible. Take a middle approach. If you're high risk, continue to protect and isolate yourself. Wear your mask. Wash your hands. Do all these things that the public health authorities have been advocating for. All of that needs to continue while we search for a vaccine in order to keep things stable. So that is my general commentary.

Your Questions, Answered. 

• "I'm a teacher, so some have expressed concerns about giving out papers to students when they come back. Is it possible to transmit the virus through paper?"

Good question. The short answer to your question is probably. I like to talk about transmission as sort of the hierarchy of transmission. The most likely and most common means of transmission is through droplets. So coughing, sneezing on people. That's why the distancing and the masks is so important because it keeps those droplets contained. Following that is sort of aerosols or airborne transmission. That's where smaller particles can travel over farther distances. Each of these, as you go down, they're less likely to transmit because the dose of the virus you're getting is less if you think of it that way. So droplets is most likely followed by airborne, probably followed by contact. Okay. So that's touching something. But it's not just touching the thing, right. It's touching whatever the thing is that's contaminated with the virus and then touching your face or your mouth.

So if you are wearing, say a mask, a shield, whatever, I think that's half of the benefit of a mask and a shield is keeping you from touching your face after you have touched something that's contaminated. So it's not just touching the thing. It's touching the thing and then touching your face. So if you're very good about not doing those things, or you're wearing the masks or the face shield, or what have you, the odds of you getting something from touching something diminish pretty dramatically, which is good. So that's sort of the hierarchy, transmission, droplets, airborne contact, and then there's some other less likely stuff. That's out there. But I think getting things from paper is much less likely than a lot of other things, especially if you're being careful about not touching your face and washing your hands and mask wearing and all that good stuff, hope that answers your question.

• The press is reporting that COVID hospitalizations are increasing in several states. Are you suggesting that we should not give credence to these reports?

No, I think that's probably true in some areas. Like I said, this continues to be a local. Everything's local, right? Everything's local. Politics is local. Pandemic. Everything's local across the board. Across the board, in general, things are stable. And I think they're going to stay that way until we have a vaccine. That's just my feeling on it. But yeah, no, in certain places hospitalizations are up. And I can't think of any off offhand. I know they were up briefly in Florida and I want to say Texas recently, but they have come back down. But no, there are certainly are some places that are seeing upticks in hospitalizations for sure.

And you should absolutely believe those reports. I look most closely at the Virginia data every day because that's where I live and where I take care of patients. So those hospitalization numbers have been going down. But across the board, things generally are what I would call roughly stable. There's going to be some fluctuation here and there across whatever metric you're looking at cases, hospital stays, deaths, etc, but whatever reports you hear on hospitalizations and deaths, I would give credence to those things and shy away from focusing on overall case numbers, just because that number, that metric is so fraught with problems and issues with test accuracy and a whole lot of other things. And, to be quite honest, there's probably a lot of cases out there that we're not even capturing.

Because again, the sensitivity of the testing instruments we have is so bad. So there's a lot of, I've had people very recently that I'm quite convinced have coronavirus and their tests continue to come back negative, which I think is bizarre and very concerning. And so I think that it's a flaw in the test more than anything. So I think there are even more cases then we know about most likely, which is why I don't put a lot of credence in the case numbers. I really just focus on the hospitalization numbers and the deaths, because it's a much more concrete thing to follow. So absolutely, I would pay attention to those reports. Things that are trying to scare people about case numbers and such, I wouldn't worry so much about those. But hospitalizations and deaths definitely very important to follow. I would absolutely give good credence to that.

• Any new findings about immunity?

Not that I have seen, unfortunately, so I think that that's an interesting question. The antibodies seem to be lasting in some people but it's unclear how many and for how long they will last. I think this question of T-cell immunity is extremely important. The problem is we don't have a way of testing for that. So I know a lot of people are very interested in this whole T-cell immunity concept. I am too. The problem is there's just no simple lab tests like an antibody test where we can say, "Oh, you've got T cells to COVID." So like I said, there's been some interesting studies out about that showing that some people may have even preexisting T cells that work well against the virus, which I think is again, if we find out that that's true and accurate, I think it's great news to celebrate.

