COVID-19: Ask Me Anything Open Forum with Rishi Desai, Md MPH

Hey guys, this is Doctor RHA Desai, chief medical officer here at osmosis. And I'm also a pediatric infectious disease doctor.

Um uh a few years back, I was working in the CDC doing outbreak investigations for viral diseases. I was one of uh the epidemic intelligence service officers.

And so they would send me to go and do outbreak research. So with COVID-19, it's really a um confluence a lot of my interests, you know, between disease outbreak where public health uh infectious diseases and education.

Uh this is uh really something that I care deeply about very personally. And so I'm doing these weekly AMA S or ask me anything sessions and what I want is to get the best questions from, from you all to try to make sure I understand kind of what's on your mind and give you my sense on uh tell you what's on my mind in terms of how I'm viewing this outbreak.

I'm here in Oakland, California and it Thursday um kind of March 19th. Now we're seeing the cases rise in the US.

We understand, I think day by day uh on the ground how serious this is. We're seeing the uh the cases come into the hospitals and I think more and more efforts are underway to kind of manage this uh in my own county, Alameda County, they've shut it down in the sense of uh there are travel restrictions, work restrictions.

Um There are uh limitations on what businesses can be open. And so I'm feeling firsthand kind of the effects of that.

We've got daycare closures. So I've got my three year old son at home now and so I'm gonna just quickly start going through the livestream for the next 20 minutes, grabbing questions and answering them.

So, um, symptoms of COVID-19, uh fever, cough, shortness of breath are the main ones. Uh you can see other symptoms, it can be more mild things like runny nose, uh fatigue, it can cause gi symptoms as well.

So those are the kinds of things that people typically talk about. Uh And if you're having s kind of mild symptoms, uh you should monitor them, make sure they're not getting worse, the temperatures are not getting higher, the shortness of breath is not getting more severe.

Uh Next question, should you store some food if you're in a situation where you should be quarantining or if you're isolating, you know, because you're sick.

Um It definitely is a good idea to have a couple of weeks of food. That's the recommendation.

Um, the uh key uh stores are all open. So even when, uh you know, countries put uh draconian measures in place.

Grocery stores are open pharmacies are open Police Department, uh Fire Department and those supply lines are prioritized.

So you can supply, you know, yourself with food um staples, you know, things like beans and rice and, and whatnot. But, but you can certainly kind of go to the grocery store and get more.

Uh tell us about the vaccine. The uh so currently there is no vaccine available for uh the public.

Uh There are vaccines in clinical trials. Uh One is an Mrna vaccine that's in uh phase one trials.

There are a couple of other vaccines out there around the world that are also being tested out. But again, they're all in trial stages, there's nothing that's available publicly.

Um What do you think about people buying infinite toilet paper? Um II think it's unnecessary.

Uh II really think that that sort of level of panic is, is unhelpful. Um In this case of toilet paper, it kind of causes like other people to obviously run out.

Um And in that sense, it is uh a problem because if you're, let's say an older person, uh you have um you know, you're, you're homebound and you need to get a little bit of toilet paper, it can be disconcerting if you don't have any at all.

So really, these are the kind of public goods we need to be uh resourcing more equally and you can do your part by not hoarding.

Uh you know, it's just not needed. Um Next question, what do we do as students to help out the situation?

It really depends on the level of student. I mean, uh one of the things that they were doing in China, which, you know, a big report just came out of China yesterday.

Uh on kind of it was a 4050 page document on things that people can do. One thing that students were doing there was they were monitoring healthcare professionals to make sure that they were wearing PPE correctly.

Remember even one person, one healthcare professional with um uh a break in their PPE they go down, they get sick, then everybody, they were around all of the folks that they were working with having lunch with dinner with um sometimes their partners, significant other, all those people get quarantined, right?

So you can have a whole emergency department. Let's say it's staffed by 30 people.

You could easily imagine a scenario where 1520 people are quarantined. Now you're left with just 10 people.

So students can do things like making sure that people are wearing pp correctly doing checklists for protocols saying OK.

Did you use the, you know, uh hand sanitizer three times? Did you button up properly?

Did you wear your mask correctly? Did you do all those things?

