COVID-19 Update 11/4: New Research, Surgical Masks, and More

On this week's COVID-19 update, Dr. Steven Bishop discussed new research on a variety of topics, what masks are the best masks, how often you can use an N95 or surgical mask, and more. Watch the full video below or read on for the transcript. 

New Research

We got a nice research summary from the American College of Physicians, and there's a lot of great data that's coming out. At this point we're, we're nearly a year since the virus was first discovered, as hard as that is to believe. And it didn't really reach the US in earnest until February, but it was going on in China, in November, December a little bit. So we're nearly a year into knowing about the virus and having it out in the community. So we've got more data coming which is great.

The first couple of things is that there is some good news on the treatment front. There was a research study where they did a small phase II trial on what's called a monoclonal antibody. So that's an antibody cocktail, not unlike what President Trump received a few weeks back from Regeneron.

It's a little different than that, but similar. And they did find that it reduced the viral load in the patients with the number of copies of the virus pretty quickly. So that was a good study, hopefully that treatment will continue on to a phase III trial and we'll get some more data on that. So that is a little bit of good news.

Antibody Longevity

Some other good news, it's a little bit of a mixed bag. I think it's good news, but we're waiting on more confirmation. Several more studies have come out showing that the antibodies to COVID do persist at least four months in some cases and some over five months after infection, even minimally symptomatic infection, same thing with T-cell immunity. That also seems to be persisting at least into the four and five month mark.

There's been some conflicting data. Some studies come out showing that in certain people that the antibody titers do decline after around three months, but the overall preponderance of the data seems to indicate the antibodies are probably going to last for most people, at least five, six months, something along those lines. So that is good news. And that bodes well for lowering the risk of reinfection as we continue to be concerned about that.

Cardiovascular Effects

The next set of data that's come out is around cardiovascular effects of COVID. And what they're showing is kind of what we've been seeing, but in with more robust data, in that people who are put in the hospital in the ICU for COVID do have a fairly high risk of having cardiac heart rhythm problems and cardiac injury.

Now some of that may be related just to the stress of being critically ill. Critically ill people, regardless of the cause, are more at risk for having arrhythmia rhythm problems and having ischemic and other heart injury events in general. That being said these numbers seem to be higher than what we would generally expect, so there's probably some specific effect of the virus going on there. So there's more to come about that.

And I think eventually at some point we're probably going to see some kind of recommendation for cardiac follow-up for people who get sick with COVID. And I think that's been the cause, or it seems to me from my reading of the cases of younger people, especially younger, healthy people, you've seen a few college students here and there who have gotten very sick and passed away after seemingly recovering from the virus and they have died unexpectedly. I think most of them had cardiac injury more than likely. And so we may find over time that we do in fact need to do some sort of post-infectious cardiac screening for people and make sure that they're doing okay after recovering from the illness.

So that is a little concerning but again, more to come on that. They did not find an association in another study with strokes. So that's good. The initial concern about the increased risk of stroke, I'm not going to say this one small study that came out is telling us there's no increased risk of stroke, but it sounds like it's not dramatic. They're not going to be dramatically higher than the baseline of what we would normally expect for people with the same age and other related medical problems. Now that does not negate the blood clot risk. That seems to still be an issue in people who get COVID and that, of course, can cause strokes as well. So different types of different kinds of strokes there, but yeah, we will see.

Risk-Adjusted Mortality

In other good news, another data point that came out, Journal of Hospital Medicine, the overall mortality, risk-adjusted mortality is coming down for people who are admitted with COVID to the hospital.

And that is great news. Very good news. It means that we're learning better how to take care of the virus and take care of people with the virus. And we learned a lot about some treatments, some different things to do to lower the risk of people getting worse once they're in the hospital.

So I think that's good and we'll continue to learn more as time goes on, and hopefully those numbers will continue to climb down. And we're seeing that reflected in the data, I think, where hospitalizations have gone up but deaths have not gone up dramatically in response to that in many places, or may have even gone down in many places, and I think it's because we're better equipped now and know better how to take care of people with the virus at this point in time.

Cloth Masks vs. Surgical Masks

Let's talk about masks. The question I got about masks, this relates to the concern that we're still seeing an upsurge of cases, despite more people wearing masks. And I think that, you know, some people think, "Oh, well, people are wearing masks. Why are we still seeing more cases?"

