COVID-19: Ask Me Anything Open Forum July 20, 2020

Hey, everyone. I'm Doctor Rsai.

I'm the uh chief medical at osmosis and I'm really happy to have you here with us right now. I wanted to quickly just say thank you for uh tuning in.

Uh This is gonna be ask me anything and, and first off, you can hear the background, there's a little bit of noise, construction noise.

Uh That's because uh our neighbors are getting some work done and I apologize for that, but we're just gonna try to block that out.

Uh wanted to just say, look, uh I'm gonna be here for 30 minutes trying to catch up with all the questions that um that you might have uh rumors, misconceptions, myths, you know, anything that you want to try to talk about, put in the chat.

And we're gonna try to get to that as soon as quick, as soon as we can and as quickly as possible, I also have a number of things I need to uh say uh because it's been a while.

And so I wanted to just make sure everyone's on the same page with where we are with COVID-19. And that is uh that, you know, my background.

I'm uh pediatric infectious disease train. So I'm always thinking about it from a clinical standpoint.

Uh I also uh worked at the division of viral diseases at the CDC. So I'm uh also obviously very tuned into what the CDC is saying from like a public health standpoint.

And of course, I work at osmosis as I said, as the chief, not a cluster. So I'm thinking about it from an education line.

So those are kind of the three main lines as I bring to this and again, COVID-19 is affecting the world. So there might be issues and concerns internationally that, that we can try to address as well.

Um That's just a bit of introduction. We all all know the importance of flattening the curve.

And here in the US, we were flattening the curve for a few months, you know, in February and March, things were pretty bad and then really April and May were good months in the sense that we were flattening the curve, making sure that the cases weren't exploding nationwide, doing quite a good job here in the in the US middle of June.

However, things really took off again and, and now a month in the cases have been just uh really at levels we've never really seen before and that has cause hospitalizations to go up.

A number of hospitals in Florida, specifically kind of the new epicenter of the uh COVID-19. Uh pandemic is Florida and in that state, we've seen a lot of hospitals really cap out in terms of ICU beds, deaths have started to go up as well.

And so we're seeing all the uh natural sequelae of having so many cases. So since we last spoke, uh we talked about cases, but also we've made progress in a lot of areas.

You know, we now know uh antiviral therapy or ranvir is uh very helpful. We know that anti inflammatory medications like dexamethasone can be really helpful.

So those are two different approaches. Uh one attacking the virus, the other is a steroid that actually dampens your immune response.

Those two things really do seem to be helping and dexamethasone in particular is, is quite interesting because that's a medication you can get in even low income settings.

So we know uh other countries are dealing with COVID as well. One in particular uh is near and dear to my heart, which is India because uh my, my family is from there and in settings like India, uh dexamethasone is available.

What's not available, of course, is remdesivir, which is much more expensive and even in the us, many hospitals can't get access to remdesivir.

So that's really been reserved and uh for certain cases and it has been a challenge to acquire in certain settings. So that is effective less uh available.

Now, in terms of uh what we can all do, uh we talked about flattening the curve, uh part and parcel with that is, is wearing a mask which is, of course, now we know scientifically uh and uh it, it, it, it works, it's cheap.

It's probably the most effective way to reduce viral transmission, uh dollar for dollar. So that is the best way that we can all kind of do our part.

The other half of the side of the coin is really, you can find the curve. You also have to raise the line of healthcare capacity.

And now a lot of hospitals are shutting down elective procedures again, uh relying more and more heavily uh than ever before on telemedicine.

And we're trying to get uh clinicians trained up to be on those front lines. You know, this is not a um uh a sprint, it's a marathon and we need to make sure we have nurses and doctors and other healthcare workers that are available, not just, you know, in the, in the near term, but in long term too.

So that's just a bit of preamble. Let me just jump right into the questions uh as well because I know we've got questions kind of pouring in.

Um Is it true yet? Is it true?

We yet have no proven cases of an asymptomatic person infecting someone. Uh That is not true.

So let me, let me um uh end that right here right now. It is not true that asymptomatic people cannot transmit the infection.

Absolutely. They can, unfortunately, there was a wh o they came out with a statement that I think was really confusing and, and they, they seem to imply that asymptomatic transmission is not a big deal but, but that's not true.

And actually Dr Fauci among, among many others kind of said, hey, the sa the same thing that, that actually asymptomatic transmission is important to consider.

