COVID-19 Update 10/7: Vaccines, Trump's Treatments, Holiday Advice, and More

After a week off, Dr. Steven Bishop returned to Facebook Live to discuss the latest news regarding coronavirus. He offered an update on the 11 vaccines in Phase III trials, thoughts on the treatments President Trump received, and answered questions from the audience. Watch the video below and read on for the full transcript. 

Vaccine Updates

So if we check our New York Times COVID vaccine tracker, it looks like we've got about 11 vaccines in phase three trials, which is good. That's good news. That means we've got 11 different candidates that are being seriously vetted and evaluated for being possible candidates for the vaccine. Some of them are the mRNA platform. Some are adenovirus and some are inactivated virus. So there's several different options there, which is great, because we don't know which one's going to pan out and work really well and which one's going to be the safest.

Now what I am seeing is that most of these large scale trials that the companies are reporting, whether it's Moderna or Pfizer, AstraZeneca or Johnson and Johnson, they're not really expecting to see a lot of results and data on their trials until late in the year. There's not a lot of the year left, the next couple of months, and they're saying they probably won't be able to really begin mass producing the vaccines for large scale use until early 2021. So that's when I'm expecting that vaccine. And that's pretty consistent with what we've been thinking about since the spring is that it would take about year 12 to 18 months to get a good vaccine. I think that's in line with what many of us were expecting.

I think that if something comes up now prior to that, I would be surprised. So we'll just have to wait and see.

COVID Numbers

Let's talk about numbers and let me, actually, Andy has got a good question here and I'll try to address this question during this section here. So case numbers, if you look at Virginia, our percent positivity rate continues to drop slowly. It's been at about 4.8% for the last few days. It's been under 5% for quite some time. Now, overall cases are continuing to trend down. There was an uptrend in the late summer, early September, but it's been trending down since then and the same thing with hospitalizations and then deaths unfortunately have not ceased but they have dropped quite a bit and the seven day moving average is about three per day.

It's definitely not gone. Definitely still causing fatalities every day, even in Virginia. And that's pretty consistent with what's going on across the country. Cases overall are roughly stable in the 40-some thousand range a day. Deaths seem to be around 700 to a thousand every day across the country. And of course that there's a lot of variability from state to state going on there. But overall things are stable I would say in terms of viral transmission cases and in hospitalizations nationwide with there being obviously some local variations in there .

Tracking the Data

Alright, Andy's question here. It says, in Maryland, where I live, the Baltimore Sun reports this morning that there are 31 newly-hospitalized Covid patient in the state and the total Covid hospitalizations is as high as it has been for over a month. The state’s 7-day average of new cases has increased 18% week over week, and Hopkins reports that the state’s test positivity rate is over 6%. Deaths have not (yet) spiked. .

Can you provide us a brief tutorial about what changes in statistics like these should concern us the most as the Winter months approach? I know that deaths typically increase a few weeks after increased COVID hospitalizations. Are there any statistics that help us to predict coming increases to n hospitalizations? Increased infections might not lead to that if many of the newly-infected are mildly- or non-symptomatic (but they might infect others who are more vulnerable). What is the best data to follow and the most important trends to assess?

So I would trend what you're following, which is the hospitalizations and the fatality rate, the number of deaths. The percent positivity rate is really more a measure of the state's testing capacity. It's not really a good measure for prevalence per se. So I would follow hospitalization rates.

And I would, in order to really get at the hospitalization rate and how bad it is, you really have to compare the hospital utilization rate the year prior in the same week. That's really probably the best apples to apples comparison. So are hospitalizations really worse than they were in the past? Because it's not about specifically COVID in that case. It's about whether we have sufficient hospital capacity to take care of people.

So that's really what the hospitalization piece is about. It's whether there's enough bed capacity and ICU capacity to take care of people who are sick. And remember that gets back to the whole idea of flatten the curve, right? It's all about making sure there are beds and ventilators and all that stuff available for the sick people.

Now, the fatality rate, that's unique, pretty much uniquely a COVID issue. So I'm following that closely in terms of figuring out how severe the virus is in terms of how many people it's actually killing primarily from COVID specifically. Now, like we've said, there's some wiggle in those numbers, but I think between some under counting and some over counting, the numbers we're seeing are probably roughly accurate so to speak.

Are there any statistics to help us predict coming increases in hospitalizations? I mean, overall, roughly a dramatically rising case count, especially if it's a case count that's rising in older populations. I think that would probably accurately predict an increase in hospitalizations. If the new cases each day are mostly in the say 20 to 40 year olds, you're probably not going to be able to use that to predict hospitalizations much, but if you're seeing a lot more cases in the 40 and up crowd or the 50 and up crowd, then you can probably predict a week or so after that, you're going to see a spike in hospitalizations more than likely.