I honestly think that we would probably have even more cases if no one was wearing masks. To be honest, that being said, I think there's several things going on here.

First of all, we're transitioning to cold weather. And so people are going to be more indoors and we have known for months now that the risk of transmission is much higher if you're indoors. So more people are moving indoors, they're going to be exposed more. So I think that's the first. I think that's one of the primary reasons the cases are back up significantly.

Honestly, they're pretty much back, the new cases, are back up to where they were at the start of things. That's concerning. But I think that's being driven, at least partially, significantly by the weather and people moving more indoors.

People are wearing masks in general, I think as much or more than they have been, I think the problem comes, and has been my concern all along with the mask material. The data has continued to come out.

There's a rapid review from Annals of Internal Medicine that gets updated every few weeks and the data for cloth masks and fabric masks and these sorts of things, it's just not good. There's no significant data showing that the masks are extremely effective. And I think that they're better than nothing like we have said all along.

And to go along with that, we have made a decision here at our practices that we're going to actually transition to having people wear surgical masks again. Now that the supply chain is better and we're better able to get access to the surgical masks. I think we all forget that we never really thought that the cloth masks were going to be equal to a surgical mask.

It was sort of that it's better than nothing thing, and that's why everyone started wearing those. And we've told everyone to wear those and that's fine, because I think it is better than nothing.

That being said, they're certainly not as good as the surgical masks, which are designed for operating room use, designed to reduce disease transmission from doctor to patient. And so it makes a lot more sense that that those would be more effective. So we're actually going to transition to all of our staff and doctors wearing surgical masks all the time in our offices, because we we've been able to procure much better supplies for these. And we're going to ask the patients to begin wearing them for in-office visits as well and transition away from the use of the cloth masks.

My takeaway from that is I think if we're going to wear masks, now that supply chains are better, I think we should encourage people to wear actual surgical masks that were designed for these purposes. So that's kind of my long-winded answer to the mask question. It's a multi-fold issue.

So in general, I think it might, at this point, my recommendation is if you can find and afford to get surgical masks and you are going to wear a mask, which I do encourage you to do, then try to switch over to wearing surgical masks, especially if you're going to be indoors crowded around other people for any reason. I think that that is the better way to go at this point given the data for the cloth masks continues to not be strong.

So I think we should default back to the mask types that we feel more confident are more likely to work.

Your Questions, Answered.

"What is considered a surgical mask?"

That's going to be this type of mask here that comes in a box. They're designed mostly to be used for one day and then thrown away. They have multiple layers of mesh fiber and other things and they're designed to reduce droplet transmission essentially. So this is what qualifies as a surgical mask. Anything like this would be best if you can manage to get them. Other than that, use the cloth masks. But these ones are probably superior based on the data that's coming out.

"Can you explain the levels of surgical masks? I purchased some level three masks from eBay."

I'm actually not familiar with leveling of surgical masks. I think if it comes marketed as a surgical mask or medical masks, that that is fine. So any of those is probably okay to use.

"Is it possible to have COVID without any respiratory problems?"

Absolutely. Absolutely. COVID is a whole spectrum of illness. Some people have very little to no symptoms at all. Some people have sort of runny nose. Some people have cough and respiratory symptoms. Some people just have GI symptoms like diarrhea. Some people have just had a rash. Some people just have fatigue and headaches, so it really is highly, highly variable. So yeah. Yeah, absolutely. 

"N95s seem pretty readily available online. Do you recommend patients use these if they have some?" 

I don't think that's necessary unless you're a very high risk person in a very high risk place. So if you're someone with a lot of medical problems who needs to get on an airplane, for example, and fly somewhere.

I have been recommending that people who are very high risk and need to get in a crowded place because they have to travel for some reason or another, I have been telling them to wear N95 masks. But I think for your average risk person, you don't need to do that out and about. But for those other folks, it might be a good idea in certain situations.

"Given the increase in infection, do you have any change in recommendation for interactions with those outside of your main household? Should those who are able to choose to spend more time at home to help reduce the spread?"

I think that's a really good question. And I think that it is something that is hard to answer except on a local level. So I think if you're seeing very high spread, and in particular high hospitalizations, so I think if you're in an area where hospitalizations are increasing, I think, yes. That is a good thing to do and we probably do need to be even more, what's the word, prudent about the social distancing in those places where hospitalizations are going up.

