Live Ask-Me-Anything with Rishi Desai, MD, MPH: COVID-19
Hey guys, this is Doctor Rsai from osmosis. I'm the chief medical officer and I wanted to talk to you because of my background.
I'm an infectious disease specialist. I uh did pediatric infectious disease and then took a turn in my career and worked at the C DCI was at the division of viral diseases.
And um my role there was that I would actually go out, they would uh have me work on investigating outbreaks. So kind of like COVID-19, other outbreaks uh of viral diseases.
And so that's what I focused on. And so for, for me, COVID-19 is a confidence of a lot of my personal interests and also is a public health issue that obviously is raging right now.
So, you know, ii infectious diseases, public health outbreaks, um education uh health, you know, all these kind of things are, are really what I care about.
And so this is very personal to me and I want to make sure we got really good information out there to make sure that we aren't um kind of overreacting to this or under reacting to this.
But but really reacting, I think in, in, in the best possible way which is to be aware of the facts and not um and not kind of getting misled by, by uh missteps.
So that's the the premise, what I wanted to do is also just point out that we will be answering questions. The, the whole point of this is to make this as interactive as possible.
We got tons of questions already. So I actually framed up a bunch of uh answers for questions that I've already received.
But if I see a bunch of questions or if you have a follow up on a question, please post it. We're gonna try to address that and stay really closely connected with us because we're gonna be dropping others.
I'm gonna mention a couple already um to give those kind of good pieces of knowledge that, that you need right now to feel comfortable, feel like you're fully armed and ready to, to tackle this and, you know, kind of manage this and meet it, you know, head on.
So that's the idea I wanna make sure that you uh engage as much as possible and I'll try to be do my best to, to answer all the questions.
So uh with no further ado I um wanted to jump in with just some background information. So COVID-19, we know started back in December of 2019.
So it's been around for three months or so. All of the data we have is, is really just for this three months.
So we don't have the full picture yet and this will come up a few times in my presentation in terms of the data we're looking at.
So, uh let's start with the, um, the, the hard numbers, wh O reports that we've had, we have currently about 98,000 people that have been diagnosed with COVID-19, uh of those 3400 have died.
And so that's where they get this mortality rate of 3.4%. Uh It's not mentioned much, but about 54,000 people have recovered.
So they've gotten COVID-19 and now they're on the other end of it where they're feeling better and feeling kind of back to normal again, those are just some quick card numbers.
What we're seeing, at least what I'm seeing on the ground here is schools are wondering, you know, what, when do we need to decide if we need to shut down?
Um, employers are wondering what they need to do to uh help deal with the fact that many employees are staying at home, uh don't want to come to work, can't come to work.
Uh And some of that is because those employees are taking care of dependents, right. So, um many of the, many of those employees have kids in daycare and if those kids aren't able to go to school because the daycare shut now the employer can't, or the employee can't go to, to work.
And so it's kind of the domino effect that's happening. Uh And we're also seeing conferences shut down, travel is shutting down.
So all across the board, you're seeing society affected in lots and lots of different ways. And then you see all this nefarious activity too.
So you see hoarding of face masks and food. And on the flip side, you see people saying, well, if you're gonna hoard, we're gonna price gouge you.
We're just gonna jack up the prices, make it harder for others to get these uh very neces, you know, needed items during this, this outbreak.
So these are all the, the things that we're seeing on the ground right now. And in this context, we've gotten a lot of questions.
So I just wanna again, say, I've tried to organize these questions as best as possible. But if I don't answer something specific, please come back to me and say, hey, you know what about such and such?
So starting out, what is the case fatality? This is the first question.
What is the case fatality rate? I'm hearing lots of different numbers.
Great question. So the case fatality rate according to the wh O is 3.4%.
And I mentioned the numbers, right? So the numerator, the top number is the number of people that have died.
It's a really easy number to be concrete about because you can count the dead bodies. And you can say, look, there are about 3400 dead bodies that.
We see, that's the numerator. You're probably not missing a lot.
The denominator is where things get really squishy and that's why different people have different estimates on the case fatality rate.
The official rate is, well, how many people have been diagnosed? And on that basis, we've diagnosed about 98,000 people.
So if you just do the math, 3400 into 30 into 98,000 is roughly 3.4%. So that's the wh O number, that's where they're getting it from.
But here's the big thing with this outbreak and many outbreaks is that early on in an outbreak, what happens? You test the people that are severely sick, right?
You're not going out and testing random people on the street for this disease. Why would you do that?
And so if that's the case, you're missing a lot of people that actually do have COVID-19, but maybe they're asymptomatic or maybe they're so mildly ill, they don't even think about it.
Maybe they thought, oh, it's just a runny nose, but actually they had COVID-19. So if you start testing more in all likelihood, you would find a lot more.
And if you found more that denominator gets big and that whole percentage falls. So in South Korea where they've done an incredible job of testing, they've done these kind of mobile clinics that are set up to test people while they're driving, they've literally blanketed everyone with PCR tests.
They found a case fatality rate of 0.6% 0.6. So far lower than 3.4%.
And this is where they're testing everybody. The Diamond Prince Princess cruise ship where it's kind of a trapped population, you're testing everybody there.