Um Also hospitals in some areas are screening patients and visitors as they come in. So you could do that sort of work where you're screening people for symptoms for, um, you know, checking with a thermometer if they have a fever.

So that's something a student could easily do as well. How does the virus spread on surfaces?

This has been big in the news, uh essentially think about surfaces as uh there's a word called fomite. Fomite is just kind of an environmental object.

So it could be metal or cardboard or uh you know, wood, it survives differently depending on the foam surface. Um There are cleaning agents you can use to clean those surfaces.

And the recommendation is to clean uh surfaces daily. Typically the surfaces you worry about are the hard surfaces.

So what they call nonporous surfaces. So it would be like a a cellphone, uh door fab uh handles things like that.

So those are the ones that are most uh worrisome. I apologize a little construction in the background there.

Um And the ones that are less worrisome would be soft fomites or porous fomites, things like pillows, blankets, uh towels, those ii, you know, the virus doesn't typically transfer off of those nearly as easily.

Um It also can uh survive in the air itself for a few hours. So also keep that in mind.

Um Does Coronavirus prevalence decrease in hotter climates? Well, there is some evidence around this that the the virus doesn't survive as well on uh on objects when it's warmer and when it's more humid.

So there is some evidence to suggest that a hotter climate, maybe it wouldn't do as well. A lot of that science and research is really based on other Coronavirus strains, not COVID-19, uh which is caused by SARS COV two.

So that data is a little bit um squishy in the sense that it's not exactly the virus we're dealing with, it's kind of relative or related viruses.

Um We also don't know whether that really is gonna be relevant here because it's a pandemic. We've got hemispheres, right.

So what's happening in one hemisphere where it warms up in the other hemisphere, it might be cool, you know, cooling down.

Um What's the best test for COVID-19 at the moment? The gold standard is RT PCR from a nasopharyngeal swab.

So that basically means you take a swab and you put it kind of through your nail all the way to the back of the nose and uh near the pharynx and kind of get as many cells as you can get.

So obviously, if you're detecting it, you need to get cells and get a good swab. So that's how you would, you know, try to detect it using RT PCR.

There's also other ways to look for suspicion for COVID-19. So for example, if you have a negative RT PCR, which actually can happen early in disease, the per the sensitivity of the test is not very high.

So it's maybe as low as 30 to 70% in those settings, you can look for evidence on CT or even on chest X ray. Typically ground glass opacities.

You can see consolidations. There's a, a finding called Crazy Paving.

So there are some classic CT findings you can look for to help diagnose COVID-19. We actually have a video dropping on that topic uh very soon.

Are there any home testing kits yet? Uh home testing kits, are, it looks like they're on the way.

There are, uh, companies out there that have done a call for this. And, um, I'm getting more and more questions about home testing kits.

Basically, a home testing kit is a swab. So you basically get a swab, you swab yourself and you send it out to a lab, uh, to get tested.

And so they're still doing RT PCR. It's the same mechanism.

It's just rather than driving down to the hospital for them to swab you, you can do it at home and mail it in. So that's, that's on the way.

I think that will likely come in the coming weeks when, um, will treatment be available. What's the latest news?

There are treatments that are being looked at, you know, kind of right now in the news, I would say the biggest two would be remdesivir.

Uh That was very, very talked about, you know, let's say last week, this week, more and more data on you kind of, uh, Chloroquine or Hydrochloroquine.

These are drugs that were used in other viruses. So for example, um for Ebola with red desir and Chloroquine is a, is a very famous antimalarial.

They've been used for a long time, especially Chloroquine, it's been used for decades. So the safety is there, right?

We feel very safe with that drug. Um but the efficacy in humans is unclear so that they're in phase two and phase three trials to kind of see how they suss out.

I think that those will likely be available and the FDA is kind of pushing to get it done as quick as possible. Of course.

So I think those will likely be available. Um In the coming months, I will say that in extreme cases on a compassionate care protocol, you can actually get uh remdesivir uh already.

So that's that's available. Um How about asymptomatic transmission?

How does that happen? Um with, with this disease, it was earlier on in the disease.

It was thought that it was mostly kind of symptomatic people that were spreading it more and more data suggest that we're seeing presymptomatic and asymptomatic people transmitting it.