I have not have COVID test. Do not have any symptoms. Should I get tested? Could I be asymptotic?

No, I do not think you should get tested unless you have been exposed directly to someone who has known and has had a positive test for COVID or unless you have symptoms. Otherwise there's no need to get tested.

I have been exposed. How long should I quarantine?

So it depends on a little bit on who you were exposed to. So if you were exposed to someone who does not live in your house generally you need to quarantine for 14 days. If you're exposed to someone who is in your house, you need to quarantine for 14 days from the time that that person is released from their quarantine. So in most cases, that's going to actually mean 24 days, because if you have a positive test, you're going to need to be quarantined for 10 days from your positive test, assuming all your symptoms are resolved or almost resolved at day 10. And then the Virginia Department of Health actually recommends 14 days past that for a household contact.

I'm asymptomatic. I'm also having a hip surgery in December. Should I quarantine the two weeks prior to that?

I don't think that's a bad idea to do that. And they may or may not require you to get a COVID test before your surgery. So make sure you check with your surgeon and the hospital about whether they are going to want to COVID test before that that surgery is done.

President Trump's Treatments

I will talk a little bit about the treatments that President Trump received. Last week, obviously everybody pretty much knows that he was hospitalized at Walter Reed for coronavirus infection last week. And he received a number of different treatments, a couple of which were experimental, most of which were not, and are fairly widely available at this point.

So let's start with the one that's experimental that he received. So that's the Regeneron antibody cocktail that we've talked a little bit about, not that specific company, but about antibody cocktails as a treatment for coronavirus. And what this is is essentially taking the concept of convalescent plasma, which is taking antibodies from somebody who's already recovered from the virus and giving it to someone essentially in a, this is not a perfect analogy, but in a concentrated format. These antibodies are generated in the lab, through synthetic means, but it's essentially like taking those antibodies from somebody who's already recovered and giving it to somebody who's currently sick in the hopes that it will prevent the person from getting sicker.

So that treatment that President Trump received was in fact considered experimental, very limited data, is not approved for wide use. 

The other things that he received were some vitamins, so C, D, and zinc. Those things are supplements. There's reasonable data around vitamin C, vitamin D, and zinc being associated with having better COVID outcomes. It's not randomized control trial data, but it's an association data and they're unlikely to cause any harm. So very reasonable treatments to give.

The president also received a drug called remdesivir. That's one of the ones that is approved and has been on the market for a few months. Now that's pretty widely available at this point. It's pretty standard treatment for hospitalized patients in most places now. It's about five doses, so he received that as well.

And then he received a medication called dexamethazone, which is a very common steroid that's been in use for many decades for a whole number of things and is generally considered a quite safe drug to use for short periods of time. And they did give that to him when his oxygen levels were briefly low and that's consistent with the studies that came out of Oxford showing that people who had low oxygen that got dexamethazone did better with their COVID infection and it was beneficial to them.

That being said, the data did not support giving it to people whose oxygen levels were not low because it actually worsened their outcomes. So of all the treatments he received, only one of them really is, would be considered experimental per se.

The rest are things that are generally widely available out there. And it seems that they perhaps did help him given that he has recovered or is recovering at this point. So that's, that's good news.

Given your guidance about quarantine times, for how long should President Trump quarantine? He says he wants to go to the debate next week, but I'm unsure whether that fits within the recommended quarantine time. Do you have a sense of this?

So he should follow what all the other guidelines say for everybody else, which is he should isolate himself for 10 days from his positive test. So whenever his positive test was, I think it was last Thursday. So he should probably be quarantined through this weekend would be what I would say if that's correct. We'll see if he does that or not. As we all know, the president kind of does what he wants, so we'll see. But that would be, I don't know when the next debate is, so I don't know if that 10 days would fall if the debate would fall within that 10 days or after that, I'm not sure.

Italy recently moved to a mask wearing when one is anywhere outside. What are your thoughts on this?

Yeah, I think this is probably getting into an area of very diminishing returns most likely. The mask wearing outside, if you're not within six feet of anyone else or a reasonable distance, a small distance from anyone else, I don't think the masks are going to give lots of benefit.

If you're outside also, the risk of contracting or transmitting COVID, it really seems to drop exponentially because the ventilation is so much better. So I don't think there's a lot of benefit in wearing the masks outside if you're not in a crowded space.