But I think it's tough to test for those things and to really trust that information on a broad scale, because we just don't have a way of testing for it easily in a doctor's office. While we're talking about immunity, I think it's interesting. I do want to comment, I don't want to make this too political, but I do want to address a thing that came up about the president's treatment of COVID. Right after he got home out of the hospital, just a few days, 5-7 days after his diagnosis, his own physicians were reporting out that he had antibodies to the virus. And I think that that is interesting to say the least, and I think that that speaks to how difficult it is to interpret all of these things.

So that's sort of the background to my comment, but they reported out in that, that he had IgG antibodies to the virus. So here's the problem though. That's great if he did, if he truly did, that's fine. The problem is where did those antibodies come from? The truth of the matter is that the president received an antibody cocktail as a drug treatment just a few days prior, before he went into the hospital. So it's likely that the antibodies they were seeing on the test were just from the drug treatment. They were not from his own body producing antibodies to the virus at that point. So, you know, again, we have to be very careful about how we communicate things, about how we interpret information, because it's very easy to get misled. And it's very easy to misinterpret stuff, especially if you don't do this sort of thing all the time.

I think the president's physicians should have been a little more circumspect in how they communicated that information, because I think they probably communicated something that was not accurate at the time. So that's what I will say about that.

• What advice do you have for high risk patients? It seems everyone around me is loosening up. I'm about to buy exercise equipment instead of the gym membership.

Yeah, I think for high risk people, I think that they should continue, unfortunately until we have a vaccine, I think that very high risk people need to continue to be very cautious. And like I've said before, you have to really assess your own risk tolerance for these things and figure out what you're comfortable with and what you're not. But I think for very high risk people, if you have a lots of medical problems, et cetera, I would really continue to more or less stay away from large groups of folks and wear my mask, wash my hands, all those good things.

I would be quite careful. Expand your social circle carefully and make sure that the people that you're interacting with are being cautious and don't needlessly expose yourself, especially until we get a good vaccine. Same thing with home exercise equipment. I think that's probably the safe route to go for high risk people rather than going to the gym.

• Pandemic fatigue, what are you observing about this?

It is real. It is everywhere. And it is I think coloring some people's way that they approach certain aspects of things. It's sort of natural at a certain phase for people to get fatigued, dealing with anything that's challenging. And I certainly understand that. I've experienced that myself. I do think that is a real problem. I think as time goes on you know, people get more comfortable with certain types of risks, right?

That sometimes, maybe they shouldn't be uncomfortable with, but some people also get more comfortable with what kind of risks they're willing to tolerate. And I think that's okay. I don't think that at this point we've reached a state where a state and that's the wrong word, a condition where everyone is just wanting to throw caution to the wind. And I don't think we should get there. But we do have to kind of make slow moves forward on certain things, especially given the fact that we continue to not know when we're going to get a safer, effective vaccine. So we've got to find this balanced approach somewhere between being totally locked down and being totally reckless. Right? We're going to have to find some middle ground here and I think we're getting there. I think we're on a middle way approach, especially in places like Virginia where things are progressing, but slowly I think that's the right path to take.

So hope that answers your question. All right. Thoughts on vaccine administration efficacy given the cold storage necessary for a couple of the leading contenders? Yeah. That Pam, that's going to be an interesting question. I actually was on a a call with McKesson over a month ago now where we were talking about that very issue. There are some techniques that labs are trying to develop to make the, this is basically about the the RNA vaccines for the most part, make them a little bit more stable at higher temperatures, because most doctor's offices don't have minus 80 degrees Celsius freezers and things like that. So yeah, that is a problem that's going to have to be overcome. Otherwise vaccine administration is going to have to be consolidated to very large scale facilities, like academic centers that have those sorts of freezer facilities available.