And that's actually why masks are so important because you can easily go into a grocery store or a pharmacy and think, oh, you're, you're fine because you don't see anyone maybe with a fever or symptoms.

But that doesn't mean that you can't acquire just through breathing loud, talking screaming, uh singing any of these kinds of things really puts the virus out in the air and breathing itself, gets the virus out there.

So all those things from asymptomatic people, uh meeting people with the virus but just don't have symptoms can actually get other people sick again.

That is why we need to be wearing masks. Next question, what are the chances that COVID uh vaccine will work?

I read somewhere that immunity will provide only temporary relief. So at the moment, there are many vaccine candidates and increasingly it doesn't look like, you know, if there's gonna be a vaccine, but simply a matter of when there's gonna be a vaccine.

And so that's the first thing that's a huge cause for hope. One thing about vaccines you have to understand is that there are multiple stages of how they get tested.

There's safety which is phase one immunogenicity, which is phase two and then there's efficacy uh and then effectiveness uh which is kind of uh afterwards.

So, efficacy simply means like does it actually work? Does, does it make a difference?

And we're in that trial or we're in that stage with, with the vaccine already a couple of vaccines looking at efficacy. Does it actually work?

And, and what it looks like is that it works in animals, it works in mice, it works in baboons from other Coronavirus uh studies.

So remember, this is not the first Coronavirus to hit humanity. We've been hit by MERS and SARS previously, it seems clear that when you get immunity to one of those other Coronaviruses, that immunity lasts for the order of at least a few years, it seems.

So I would say that here uh the same is likely to be true. We haven't seen cases of reinfection.

I know that's been in the news and caused a lot of confusion. But that was essentially because of the lab testing being not 100% reliable.

And so we haven't seen cases where people got, you know, uh COVID-19 and then recovered and then, and then really got COVID-19 again in the absence of people with immune deficiencies.

Of course, in those individuals, that's a different story. So in general, that is not the case that doesn't happen, what does happen is you get COVID-19, you mount an immune response and then you don't get it again.

So the thought is that the vaccine would work the same way it would cause your natural immune system to get a boost and prevent you from getting the disease in the first place.

Uh, does COVID spread by air. Absolutely.

And in fact, the wh O has now come forth and say, hey, you know, we thought it was essentially just by droplets, but more and more evidence now, now that we're in July shows that it's airborne and that you can actually spread it through airborne um means and what that means practically speaking is that, you know, it's not just the big fat droplets that the virus kind of uh spreads on, but it's more of the tiny, tiny, tiny droplets, the ones that linger in the air for a long period of time.

So I think it's much simpler and less confusing to think of it as big droplets, little droplets rather than droplet and airborne, but simply put, yes, it can linger in the air.

And yes, you can actually walk through, you know, let's say a cloud of, of viral droplets um and, and acquire it even when that first person is long gone.

So that's again why we all need to be wearing masks so that we're not putting out so much virus in the air. And that really, it's being caught in that, in that mask.

Uh next question, uh which of these are reusable masks ineffective against COVID-19? No reusable masks are not ineffective.

It's a double negative. So let me say that differently.

And probably it's more simply reusable masks are effective against COVID-19. So you can take a mask, you can wash it and reuse it and, and it's effective.

Now, those masks I'm talking about are the ones that, you know, you and I might be wearing in the community uh separately.

There's of course N95 restr there's uh surgical masks, things like that that are used in the hospital setting. Spe specifically talking about N 90 fives.

There are studies that show that you can actually clean those and reuse those as well. So a simple example, you can take uh hydrogen peroxide or you can take heat or you can take UV light.

These are all different ways of potentially sterilizing masks and, and that's been tested. What seemed to be most effective was the hydrogen peroxide and the heat.

And so there are studies and protocols looking at how you can use heat or hydrogen peroxide to clean masks in the hospital setting so that healthcare workers can use them more than just once per shift.

Um Because that of course, is a, is a problem, we still have PPE shortages and by recycling and reusing these masks, it really helps.

OK. So what do you think is the best time to administer plasma therapy to a COVID patient let me just explain briefly what plasma therapy means.

It's essentially where person A has COVID, they mount an antibody response, meaning that their cells make antibodies. And again, sorry about the the noise here, the construction noise.

And then person B has COVID-19 and is struggling and suffering with it. And they are given those antibodies that came from person A that that antibody therapy is, is called plasma therapy.

And so when would you use that many hospitals across America are already using it for their sicker patients? Because of course, um in those settings where someone is sick and they're, they're not doing well, you want to basically give them every chance that you can.