If you're in a crowded space and you can't social distance from other people, I think that the masks do make sense outside in some circumstances but not if you're not around other people.

So for example, people hiking a trail, riding their bike, far away from others, I don't think there's a lot of benefit to that.

That being said, like everything else about the masks, the risks are pretty minimal, so I don't think it's going to harm people to wear them, but I don't think that there's a whole lot of benefit to be gained by wearing them outside, especially if you're not in close proximity to other people.

Do you expect infections to spike during the winter and we spend less time outside?

I'm certainly worried that that's going to happen. I think a lot of us are worried that that's going to happen. I hope it won't pan out that way. So far things seem stable, but I think time really is going to tell over the next couple of months, as we really head into flu season, whether the infections do indeed spike or not. I think that what we've seen so far from the Southern hemisphere and elsewhere is that flu infections have been low, which I think is good. And it's probably a result of the fact that people are doing a better job of distancing, washing your hands, and wearing masks and all that sort of thing. And it's helping with the flu as well.

So I hope that would mitigate both flu and COVID, so we we will see, but yeah, definitely something that something I'm worried about. So we'll have to keep an eye on it. We're starting to see a little bit of flu here and there. Like we've talked about in the prior weeks, make sure you guys get your flu shot. It's time. Go ahead and get it now.

Is there any more recent news about recurring symptoms of COVID after?

There continues to be discovery about sort of post-COVID syndromes, which are not terribly surprising. Many viral syndromes, many viral illnesses have a post-infectious syndrome, or people either take a long time to fully recover, or they don't feel quite right for some time. And that's somewhat dependent on age and what other medical problems you have to start with. We're seeing some of that.

I don't think it's anything other than what I would expect for most respiratory viruses like flu. In some people it's more pronounced than others, especially people who've been in ICU or have been on a ventilator for COVID, it really doesn't surprise me at all that they still don't feel well many weeks or months out. Being in an ICU takes quite a toll on the body, so it takes time to recover regardless of the cause of the hospitalization in the ICU, COVID being just one of many possible things. In that way, it doesn't surprise me too much. So I'll have to keep watching that.

We were diagnosed 11 days ago. Ron still has a low grade fever and a cough. Is that okay? We're taking Tylenol and a cough medicine.

Yeah. I would continue to isolate if you're still having symptoms. The whole quarantine, I think that's the most important thing, managing the symptoms. If you just have a low grade fever and a mouth cough, continue to take things like the Tylenol and symptomatic treatments to minimize the symptoms you're having, but otherwise I would continue to stay isolated until you really are feeling better.

Even though the 10 days since your positive test has elapsed, the guidance really is 10 days and fever free and feeling better. So I would wait to go out and about until you really are feeling better. It doesn't surprise me that you're still not feeling well. Many people, it takes the full two weeks to really start feeling better. And some people, in fact, feel worse in week two compared to week one.

Do you have recommendations about extended family gatherings over the holidays?

Yeah,  I would follow the CDC's recommendations in that way. I would not necessarily go out of my way to be around extremely large numbers of extended family members that I'm not usually around. And I would continue to avoid unnecessarily exposing the very older family members or the very vulnerable family members as much as possible.

Everyone is going to have to make their own risk determination about these sorts of things. And even the older family members may say, look, I'm 95 years old and I may not live another year anyway, so I really want to do Christmas or Thanksgiving or Hanukkah or what have you with the family. And that is a risk I'm willing to take and that's certainly their choice.

But I would be very cautious about exposing people like that knowingly or without them explicitly making that kind of choice, because that I think would be unethical and not appropriate.

In general, what I'd say is follow the CDC's guidelines. Don't have big parties. Don't have 50 or 100 people at your house. And don't go out of your way to visit with every extended family member, especially if you are older, especially if you do have medical problems underlying since I don't think we're going to have a vaccine the rest of this year. Hopefully next holiday season will be a different story, because hopefully we'll have a vaccine by then,

Are there any additional special precautions people should take if you don't have a spleen?

My husband had his removed after bad car accident many years ago. Probably not. In general, not having a spleen is more of an issue for certain types of bacterial infections, not so much viral infections.

That being said, the immune system is not completely normal without the spleen, so there is some increased risk there. But I would not necessarily, if he's otherwise healthy, et cetera, and of a young age, I would not consider him necessarily to be at higher risk just because he doesn't have a spleen.

Because again, the spleen is much more critical for certain types of what's called encapsulated bacterial infections rather than viral issues. Something to keep in mind, not something I'd be overly concerned about.