• Thoughts on vaccine administration efficacy given the cold storage necessary for a couple of the leading contenders?

That's going to be an interesting question. I actually was on a a call with McKesson over a month ago now where we were talking about that very issue. There are some techniques that labs are trying to develop to make the, this is basically about the the RNA vaccines for the most part, make them a little bit more stable at higher temperatures, because most doctor's offices don't have minus 80 degrees celsius freezers and things like that. So yeah, that is a problem that's going to have to be overcome. Otherwise vaccine administration is going to have to be consolidated to very large scale facilities, like academic centers that have those sorts of freezer facilities available.

So that's going to be interesting. That's still a problem to be solved and that's kind of what I'm getting at. We, even though we've got some good vaccine candidates, we still really don't know when a safe and effective one's going to be widely available. I think it's still going to be a little time.

Let's see. Do you think Trump really had the virus? His behavior has become more bizarre? Could that be from the steroids? I do think he had the virus. I think all the data that's come out that they've released has been pretty consistent with the fact that he had it. The president is a unique individual. That is to put it mildly. So I'm not sure the steroids have had any unique impact on his behavior that wasn't already there.

• Do you think Trump really had the virus? His behavior has become more bizarre? Could that be from the steroids?

I do think he had the virus. I think all the data that's come out that they've released has been pretty consistent with the fact that he had it. The president is a unique individual. That is to put it mildly. So I'm not sure the steroids have had any unique impact on his behavior that wasn't already there.

That's it. That's a nice way to put that. The dose of steroids he got, dexamethazone, is actually a fairly low dose. And these things are given very commonly. Steroid induced psychosis is pretty rare. I mean, exceptionally rare. I've only seen it a couple of times and at much higher doses of steroids than what the president received. It may have made him feel a little energetic temporarily, things like that. That's pretty normal for a steroid reaction, but I don't think it's had any significant impact on his behavior, because he's just - the president is the way he is. I don't think the steroids had any impact on it.

• Can you remind me about the accuracy and precision of the rapid antigen and antibody tests? My daughter spent a few days in New York visiting friends and had negative results on both rapid tests. What is the quality of these combination of tests for someone who just back with more interactions than normal?

The accuracy of these tests is it's about 50-50 is the bottom line. Any of them, whether it's the blood antibody rapid test or the swaps or the antigen or the PCR, they're all not super great. So the thing is timing the test properly. So we've been telling people if they have exposure, potential exposures and they want to be tested, we've been having people wait five to seven days because what's happening is people are getting exposed and then they're rushing out to get tested four hours later. The likelihood of the test picking up something is minuscule. So if you really want to know, you really do need to wait some days to let the virus go through its incubation period, which is about 5.5, 5.6 to six days.

So you do need to let the virus go through its incubation period before you test, I think, and that's my opinion. I don't have a lot of solid data back that up, but that's what we we've been doing at our practice, because it makes the most sort of medical sense to us, so we've been telling people to wait a few days before they get tested to really have the best chance of figuring out whether they truly have been exposed or not. And that's because of the sensitivity of the test not being good. And just because the virus does have an incubation period.

• How much will an antibody test tell me about possible immunity if I already tested positive, but did not have any symptoms?

My feeling on it is that we should probably think of this like any other virus. If you have antibodies, I suspect you're probably immune. We can't guarantee that, of course, and we won't really know for years to come most likely, but I think if you have antibodies because you've been exposed to the virus, the strong likelihood is that you probably have at least some immunity to it for now.

Again, don't know how long the antibodies will last, but for the time that you have antibodies, I think it's reasonable to assume that you have some immunity, but that can't be guaranteed. So in other words, I think it's okay to know that and say, in your mind, okay, I'm probably at less risk than someone who doesn't have antibodies, but I wouldn't use that as a license to go out and go out in crowds of people and expose myself intentionally. Hope that makes sense.

• Should I get tested before visiting my daughter at home with her newborn?