What does that mean? Presymptomatic is basically within the first five days.

If you think the median incubation is five days in those five days, while, while you haven't had a chance to have symptoms, you might be already spreading it.

So you may not look like you have symptoms, you might feel fine, but you're already kind of harboring the virus viral levels are rising maybe in your nose and you're spreading it.

And so that's already happening. We think that that's a big deal and a bigger deal than we certainly thought maybe a, a few weeks ago.

Um What is the reason behind Italy's increased caseload of COVID-19? It's very clear what has happened in the sense that you, you see two patterns, Italy has now surpassed um China uh in terms of the burden of disease, Italy has done, I think now has done the right thing with putting draconian measures in place to prevent um spread of the disease in the community.

That's all about flattening the curve, the other half of this. And what I wanna kind of impart with you all is this idea of sort of raising the line.

And what I mean by raising the line is if you've seen these graphs where there's a curve, there's a line, there are things we can do to raise that line, that healthcare capacity line.

Italy has this problem because they're seeing this massive number of cases that have, you know, kind of festered and grown in the community and their healthcare system is completely overwhelmed, completely, completely overwhelmed.

So they're seeing high mortality rates, lots and lots of disease that um now frankly, it is kind of overwhelming local hospitals.

Sometimes in some cases, they may be running out of ventilators or echo machines. And so it's a major problem and I think other countries can learn from watching that.

Uh that, that we really just don't want to get close to that with dealing with that many cases. So we really need to reduce and flatten the curve and also put measures in place to raise the line.

Uh How do you know your immune system is strong enough? That's a great question.

It's uh it's gonna be mostly monitoring symptoms if you are kind of healthy with no comorbid illness. If you're younger, uh younger than 60 you're in a lower risk stratification.

So at that point, you can watch yourself at home, make sure you're still eating, drinking, sleeping, you know, getting rest, staying hydrated.

If you're doing all those things, then essentially you should start seeing improvement in your symptoms. If those symptoms are getting worse and worse, specifically shortness of breath coughing much more.

You know, your fevers are going up, that's when it's time to call in and get help for the high-risk people. You should have a much lower threshold for just calling and getting help immediately and getting guidance from your, your physician about, you know what to do.

Um, incubation time median is five days, but there is some data that some people kind of have longer incubation as long as 24 days.

But generally speaking, it's now pretty clear that's uh it's about five days. What I will say about that is that there's also something called the serial interval time, which is kind of when you have one wave of people getting sick, when does the next wave happen?

And it seems like the serial interval time is actually less than five days. And what that tells you is that in general, on average, what we're noticing is that the incubation time may be five days.

But if the, but if the serial interval is less than that, then pre-symptomatic people are probably a big part of the spread of the disease.

Um What do you think can be done to impress upon people, the importance of social distancing right now? I think frankly, you just look at two examples, look at Italy, look at China.

China has more imported cases of COVID-19 right now than domestic cases. They're really locking down their borders and quarantining people that come into China because they don't want to have to deal with more COVID-19.

They basically had enough. Um They got over the worst of it within two weeks and they did that by basically putting down mandated federally mandated restrictions on movement.

They, they required it Italy. On the other hand, took a long time to kind of get to that point, they sort of hemmed and Hawed and hemmed and Hawed and finally got to the point where they said, ok, you know, we have to just do the same draconian measures here.

Um And that longer period of time is why you're seeing the, the much worse outcomes in Italy right now And so if they had been much more aggressive with draconian measures, I think this wouldn't be the case.

And having seen this now, I think the US and many countries around the world can learn from that and say, hey, we probably need to put this sort of measure in place right away to shut it down and we can always relax restrictions when we feel better about it.

But right now, nobody should be feeling better about the situation. Um Is it true that the treatment uh treatment on the stage of uh that question is a little hard to follow.

Um Can you explain what the factors for developing severe pneumonia in uh patients that are immune competent and with no medical history of using NSAIDS.

Uh 22 important points are NSAID s right now are being discussed. Uh The French Ministry of Health said, hey, you know, I think that there uh we shouldn't be using these.

