COVID-19 Update 7/15: Treatments, Vaccines, and More

Another week, another COVID-19 update. This week, Dr. Steven Bishop discussed the latest numbers, new data on potential treatments, and updates on the vaccines under development. Watch the full video below and read on for a recap. 

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Numbers in Eastern Virginia Rising

In Virginia, we are seeing a definite increase in cases and hospitalizations in the Eastern part of Virginia. Most of the rest of the state, including Northern Virginia and Central Virginia, continue to see decreases. 

The one thing that is a little concerning is that the positivity rate has trended up a little bit. We're at almost 7% now, as opposed to just over 5% a few weeks ago. This could mean a lot of things. It could mean more people are sick, or it could mean fewer people are getting tested who are negative (the worried well, people who think they got exposed but are not actually sick). There's just no way to know which one it might be, which is why it's important to follow hospitalizations and deaths. 

One interesting thing about the percent positivity rate, which informs how we test people. Part of the problem is when the prevalence rate gets below 5% in a community, you start to get an uptick in false positive tests for antibody tests, in particular the IgM test.  At that point, you probably have a higher risk of getting a false positive than a true positive.

This is something we, as medical providers, take into effect with testing strategy. That's something to keep an eye on regarding antibody tests. However, the PCR tests would still be considered definitive in that scenario. 

Tracking COVID-19 Treatments

This is a helpful website that tracks studies involving hydroxychloroquine as a treatment for the virus. I know a lot of the large institutions have stopped their trials, but most of those trials are being done on inpatients who are already very sick. This is a helpful guide to get a lay of the land of where all the studies are being done and what's coming out. 

The drug does seem to have a better effect early on. I continue to hope the larger institutions, the NIH, the CDC, the WHO, will do a large trial on outpatients, so we can get more information that way. A lot of smaller studies are being done showing the drug may in fact work on outpatients and those who are less sick. 

Another treatment is remdesivir, an anti-viral drug that has been approved by the FDA. At first, most of the data just indicated it reduced the hospitalization length of stay by a bit. They did release some follow-up data showing it also reduces the mortality rate somewhat as well in the very sick, which is encouraging. That drug does seem to be very helpful, especially for those who are very sick. 

And then the other thing to touch base on is the recovery trial from Oxford from several weeks ago related to dexamethasone, a steroid being used that had been shown to improve mortality rates. They finally released update data on that. It looks like that steroid might be effective for people who are very sick. However, for people who are not very ill, who don't need oxygen, it actually worsened their mortality. For someone who does not need oxygen or is not very ill, I would not give them inject-able or pill steroids at this point. 

Your Questions, Answered

• I just got back from OBX. As long as you distance on the beach I heard that being outdoors is probably safer than indoors. What are your thoughts?
  
  Yes, absolutely. Being outdoors is definitely safer than indoors. You aren't getting recirculated indoors and you have a much better chance to distance from others. If you do that at the beach, I think your risk is very low. 
  
  
• What is your take on the Moderna vaccine immune response results?
  
  Again, we need to read the data very carefully on this, as we've talked about in recent weeks. Here's a link to the full study. We'll need further outcome studies to confirm, but they did publish some follow-up data on their initial trials. All 45 of their patients developed what is called neutralizing antibodies. This is great. This is what we want. There are many kinds of antibodies, and neutralizing antibodies are the best to have, because they neutralize the virus and prevent it from spreading. 
  
  On the flip side, while this is great news and they'll move forward with Phase III trials, the thing that concerns me a little bit about this vaccine is that it is new technology. We have never had an mRNA vaccine before that has been used in any setting.
  
  It remains to be seen what the safety profile is of this vaccine. In the study, they did not report all the adverse events in detail, but they reported some of them. It worries me a little bit that, in a group of 45 people, about 40-50% did have adverse reactions to the vaccine, most of them being fever. It isn't the worst thing, but it is concerning that about half the group have fever and about half the participants also had fatigue, headache, muscle pain, pain at the injection site, and chills. About half the people getting a side effect from the vaccine is pretty high. 
  
  I'm going to be very tuned into the data about which individuals got which symptoms. Because it's a new technology, I'm going to be wary about the adverse affects until we get more data, which we will get with the 30,000-person Phase III trial. None of these side effects seem serious, but it is a concern until we learn more. 
  
  
• How will you get accurate statistics about new cases if the White House won’t let hospitals release that information to the CDC, but only to the White House? It's a challenge all around, but I don't think we'll ever get totally accurate information, because the virus is so widespread.
  
  Even if the government was operating efficiently and sharing data wholly and all that, I still think the numbers would be wrong. There are probably a huge amount of asymptomatic people out there that aren't getting tested, because they have no reason to be tested.
  
  We're always going to be guessing, to some degree, about total case numbers, which is why I think tracking hospitalizations and death rates is the way to go at this point. 
  
  
• I know we don’t know much about how significant aerosols are a source of transmission. But the recent Nature article makes a pretty strong argument that converging evidence suggests this may be an issue. Do you believe that public policy, health guidance, or indoor public behavior should be changed in light of this convergence of evidence? 
  