Only if you've had a specific exposure. Again, I think that's one of those questions that really depends on what you and your daughter's risk tolerances is for that. The absolute safest thing to do right, would, would be for you to quarantine yourself at home for 14 days before you go over there to see them. That would be the absolute safest thing.

Barring that, I would not necessarily go out and be tested, unless you have been exposed to someone that you're pretty convinced had it or is known to have a positive result or unless you feel sick.

• Typically speaking, what are the first signs and symptoms?

So it's different for everybody, right? Some people will never have any symptoms. Some people just have a runny nose and feel a little blah, like they have a cold. And then some people, their first symptom is that they're short of breath and needing oxygen. So it's really highly variable, which is what has made this so challenging because we, It's just hard to know. It's just hard to know. So it's a whole range of things I would say far and away. The most common symptom is either kind of - it's two categories. So there's sort of this people who get a cold-like symptomatology, so runny nose congestion and kind of feeling a little crummy.

And there's some people that get more like a pneumonia symptomatology, which is like the fever, cough, body aches, or like the flu. That sort of thing. So I think those are the two main buckets of people. And then you got some other weird stuff, COVID skin issues and things like that. But most people either have sort of like a cold or more like pneumonia slash flu. Those are the two main clusters that seem to be how people get sick. But some people just have that odd "I've lost my sense of smell and taste" and that's it. So again, it's just a very weird virus which is what's made managing it so challenging and difficult.

• Has there been any data yet about whether flu season is less worse than usual for this year? 
  

So there's not much flu yet this year, which is good. I've only heard of a couple of positive cases of it so far. And actually let me check, while we're chatting and check the the Virginia flu map, and see what is there. Last time I checked we were still in the low or no activities zone. I think most of places are still there, which is good. Yeah. We're still there. Yeah, no activity level, which is great. So hopefully that continues for some time to come. I do think that some of this is going to be mitigated by the masking, the distancing, the hand-washing, with more attention paid to that. I'm very hopeful since the Southern hemisphere had a pretty light flu season that we're going to do the same, which will be great for a lot of reasons.

• Is there any value in getting an antibody test if you already know you were positive?

Probably not. Unless you're just curious and want to know. I don't think it's going to give you anything actionable in most circumstances. So unless you have a really specific reason for wanting to know that you have an antibody or not, I'm not sure that there's anything to be gained from, especially if you already know you had a positive PCR test at some point and were exposed to the virus. I don't think that getting the antibody test is going to tell you anything meaningful.

• Is it even more important this year than ever to get your flu shot?

Yes. absolutely. I think it's, I think it's important to every year for sure, but I think it is especially important this year for a whole lot of reasons.

Not least of which is making everybody's life a little bit easier. If we can kind of take flu off the table or at least mostly off the table as a major concern, that's gonna let us continue to focus on taking care of people who do get COVID and making sure we have the resources available to take care of them.

And also so that we don't have lots of people unnecessarily quarantined and things shut down because we're not sure if they have the flu or they have COVID, because we can't tell the difference for the most part clinically. Two people, some with flu and some with COVID, can look exactly the same. And so anybody who comes in with flu-like symptoms is going to get tested for COVID and you may just have "just the flu," which by the way, is a pretty serious illness that I think people have gotten way too complacent about in general, because they are like, Oh, it's just the flu. The flu kills a lot of people every year. It is a dangerous virus as well.

I think for a lot of reasons, absolutely, it's more important than ever to take your flu shot if for no other reason than to really dramatically reduce your risk of getting flu so that if you do get sick, we can kind of, hopefully you won't get sick at all, but that way we don't get confused about whether you have flu or something else and make that less likely to wind up in a COVID quarantine or something, because you got the flu.

That is a little bit of why we should get the flu shot. A whole lot of other, I could talk about that for an hour by itself, for getting the flu shots good for you for a whole lot of reasons. They're not perfect vaccines by a long stretch, but they do reduce deaths related to flu and hospital stays. So I do think it's a good thing to do. I already got mine. So if you haven't gotten yours, go ahead and get it anywhere it's available.