Um There's a lot of uh debate about exactly whether the risk is higher with nsaids, the who has come out and said, hey, let's stop the use of Ibuprofen for, for fever and, and pain.

So instead using acetaminophen. So that is the current guidelines.

Um in terms of what happens with severe pneumonia, what what fundamentally is happening is that you're getting this, this powerful cytokine release uh as your immune cells are kind of coming to fight the virus, those cytokines are causing inflammation that inflammation makes the blood vessels around the alveoli leaky fluid goes into the alveoli.

Now, what should be full of air is full of fluid and gas can't get across and when gasses can't get across, you feel short of breath.

And so that's essentially what's happening to cause that. The extreme of that is A R DS acute respiratory distress syndrome.

And when you start seeing A R DS and severe A R DS, what you need to manage that is ventilators and Ecma. So that's kind of what's happening.

Um Next question, can a mask actually protect your face. This is really the crux of it.

We're seeing uh across the world shortage of really adequate PPE or pro you know, personal protective equipment and a big part of that is how to protect your T zone, your eyes, your nose and your mouth.

Remember if you can unprotected something. Uh let's say you, you, you didn't have a knee protector, you know, it's not like the virus lands on the knee and marches up to your nose, right?

So, so really the area to protect is the face. That's the key area.

And for that face, you need an N95 mask. If you're a healthcare worker, a surgical mask does not protect you against this virus.

And so that's what's recommended in high um risk settings. Now, the there is the truth that many hospitals simply don't have N 90 fives and that is a um political and manufacturing issue.

Uh, we need to get more healthcare workers are running out to, you get painting supplies, stores, you know, or construction masks.

Um, you know, and trying to maybe buy their own, uh, Pampers pap is one of the personal air purifying filters, kind of the machine that's on your hip and a hose that's hooked up, um, to a body suit.

So people are doing all these things to kind of protect themselves. And I think that spirit is right.

We need to protect ourselves as much as possible. Um, because otherwise if you have one healthcare worker go down, many could go down instead.

Um, do you think the flu season should have a large response? And so many people are dying considering how many people are reacting to, uh, COVID-19.

So it's a good question. We're in the middle of flu.

It is gonna be country to country in terms of how much of this disease we're seeing that's not really being tested for, is really flu versus is really COVID-19.

And, and I think we'll, we'll probably have a lot of, um, mathematical models that'll help figure that out for us in retrospect.

But I think at the moment when you don't know if you have the flu or COVID-19 and you have mild cases of that they're largely treated the same, you know, once you go into the hospital setting and they do rapid flu testing or, you know, rest viral panel testing they can distinguish, is it flu or is it COVID-19?

Um But before that, you're basically managing it the exact same way. So again, if you have mild symptoms, that's why I say, I think it's fine to manage it at home.

Um ok. Next question, are there positive COVID-19 cases in kids?

Definitely there are kids do very, very well in general against COVID-19. It's unclear exactly why that's the case.

And so I think there again, there's gonna be research in, uh as we look back on this into that, but really, in the 0 to 18 category, the risk is quite small, um really on par with, with the flu.

Um, it, it, it is a little higher but, but it's really on par with the flu. So that's, that's what I'll say.

Um What do I think is gonna happen over the next 6 to 9 months? It really depends on what kind of country you're talking about.

If you're in a country or if you're in a country where they're putting down strict measures today, then I would say, you know, depending on how much disease is already circulating.

You're looking at a good outcome probably in a month, month and a half, you'll start seeing the cases go down. Uh if you're in a country that's not doing those things where it's still kind of left up to the local municipality or the local county and one county is doing this and another county is doing that.

Then I think you're in for a long haul. You're, you're basically gonna eventually probably need the same measures, but maybe instead of six weeks or eight weeks, you're looking at three months, four months of kind of these strict measures.

That's my best guess based on what we're seeing today. And the other piece of this is that, of course, this is the, the healthcare ramifications in terms of loss of lives and loss of health.

There's also economic ramifications that the longer you let something like this last, you've got a chance for a recession and you know, our world is tightly interconnected.

So having one large economy go down into a recession can easily spiral the global economy. And so I think leaders around the world recognize this and recognize that the decisions that they make in their country really does affect every other country as well.