  Yes, I'm more concerned now about airborne transmission than I was a few months ago. However, it seems to be the least significant mode of transmission. Droplets are first, followed by contact, followed by airborne.
  
  There have been some small outbreaks that have been traced back to ventilation systems and things like that. What this tells me is, for the most part, I'm trying to stay away from enclosed small spaces with large groups of people for long periods of time. If I'm going to be in that situation, I'm going to wear a mask.
  
  That being said, large, indoor places like large churches, grocery stores, etc., that have good ventilation systems are probably less of a risk a risk as long as they are paying attention to their systems. Even smaller places, there are things they can do to adjust their HVAC systems to increase the air exchange rates and reduce the viral particles that may be in the vents, and I think those are smart things to do.
  
  Overall, continue to avoid confined spaces with large groups of people, and if you are stuck in that position, wear a mask. 
  
  
• So I have COVID-19 and the total lack of taste/smell is unnerving. What are the chances it's permanent? Also, I'm willing (and my husband) to participate in any studies/questions/tracing available. Can I expect to just be contacted? By whom?
  
  The people who we have seen who have the lack of taste/smell symptom, while unnerving and strange, most of them do recover completely. There have been some reports of a few people who have not totally recovered, but by and large, most recover within a few weeks.
  
  For tracing, you should be contacted by the Health Department. They probably will call you and ask who you've been in contact with and things like that. The health department may also know about studies, but they may not. Often, researchers doing studies looking for volunteers just put things out in the media, so be on the lookout for that in the news and see if you meet the criteria. 
  
  
• What information do you have about toddlers contracting COVID-19 or about them being carriers, infecting parents/grandparents?
  
  I'm going to take this from Dr. Danny Avula from the Richmond City Health Department and other studies I've read. The data we have is very scarce in terms of children having the virus and giving it to other people.
  
  That was a concern at first when shutting down schools, which made sense because we just didn't know what was going on, but there is little data to support the assertion that children transmit the virus on a wide scale. There have been studies where infected children show symptoms and have been exposed to many people, but very few to none of their contacts contracted the virus.
  
  We haven't gotten widespread data to confirm the conclusion, but my gut, based on what I've been seeing and reading, is telling me that the risk of children spreading this around is small and maybe negligible. 
  
  
• What do you think about using inhaled steroids to treat COVID-19. I think one I heard of is Budesonide?
  
  There's a video going around from a doctor in Texas who has been using Budesonide, a mild, inhaled steroid used to treat asthma and COPD, to treat COVID-19.
  
  I am trying to get the data, so I can look at his information. It sounds promising, like a lot of things, so I don't want to get overly excited, but I also don't want to downplay it either. Like a lot of things, Budesonide is a pretty harmless treatment that we know a lot about. It probably will work for some people, but not for others, such as people who are very ill.
  
  Once you are very ill, most of these drugs will probably not help as much as they would if you used them when you were not as ill. It's the same story with hydroxychloroquine, zinc, and azithromycin.
  
  Budesonide is a pretty harmless treatment as an inhaled steroid. I wouldn't have any problem taking Budesonide myself or prescribing it for my patients. It's something I might give to them anyway if they had a viral pneumonia or a bronchitis to help ease up the inflammation. It's a common used drug. We don't also use that brand, but an inhaled storied is commonly used for pulmonary inflammation when people have viral illnesses. 
  
  
• It's difficult to keep up with how treatment options are progressing. What are we finding that actually works to any degree, medicine-wise? 
  
  Remdesivir seems to have good results, especially in the very ill.
  
  We need to shift hydroxychloroquine studies to outpatient studies, instead of inpatient studies.
  
  Losartan has yet to have trial data come out, same thing with ivermectin and the glutathione and Vitamin D.
  
  Convalescent plasma, the early trials to come out were negative. It did not show any good outcome.
  
  The best thing continues to be finding a vaccine. However, that will take some time, so these treatments are important. 
  
  
• If someone comes down with COVID, what's the current recommendation of treatment (prior to it potentially getting worse)? Do you prescribe hydroxychloroquine to those that test positive but don't need to go to he hospital?
  
  We are not just yet. The preponderance of the evidence for outpatients is tilting toward prescribing it, but luckily, we have had very few really sick patients. Most of our patients who have tested positive for COVID-19 have had very mild symptoms. I think hydroxychloroquine is going to be best used in someone who is sick with fever and cough who is in the high-risk population (60+ and up), but is not sick enough to go to the hospital. That being said, based on the data I've seen, I would have a conversation with the patient about that. 
  
  
• Has there been any data about if the virus is weakening as it mutates over time?
  
  No, we don't know that answer yet. The virus is mutating very rapidly, which is causing a lot of consternation about if we're going to get a good vaccine. We just don't know yet if the virus is weakening through mutation. I think we'll know more once the fall comes around, and we'll see if the cases tick up again once flu season comes. Then we'll know one way or the other. 
  
  
• Has it been determined yet if once you test positive, you are immune to it again?
  
  No, it has not. There has been some discouraging information coming out showing the antibodies may not last longer than a few weeks or a few months. That said, you could still be immune through Memory T Cells or an undetectable level of antibodies or Memory B Cell immunity. The vaccine research will really help us determine how long the antibodies last.