COVID-19 Update 7/29: That Hydroxychloroquine Video, Rapid Testing, Vaccine Timeline, and More

On this week's COVID-19 update, Dr. Steven Bishop discussed that hydroxychloroquine video that made the rounds on Tuesday and answered questions on cleaning supplies for college, what needs to happen for more rapid testing availability, the timeline for a vaccine, and more. Watch the video below and read on for a recap.  

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Hydroxychloroquine: The Video

We got a lot of questions about the hydroxychloroquine video that made the rounds on Tuesday from a group of doctors calling themselves America's Frontline Physicians. I watched some of it and read the transcript of most of it to get a gist of what they talked about. 

They had some valid point, and some points that didn't completely make sense. My first comment is a general one about the way they were talking about COVID-19. Most physicians who are trained well, have a good grounding in a science-based education, or have experience working as scientists (either in a lab, during medical school, doing research, doing trials)...they don't typically talk the way those doctors talked. 

You will find, if you have a good physician, that physicians don't talk in absolute terms like the doctors in the video. You won't hear "a cure for" or "this definitely is...". Most physicians, if they have good scientific training, tend to be much more circumspect about disease and treatment. I will let you take that for what it's worth. It is the caveat I will provide about my impression of that group of doctors.

I get concerned when I hear people talking in absolute terms about medical things, because very little in medical science is an absolute, very little is set in stone, and to suggest otherwise is often disingenuous, at best, or nefarious at worse. I don't think the way they presented themselves was the best way to get their message across. 

Hydroxychloroquine: The Treatment

Now, let's move onto some of the things they addressed. The constant controversy over hydroxychloroquine, azithromycin, and zinc continues unabated.  I find this fascinating from a lot of angles. It's quite clear from the trials that have been done so far that hydroxychloroquine, whether alone or combined with other things, probably does not work for hospitalized patients. People who are already very sick. The data is fairly clear at this point that it probably does not help much, if at all, in a hospitalized person.

That being said, there's only been a couple of trials done so far, so I'm not even willing to say that definitively. But, I think we do not have strong evidence that it helps the hospitalized person or the person that is already very ill. 

Now, that is different from an outpatient or someone who is moderately ill. And I think this is the point that these physicians were trying to make, and I do agree with their point on this. There are a large number of studies, about 65 studies, on COVID patients with hydroxychloroquine. A lot of them are on outpatients, and all of the studies, except for two, have shown a positive impact on viral outcomes when used early in the disease course and when patients are moderately or mildly ill. 

I think there is sufficient data to say two things. 

First, we need a large-scale trial on outpatients to be done by our major medical institutions (NIH, WHO, CDC) and our large academic institutions. They need to take this data seriously and evaluate it in a trial like it has been done for hospitalized patients. It needs to be done.

Why it hasn't been done? I can't say. I don't know. I think it's a mystery. I think it needs to be addressed, because there are quite a large number of small-scale studies with more than enough evidence to go forward with a large-scale trial. And more than enough evidence for people to say, for the moderately ill outpatient, this is something reasonable to consider, especially if you don't have strong risk factors for having a negative side effect from any of the drugs.

We recommend other treatments and therapies with far less data than what's been presented here. The bottom line is, what those physicians were commenting on with hydroxychloroquine, while I don't agree with the way they presented and I don't agree with them saying its a "cure" for COVID, it deserves a further look and it deserves further evaluation. I think for the moderately ill person who is high-risk for COVID, who is an outpatient, it is a reasonable thing for you and your physician to have a conversation about whether its something for you to try. 

I don't think it should be a blanket recommendation. I don't think it should be over-the-counter, like some of the physicians were calling for. I do think there is a space for that drug combination to be used in the right person. 

Hydroxychloroquine: Treatment for Rheumatoid Arthritis and Preventing COVID-19

Someone asked a follow-up question about if taking hydroxychloroquine already for an ailment such as rheumatoid arthritis provides protection from COVID-19. The answer is maybe and I don't know. There is some data out there about using hydroxychloroquine for prophylaxis.