And we know that plasma therapy seems to be effective in the, in the trials that have looked at it, it seems to be helpful.

Now, generally speaking, these trials are looking at plasma therapy in conjunction with, let's say remdesivir an antiviral or with dexamethasone, a steroid.

So it's hard to know like what is actually making the difference. But again, in these settings, you want to just give them every shot that you have.

And so that's why positive therapy has been used and is used uh to help patients that are generally not doing well. Can you explain if the DNA technology can help in making a COVID vaccine?

So there are lots of different ways that people have thought about making a COVID vaccine. Some is using DNA some is using MRNA at the end of the day.

Here's what most of the vaccine manufacturers are trying to do. You have a Coronavirus.

It looks like a circle and on the edges of that circle, on the outside are spike proteins. So they're trying to attack that spike protein somehow because that spike protein is basically what the virus is using to get into cells.

So they're trying to attack. It makes sense.

Now, how do you attack it? Well, typically what you're gonna wanna do is create an antibody response to that spike protein.

You wanna create some antibody that sticks to that spike protein so that the spike protein can't stick to your cells. So, so far, so good, you're basically just trying to interfere and a lot of the vaccines, what they're doing is they're saying, hey, maybe we can introduce some DNA somehow.

That helps to, that looks a little bit like that spike protein. So you mount a response to it.

Uh And let me, let me clarify that DNA that creates a protein that looks like that spike protein or maybe you introduce some Mrna that helps encode that spike protein.

So you can mount a response to it. So, however, you do it, whether it's DNA to RNA to protein or, or you start with the RNA and go directly to protein.

However you do it, you're trying to get eventually that protein so that your body can mount a response to it. And then can, when you see, you know that spike protein later on from the actual virus SARS COV two, you can mount a response to it.

So that's essentially how it works. Uh More questions here, are there any documented cases of contact surface or fomite transmission?

So there, so this is a hard one. There are studies looking at how people got COVID-19.

And it's hard to say that a person got COVID-19 from a surface instead what people are looking at for the most part because of course, you might say, well, do they get it from a surface or do they get it from a grocery store where someone sneezed on them?

How do you know exactly where they got it from? That's a hard question to, to actually answer.

And so instead what they're looking at is how long does the virus survive on objects? And so there are lots of studies looking at this now that have essentially answered that question and said, hey, it seems clear that SARS COV two, that virus lingers in the air for hours and it lingers on objects depending on the object.

Maybe cardboard is different from wood, is different from metal, different from plastic, but it lingers in the environment for days depending again on the surface.

And of course, it depends on how much you initially put there. So if you put a lot of virus there, of course, it's gonna last for longer whereas if you put just a little bit of virus, maybe it'll die out quicker.

So these are all things to consider. And the bottom line is that we don't actually, in most cases have the bandwidth or the, uh you know, the ability to know exactly where person a got it.

And so the best proxy we have right now is generally like in a house who's the first person I got sick. So that's where the studies are at.

And on that question, it seems clear that most households as of the data of now, uh got sick from an adult. So usually an adult brings into the house and then they get it spread to kids and other family members.

What seems um also clear is that kids don't seem to be the ones that typically introduce it to family members. And the reason that that's so important is that of course, nowadays, we're talking about opening up schools and if kids aren't the ones bringing at home, then that of course, makes you a little bit more comfortable in terms of opening up, at least the uh the younger kids, schools like K through eight or something like that.

So that's a piece of information. I always want to put out there to contextualize why, understanding who got it and how they got it can affect real policy decisions.

Uh All right. Do I think the vaccine will be available this year?

This is a loaded question because there is a vaccine out there. The the question is, is it gonna be mass distributed this year, this calendar year?

And I think the answer is no, I think they, that the vaccine will be mass distributed to everyday people in 2021 which is next year, not this year.

Uh any idea how medical residencies will adjust the process this upcoming match season. That's a good question.

And it, and it expands beyond just medical residencies. This is a question really for, for the nursing pipeline for every pipeline of healthcare trainees because you can't have a lapse in training because and that means you have a whole group of people that can't be out there taking care of patients and you can't allow that really because we're already at a deficit of healthcare workers.

So I'm not sure exactly how residencies are gonna do with this. I can tell you that a lot of education leaders are putting letters out there to hospitals and saying, hey, you really need to take our trainees because they are critical, not just for COVID-19, but in a post COVID-19 world, we're gonna need those people working and you can't have a gap in training.