If things are otherwise stable and it's just cases, I would recommend people continue to follow the standard advice that's being sent out by your local health department in.

In places where hospitalizations are going up. I think it makes a lot of sense from a moral, ethical, practical standpoint to be more vigilant and more strict about the distancing piece to keep the hospitals functioning properly and to keep the hospitalization rates down for everyone's sake. So a little bit of an extended answer to that question, but I think it depends a little bit, I would gauge that based on what's going on with the hospitalizations in your area.

"Our extended family decided to celebrate Thanksgiving and Christmas apart, which is sad, but seems prudent."

Yeah, I think some of my family is going to be doing the same. It is sad, but I think again, everybody and every family needs to figure out what their risk tolerance is and make a decision based on that. And so it is sad, but, you know, I think in the long run, everybody probably knows what's best for them and their family. So they, they need to make those choices.

"If you have an N95 masks, can you reuse it if you only wore it for an hour?"

Yeah, I think that's fine. What I would do is just make sure that the outside of the mask didn't get contaminated. That's really the key thing with those making sure the outside didn't get contaminants. So if you just wore it out and about, and you weren't really around other people too much, or you're not really worried that you got exposed to anyone, it's fine to rewear it again.

What you could do, if you want to be super safe, it's just leave the mask off to the side somewhere for a couple of days and let whatever virus particles might be on the exterior of it die off.

But otherwise for the general public, it's fine to reuse them. Healthcare environments are different. They're really not designed to be reused in those instances and unless under very emergent circumstances like we were in the spring. And so most of the many facilities now are reverting back to single use N95s now that supplies are better. So that's the appropriate way to do it, but for what you're asking, yeah, it's fine to reuse that.

"Any news on vaccines over the past week?"

No, I have nothing significant or new that I have seen except that Moderna, one of the companies, did indicate that they seem to think that they would have a vaccine perhaps ready for use by the end of the calendar year. But I haven't seen any more details on that. So I'm waiting to hear more from them on that piece. I think that's the big news, which isn't exactly news about the vaccine in terms of effectiveness. The big news that we're all working through right now is trying to figure out how to transport and store these things.

So many of these mRNA vaccines, which seems like it is going to be the likely route since many of them are being used, are being made with that technology platform. They have to be stored at minus 80 degrees Celsius, and that is not a typical freezer type that most doctor's offices have.

So we're all scrambling right now, trying to find these freezers and buy them so that when the vaccines do come out, we are able to store them properly at our offices. And I think a lot of primary care offices across the country and hospitals are trying to figure that piece out right now. So that's really the only news on vaccines, is just trying to figure out how to make sure we can store and manage the inventory properly.

"I have a UVC sanitizing box. Can I use it for my masks?"

I think so. Yeah, I don't know a hundred percent for certain because, and especially if you do it a number of times the UV light could potentially damage the fabric, but I think if you were doing it once or twice, something like that probably would be okay to use for that.

"Any new insights about the logistics and timing of dissemination once vaccines are approved?"

Nothing new. I think that most states, the plans I have seen, they still plan to roll them out to healthcare workers and patients who are in nursing homes, long-term care facilities first. And I think that makes sense still. I think that we probably will only have enough supply to do it for those people at first, most likely.

"How many times can the masks be reused and still be effective to include the surgical masks?"

So the N95s, if you just wear it for a little while, it's fine to reuse. The surgical mask, same thing. If you don't get exposed to anybody, you could probably reuse it for a couple of days. They do get dirty, so I would recommend, you know, one a day or so. Maybe two days, you could extend it out, but probably a day or two, and then toss it and get a new one.

"We're still trying to get a handle on what 2021 looks like if vaccines are approved as expected and if they are reasonably effective?"

Yes. Still trying to get a handle on that. Agree. I think I'm hoping by the end of calendar year, we'll have at least a decent idea of whether we're going to have a vaccine at all that's safe and effective.

And hopefully it will start rolling out in the new year. And that would be about my expectation. I think back in March, I was saying it probably will take 12 to 18 months and I think that's probably going to turn out to be true before we have a widely available vaccine. I think it really is probably going to be early spring for the most part for most people. Probably not until the summer.