But the strongest data is when it's being used in the combination therapy, either with azithromycin, plus or minus zinc, for treatment of active COVID-19 illness. The study results, if you go to the link above, you can divide them up into pre-exposure/prophylaxis. The study results are fairly positive for that, but again, to really get to the bottom of these things, we've got to have a randomized control trial on a large scale. 

Impact of Lockdowns

This is about the point where the video cut off for me. They did go on to discuss the negative impact of the lockdowns in terms of the lockdowns harming people and schools being closed harming people. I think there is a lot of merit to some of these things. I don't think we, and our government officials, have not talked enough about the negative impacts of the way we have managed this virus.

VCU put out a study a couple weeks ago showing there was a large number of excess deaths that occurred in the severe lockdown period that were not attributed to COVID. They were probably a result of the lockdown policies. The lockdowns were always a gamble that we would have fewer people die from the lockdown than die from the virus.

We never knew what was going to happen, because we didn't know what the death rate from the virus would be. At the time, that trade-off made sense. I think it probably does not make sense anymore. Just from a pure numbers perspective, given all the negative outcomes we've seen from the lockdowns, the spikes of suicides, the spikes in severe depression and anxiety. Many studies are coming out showing these lockdowns have had serious detrimental effects on people's mental health, on the economy, on food security. 

And of course that doesn't even speak to the issues that are going on with our children in the community. Many of you know that I have advocated for kids to go back to school in some way or another. A lot of that is for their own health. It has had a negative impact on the health of children and adults in our country.

That being said, we have to continue to tread carefully. We've got to do the other things that our public health officials recommend. The social distancing is important. The hand washing is important. The mask wearing is still a good idea in many situations. 

The thing to remember is everything is nuanced. There are no cut-and-dry answers for almost any problem in life. Medicine and public health are no different. We have to be careful about how we approach things. We have to investigate this hydroxychloroquine thing a little more.

We have to do many of things our public health officials are recommending, but we should take their recommendations at face value and see what the data is behind them. While the data behind wearing a mask all the time is unclear, it's a pretty harmless intervention. If you can do it, you should, especially if you are out in public around crowds. 

More Questions. More Answers.

• Any progress on getting tests with faster results or new types of tests that are not so uncomfortable?
  
  We do need more rapid testing. We, at PartnerMD, have been working fervently to try and get rapid testing available. We have struggled getting the machines, the swabs, and all the reagents necessary for this. It's a challenge.
  
  There are tests that can get results in 20-60 minutes. Some other providers, such as BetterMed has them, and some of the hospitals, but getting them into private practices has been much more difficult. We do have a point of care antibody test, but that has also been difficult due to regulatory problems. 
  
  Our government officials need to help us out. We need help from our regulators to allow tests to be available more widely. Most of these tests, the availability hinges on something called the CLIA status. CLIA is a lab designation. Every test your doctor does in the office gets a CLIA designation. Some are low, some are moderate, some are high complexity. Many of the new tests for COVID-19 that can be done in an office, because they are new and somewhat experimental, they are being auto-classified as high complexity CLIA, meaning they aren't what's called "CLIA waived" and it's hard for doctor's offices to offer them in the office. 
  
  We need our regulators to CLIA waive these tests immediately. These tests are not hard to do. They are easy to interpret. They are easy to train staff on. This is the barrier to more testing. We need CLIA waived tests. 
  
  That's the first thing we need for faster testing. Second thing is just supplies. The swabs are at a premium. There still seems to be a backlog with the supply chain on those. 
  
  
• What supplies — PPE, cleansers, medicines or medical equipment, etc. — do you suggest college kids bring with them when they move to a college dorm this Fall?
  
  For the most part, general cleaning wipes (lysol wipes, etc.) are good for cleaning. Hand sanitizer. A mask to wear. For the most part, they won't need anything beyond that. Many colleges are going to do a lot of virtual learning and small groups, so that should limit the need for anything more. 
  