Uh Another question can uh can I talk about anosmia ap peculiar symptom? So this is uh where people say they can't smell too well and this is a uh something that I think grabbed a lot of headlines and the real truth of this is that I think there's a lot of confusion about exactly what the cause is, is it that the virus is targeting the, you know, let's say the neurons that are involved in, you know, sensing smells, the olfactory bulb is kind of in the upper nose.

Uh Is that really what's happening? Uh or is it just general congestion, you know, oftentimes when you have any Coronavirus, any, any virus in general, uh you often lose your taste of sense, your sense of smell and your sense of taste.

It's not an unusual symptom, but it sounds unusual because people think it's permanent and all that kind of stuff. So I'll say at the moment, the mechanism around why you lose your smell with uh with SARS COV two is a little unclear.

Uh what is clear is that with a lot of viruses that cause stuffy noses, you do generally lose your sense of smell and with it, your sense of taste as well.

So it's, it's not that uncommon uh in general, why the cases decrease and then spike again. It's a great question.

I mean, what what I think uh it points to is that there was some behavior change. So it wasn't the virus that was changing, it was humanity and specifically in the US.

What happened is that I think in um April, we were as a country generally on the uh c shutting down or had shut down. And so you saw the flattening and then in May and in June, a lot of states started opening up and some states really never shut down if you're being honest, and people were still congregating in bars and clubs and beaches and in those settings, you saw it just take off again.

And when you get a critical number of people that are getting sick with it, let's say in Florida, for example, you see this, it really shoots off and the the bulk of the disease and disability and death frankly is happening in places like skilled nursing facilities.

But you have to pause and think, well, why is it getting there? It's getting there because people that are in those settings are having dinner with the, their grandkids or having lunch with their kids.

And those cohorts like the basically uh middle aged individuals or young adults are the ones that essentially were going out, spreading it, getting it asymptomatically and probably bringing it home to those really vulnerable people.

And that's why we're seeing so much uh death and, and disability from, from COVID-19. Um All right, let's see what the next question is.

I'm just wanting to be mindful of time here. Had they discovered what predisposes an individual to A R DS complications from COVID-19.

So A R DS is acute respiratory distress syndrome. And one thing I just want to kind of break down real quick is that this virus and we didn't know this months ago, this virus really affects two different organ systems.

It affects your lungs, which is what causes A R DS, which is where your lungs are failing. It also affects your blood vessels.

And because it affects your blood vessels, we're seeing people that are young, developing strokes, having uh young kids developing uh Kawasaki like illness.

This is really a blood vessel issue. And so because it's affecting those two different types of cells and two different types of tissues, we're seeing a whole lot of different complications from, from what you would expect if it was just A DS.

And it's unclear exactly why some people develop one pattern versus another. But the fact is because of those two big groups, the comorbidities are really becoming clear.

So things like diabetes, heart disease, lung disease, those are gonna set you up for both types of problems. And that's exactly what we see.

And of course, people that are elderly often have those problems and in the USA major predisposing condition is obesity.

So many people in the US are obese and that sets you up for problems with blood vessels and also pulmonary problems where they have sleep apnea and things like that.

So it really is a, is a mixed bag in terms of why this is happening. But those two different groups, again, blood vessels and lungs are the two categories where where COVID-19 causes uh kind of the bulk of its trouble.

Um as a doctor. How do you deal with individuals who don't believe COVID is serious and refuse to wear a mask.

You know, one of the things that we're noticing is that COVID-19 is um in many ways it's affecting sometimes the same city in very different ways.

So let's take San Francisco, for example, San Francisco is a very rich city, very, very rich city with, with millionaires and billionaires.

Uh there's also a lot of poverty in San Francisco. Tons and tons of folks are living on the streets homeless or intense.

So you've got two different worlds and COVID-19 affects those two worlds very differently. So in one world, you have a lot of uh wealth and with it privilege, people can work from home if they want to, they can uh order food in and they don't have to worry about exposing themselves.

Uh in the other group. You've got people that are essential workers, uh the poorer class, essential workers, people that have to phy physically show up to work.

They often live in large families because they have to or because they want to and all those things predispose that second group to COVID-19.

So you see these astronomical numbers, you know, people uh getting sick and, and and more and more deaths happening and in that same community, you'll have people come up and say, you know, I don't really don't think COVID is that serious because in their circle in their community, they're not seeing it.