So we need to act as a team as we kind of try to combat this. Um All right.

So is, let's see, how much time would it take to make the vaccines available throughout the world? Um If the results of uh vaccine are favorable.

So vaccines are in trials, we're seeing that, you know, the um that the studies are, are, are just starting frankly. If those turn out to be safe, there's usually a safety step and then an efficacy step.

If they turn out to be safe, then I think the next thing would be to figure out kind of global production of this. And typically what happens is that you have some sort of public private partnership.

Um There is something called GV, which is a global alliance for vaccine initiatives that, that has a lot of this infrastructure in place.

So what you're, what you'll likely see is that current um partners are gonna have to basically take what they're doing in terms of routine vaccination and help to uh transition or pivot that into COVID-19, uh disease vaccination.

So that's really what's gonna happen. Um OK, another question, I just read that certain blood groups are more susceptible to COVID-19.

How true is that I actually came across that as well. Um These kind of stories, I think uh kind of populate all, all of our feeds at the same time.

Um There, so I'm not sure it is a quick answer. I haven't read the research on that.

I think it's fair to say that at this point, any sort of um blood group analysis would probably be uh unlikely to change any sort of guidance in terms of what they would recommend.

So maybe in retrospect, we'll say, oh, you know, this group was slightly more susceptible than that, but at this time, it's clear that many, many people are getting sus are getting sick.

People of all blood groups are getting sick from this disease and if there is some marginal difference in risk, um that that would be an interesting uh I think research angle and maybe even something in terms of treatment.

Um but it remains to be seen if that's gonna be clinically relevant today. Uh If you're already sick with it.

Um Let's see, are there any super carriers? This idea of a supercarrier?

A super spreader is another word is that some people spread the disease much more than others. Uh Certainly people that are in contact with a lot of people are gonna spread it to many more people.

So that makes sense. Um So I think that that's true.

Um I think the the other issue is there might be people that for whatever reason, have more secretions and so whenever a virus kind of gets into their system, they kind of over secrete and get it out.

So I think that's another piece to, to consider in terms of why people are super spreaders. Um Next question is testing free in the United States.

I have no insurance. There are cost considerations.

I think we're gonna see this as another moving target just like um you know, the economic stimulus package. I think there's gonna be a lot of movement in terms of how we pay for this.

So we're gonna start seeing much more in the way of free testing. There's gonna be a, a demand for uh free ambulance rides, free testing kits that are sent to your home, free telehealth that's associated with the testing kit uh free care.

Let's say you, you end up being very sick, free end to end care. So you can go to the hospital, get cared for and come home and, and have that kind of completely uh covered free physical therapy afterwards.

Can, you know, keep in mind the disease doesn't just kill i in the, in the number of people that causes pulmonary fibrosis.

And that's uh that's potentially a lifelong thing that you carry with you. So all these things have costs associated with them.

So I think that we'll see uh quick changes in terms of uh how we actually manage this going forward. Um Will the usu 3rd and 4th year medical students take care of patients when staff begin to call out due to sickness?

Great question. This goes back to raising the line.

What are the different ways you can raise the line? Well, let's say you're a 3rd and 4th year medical student, uh you're already in the clinical setting.

Can you help out? Absolutely, you already do.

So, uh I can definitely see a a scenario which 3rd and 4th year medical students are asked to be working on COVID-19 floors, you know, very, very likely we're gonna have full floors of hospitals that are gonna be taking care of COVID-19 patients and, and you may not be doing rotations through kind of, let's say uh other fields like optometry or your, your fourth year electives, you might just be working COVID-19.

Um There's also uh doctors that have retired. I actually talked to uh uh one of my mentors yesterday.

He's going back to uh our hospital to start working again. So you're gonna call out old attendings that are very experienced that are gonna go back and start working.

You also have people that are gonna be quarantined very soon. So if you have a, a case in your, er, and you get quarantined, well, you feel well, but you're quarantined because you might have COVID.

So those people are all gonna get probably transition to things like telemedicine. So immediately you're gonna start ramping up Temed.

You also, you might have an international collaboration, you might have countries that are coming out of it, let's say China and South Korea where they have physicians that have a lot of experience with COVID-19 doing telemedicine consultation with the doctors in the US that don't have much experience of COVID-19.