• Any hints on how to get a COVID test result in three days or less?
  
  If you can find a place near your locality that has the rapid test that you can get back in 20 minutes to an hour, that's the best best. Most of the PCR tests are taking several days to come back. The antibody tests, sometimes you can get that back within 3 days. It depends on how busy the lab is at that time. 
  
  
• Dr. Fauci was quoted in the media as saying that a vaccine could be approved as early as October or November. Do you think this is feasible? If so, how much time might it take after approval to vaccinate the nation? Weeks? Months? A year or more?
  
  I certainly think it's feasible that we could have an approved vaccine under one of these emergency programs by October-November. I think its more likely going to be toward the very tail end of the year. Moderna just started their large-scale, 30,000-person trial. That will take a couple months at least and then there will need to be follow-up on that data. 
  
  I would hope by the end of the year, we'll have an approval for something. I think a vaccine roll out is going to take a year. Both logistically and for other reasons. I've been talking to some other folks. The vaccines that they are testing, the mRNA vaccines, there are some issues with storage and transport. They think they have to be stored at negative 80 degrees Celsius, which presents some complexities on how to transport that around the country. 
  
  It's going to take people time to figure that out, and then also it's going to take take to vaccinate a couple hundred million people. Not to mention the time and effort it's going to take to convince people to take the vaccine, because people are going to be rightfully concerned about it since it's a new vaccine and new technology. 
  
  
• What are some different breathing exercises that will help strengthen our lungs during this time?
  
  This is a great question. Here are some suggestions from the American Lung Association that will be great to do. 
  
  
• Please discuss the study out of Israel using fenofibrate to lessen the effects of coronavirus.
  
  This was an interesting tidbit that came out of Israel in the past couple days. They found there was a drug that may have some effect in moderating how the virus works in the lungs. Fenofibrate has been used for a long time to manage cholesterol and high triglycerides in the blood.
  
  It is a fairly safe drug. I don't know if it is going to be effective or not. No human studies have been done for this drug. This was a lab-based study where they evaluated lung tissue in, basically, a petri dish in the lab and used the drug to see what it would do in the lung tissue. This is what is called hypothesis generating research. It's interesting. The researchers are planning to follow up with animal studies and if it's successful there then they would test it in humans. 
  
  
• What are monoclonal antibodies, and how significant might they be for preventing or treating coronavirus infection?
  
  Monoclonal antibodies are antibodies that come from a clone of a single cell type. They are all identical. One of the companies we've talked about before is creating something called a COVID shield. It's a combination of three different neutralizing antibodies that affect coronavirus. Each of the three in the "cocktail" is a monoclonal antibody. Many other drugs are monoclonal antibodies, things like Humira. They might be helpful in preventing infection, but possibly in treatment, too, and trials are ongoing. 
  
  
• There is an asthma steroid, forget the name, but starts with bu, I think, that another doctor was prescribing to his patients. Do you know what it is and if it may be helpful to fight COVID?
  
  Yes, this is coming from a doctor in Texas. He's using Budesonide, and I have seen this other places, too. Budesonide is a pretty harmless drug. I don't see any reason not to use it for folks, especially if you have underlying asthma or something like that. 
  
  Using an inhaled steroid is a pretty common thing to do for any kind of pulmonary infection, so I think it's a simple choice to make if you do get COVID-19. I don't know if it's effective or not, but I don't think it's harmful, so I think it's ok to try. 
  
  
• My husband is making me take a Lypo-Spheric Vitamin C. Is this really any better than regular vitamin C for the immune system?
  
  Probably not, to be quite honest. Vitamin C is readily absorbed by the body. I don't think you need any special formulations to have it work. Plain vitamin C in the cheap Kroger brand, for example, is probably fine. I would say don't take more than 2,000mg per day, or you will put yourself at risk for kidney stones.