Right. Because among their friends, maybe no one has it or, or no one really got that sick with it.

So, because of this, I think you have two different world views on what's happening and, and unfortunately, people just don't seem that effectively convinced by data.

Uh you know, numbers going up sometimes I think washes over people and, and you see that with the media and how it spins numbers too.

And of course, politicians prey on these two different worlds. They'll say to one group, one thing and to another group, another thing.

So I think what we have to do as physicians is, is do your best to use your um I guess society's reputation uh that it's given doctors uh to the best of your ability.

Uh Generally speaking, think doctors have thought of as scientists and really having a very science first approach on this is helpful.

I also think it's important to, to lead with feelings and not facts and recognize that when people think that COVID is not serious, you know, seek first to be understood uh as I said that backwards and that maybe it's AAA bit of a mistake, I apologize but seek first to understand and then to be understood, which is to say, really try to understand what people are saying, try to empathize with them and then say, OK, so I understand you don't think COVID is that serious.

Um How do you, how do you frame this in your mind like what, what is serious to you? What is the thing that matters and then try to see if they would be willing to listen as well.

So those are just some points that I've found to be useful. Um But it's a hard situation, especially when you see so many people that are, that are struggling with, with COVID-19.

Um Here we go. Let's see if I can do one last question.

Uh How accurate are the COVID test? What is the likelihood of a false negative?

So, generally speaking, I think the big concern is, is false negatives more than false positives because false negative means that the person is uh told they're negative and, and but it's false, right?

So in, in fact, they have COVID-19 and that's scary because that person might go home, get sicker and think, well, I already went once.

Why should I go again? Or I went once and I exposed myself in that, in that waiting room.

I definitely don't want to do that again or I went once and the test told me I don't have COVID. So why would I go back?

So there are a number of reasons why people might hear that news that they're, that they're negative and then believe it and then not come, not come back.

And that's worrisome, especially if they're gonna get sicker. It's also worrisome because they might say, oh, I don't have COVID.

So I can go to a dinner party or I can go to meet up with my friends and really expose other people. So there's two issues with a false negative is that it, it worsens their own chances, uh, of maybe getting sick or not getting care and also potentially it puts other people at risk if they think.

Oh, well, I don't have it so I can be a little cavalier and, and don't have to wear a mask or anything because I have proof that I don't have COVID.

So that's, that's really the concern. The percentage roughly is, is 70% sensitive.

So RT PCR testing me, it effectively is missing three and 10 people and it depends on which age group you're talking about what part of the body you're testing, but 30% of a miss rate is worrisome.

And I think that that doesn't get recorded enough. And it really again, depends on the test you're talking about.

It could be even higher than that. So that's the worry that I have with false negatives.

And if anyone is suspected to have COVID and if they have findings on, you know, CT or other, you know, kind of uh chest X ray findings or other things that are suggestive, I think it's really wise to assume they're COVID positive uh until you have confirmation that they're negative and that could be two negative samples.

It could be that you do a flu test and you find an alternate reason for their symptoms. There are different ways to kind of rule it out, but a single negative is really not, uh enough in cases of someone that's really severely ill.

So II see, there are other questions and I apologize for not getting to all of them. I tried to kind of spot check the ones that I thought were the ones that trended the most or that people had in common.

I do wanna say a few things. One is that if you're interested in this stuff, a lot of what we talked about just now is covered in our CM E course.

So we have a COVID-19 CM E course, it's free of charge. Go to our website uh osmosis.org/covid-19.

You'll see a link to our CM E course and pick up some free CM E. There's no harm in that.

So do that. There are questions there to make sure that you really understand the material, uh their notes as well as the videos.

So check that out. We also in general, if you're, if you're on the platform using osmosis for your studies, we have a sale happening right now.

50% off uh it ends Wednesday. So obviously, it's money.

You've got two more days. Take advantage of that sale again, half off until Wednesday.

So take advantage if you haven't done that, done that already. And then I mentioned the site, but I'll say it again.

Osmosis.org/covid-19. It's not just our CM E uh course, it's also a lot of other stuff, resources, videos, infographics, like things that you might find really interesting and you might find worth spreading.

So definitely take a look at that stuff and share it amongst your own circle of friends. And finally just remember this is a hard time and we have your back.

So if there's anything we can do, please reach out to us, we'd love to support you and your, your friends and family. So remember that we're here and do your part to flatten the curve and raise the line.

Be well, bye guys.