So you're gonna see a lot of uh care and that's just, that's just doctors. Uh I'm not even talking about all the other areas.

You know, we have N PSP A S uh we're probably gonna see lots and lots of uh technicians coming through um that are kind of large cohorts of people that we have to train up faster.

So those are all the ways that I think we're gonna raise the line um to, to handle this uh crisis that's on your hands. Um is reinfection uh possible.

Is it as severe as the first infection? There's no real evidence that reinfection with COVID-19 really happens.

The thought is that typically once you recover, you recover, uh if in theory, you could find someone that and I'm sure you'll get reported on that, you could get someone that might have evidence of, of having reinfection of some sort.

Uh Keeping in mind that COVID-19 is caused by SARS COV two, but that's a cluster of viruses, not just one, you might possibly get kind of one virus versus another virus.

Uh That is theoretically possible, but I think that in i in the grand scheme of things, that's gonna be a very small part of this.

Um Here we got a question about walking outdoors. Is it safe?

Uh even with sheltering at home. So I'm, I'm in this scenario where I'm sheltering at home right now and I take my three year old son to the park.

I took him yesterday. It is safe to go.

The idea is anyone you spend outdoors time with should be the same people you're spending indoors time with. So if I'm taking care of my three year old son in the house, we're at no more risk if the two of us are walking around outside.

Now, what I didn't do is I didn't let him go to the jungle gym to touch the jungle gym. You know, I don't want him touching objects out there that other kids may wanna play with later in the day.

So we just kind of played in the grass, um, with our dog. So that's kind of the idea.

Those are the things that I think are safe. I wouldn't, um, kind of, uh, try, try those kinds of things.

Um, uh, meaning touching objects and, and playing with, playing around with uh, stuff other people would touch. Um, all right.

One last question, I've heard that eki O and ventilation survival rates are low. Many people are dying from cardiac consequences like myocarditis, acute cardiomyopathy.

Is there anything we can do about this? Well, uh this is widely reported.

Uh I've heard the same exact thing. Um What I will say is that and, and one thing I'll add to this is that I'm getting reports uh from a number of emergency medicine physicians that I talked to that we're seeing even younger people, uh people in their forties, fifties that are being uh intubated and ventilated uh for COVID-19.

So this idea that the risk is higher for 60 above. That's true.

But I don't want to discount the fact that even healthy younger people are getting sick. So, you know, the the idea that ventilation survival rates are low in a sense, it's kind of a double edged sword.

By the time you get need ventilation echo, you're already in a pretty dire situation. So that's not surprising.

I think the thing that is interesting. Um in terms of how to turn the tide on this is, you know, cardiac consequences.

Is that real? And how real is that, you know, are we seeing widespread cases of myocarditis?

Are there treatments for the myocarditis, as you might know, viral? My myocarditis is famously caused by virus.

And so in that setting, we use IV IG, we do have other treatments for cardiac consequences. And so there might be a need for the, the community to step up and give blood or give serum.

Uh If, if these are the treatments that we end up finding out are the ones that actually work. So there are a lot of questions still pouring in.

I do wanna take just a couple of quick minutes to um mention some things again, we're gonna be doing this week on week. Please keep submitting questions.

I'm trying to answer them as fast as possible. We actually have a huge uh page of resources, COVID-19 resources uh set up both for the general public uh as well as for healthcare practitioners.

We just put up a ACM E course uh to train you up on what you need to know as a healthcare worker. We're also putting up uh some uh fact sheets on what medications work, what the studies show, you know, things like that.

So we can dive in more deeply again. We're gonna be back here next week between now and then.

Um I also wanna kind of plug uh taking care of your mental and physical health, which is gonna be an excellent uh live yoga session happening on Saturday.

Uh So please join us for that. And then before we wrap up, I wanna say uh a special shout out to our med students who are in the midst of match week.

Uh This is uh a crazy time to be matching. Uh But I wanna say, you know, uh we love to share your Match Day celebrations.

Be sure to tag us on social media. We'd be happy to share those and finally we're here to have you back and you know, if there's any way we can be more helpful to you, please let us know.

But with that be well take care.