The case fatality rate was 0.9%. So again, it's a little higher than South Korea, but it kind of in the ballpark, both those numbers are below 1%.
So this is why people are saying, oh, you know, we think that the case fatality rate is closer to one or below one. That's what it's based on.
But again, technically, it's, you know, if you actually go by the official data, it's 3.4% comparing this to flu flu is about 0.1%.
So even if this is kind of me playing devil's advocate here, even if the case fatality rate was, let's say 0.6 or 0.9 that's still 6 to 9 times bigger than the regular flu in terms of fatality.
So it's still a pretty serious illness. But I just wanna point that out is that that's why these numbers are varying so much.
So. Great question.
Next question, what is the are not? Um And the, and the person obviously knows a little bit about this because they say if it's over two, which it is, then how come we're seeing fewer cases out of China?
Now think about this, if you're saying or not, is two. That means that it's doubling right, one goes to 22, goes to 44 goes to eight.
If that's the R not, then how would we ever uh see that the numbers are going down, which they are in China? Well, this is a, this is basically understanding what Arnott means.
Arnat is kind of the natural state of the virus or, or any pathogen. So measles, the natural state is kind of an RNA of 12 to 18.
1 person has measles. Let's I have measles.
That means that person on the other side of the room is likely to get measles. It's just very, very easily transmitted.
So, but but not everyone in the globe has measles, right? Like that would have happened many, many uh centuries ago if that was the case, that has not happened because of the fact that we have other methods of of kind of combating that.
So, um you know, for example, quarantine contact, tracing good hygiene, washing your hands, not touching your face, making sure the sick people basically stay away from the healthy people.
And also people get over the disease and then they are now no longer susceptible, right? So they become immune.
So once you're immune, you're no longer susceptible to the disease and now you're kind of over it. So this is what we have to think about is that it is pretty transmissible or not of 2.3 compared to flu, which is kind of like 1.3.
It's, it's quite, quite transmissible, right, by comparison. But again, there are things you can do to combat that.
And that's what we saw in China is that China basically uh very draconian but kind of shut down entire cities and said, hey, you know, we're gonna keep people very, very separated here to combat.
This are not at 2.3. So that's, that's the reason next question, what's the incubation period?
All right. So um this is the period of time between, you know, you getting a sickness and you getting the symptoms.
It's about five days median. We've seen data points up to 24 days.
So it, it could be quite extreme. The CDC and wh O has set kind of settled on four, 14 days being what they think is the abundance of caution.
They said, hey, watch people for 14 days if within 14 days, they don't, they still don't have symptoms. We think they're unlikely to develop symptoms.
Let's let them kind of go home. So that's kind of one thing to be aware of is that that number is um is based on that.
Um Next question, how is COVID-19 different from the flu? So we mentioned a couple of things are not mortality rate, uh are not as higher for COVID-19, 2.3 versus 1.3 mortality rate for COVID-19.
Reportedly 3.4%. That's kind of a ceiling likely lower than that.
Uh flu quite low compared to that. It's 0.1%.
Um The Spanish flu from uh 100 years ago had a higher mortality rate. That one was thought to be closer to 2%.
Um Another difference is the burden of disease we have right now. So, uh for COVID-19, it's about 500,000 global deaths massive uh for COVID-19, globally, we're seeing again, 3400 that have died.
We have some that are one that's kind of just starting trials that's not gonna come out until 2021. Um treatment we have for flu.
Sulfair works pretty well. Uh For COVID-19, we have one again in clinical trials.
Uh this one's phase three remdesivir. So remdesivir is being tried out in Nebraska.
There are a couple of large trials in China, but again, it's in clinical trials, it has been used for compassionate care use.
Uh meaning in one off cases where someone's really sick, they have used it and it's been effective. So that's one thing to just be aware of, but again, not kind of available, not easily, uh not, not as well understood as oseltamivir All right.
Next question, what's the difference between COVID-19 and recent previous outbreaks? Great.
So let's talk about those. SARS and MERS are the recent Coronavirus outbreak.
So 10 times 12 times more, um SARS was at 10% mortality rate and that was at the end of it when we kind of had wrapped up everything and figured out kind of at the end of the day, what do we believe?
10% mortality or there about for COVID-19, it's three per 3.4%. And as I mentioned earlier, it might be lower than that.
MERS was actually even more uh extreme. It affected far fewer people, 2500 people.
Um, whereas the mortality was 34%. So 10 times the mortality rate of COVID-19.
So, what you're seeing here is that SARS and MERS both affected far fewer people but were much, much more um dangerous in terms of if you got them, the mortality rate was much higher.
Uh And one thing to note here is that coronaviruses are gonna keep coming through. So bats or the reservoir, uh there are interactions between bats and other animals, uh like civet cats and um, you know, uh camels for MERS and then for this one Pangolins.
But there are other, these kind of animals that then transfer them to humans. In other cases.
Sometimes humans just get them directly from bats too. So this is likely to happen again.
And it, it's happened again twice already in the last or three times. Now, in the last 20 years, it's gonna happen again.
And we just have to recognize when it starts happening, how to, to quickly, uh, squash it. So it doesn't kind of explode the way this one has.
Uh, next question, what percent of people getting this virus will develop serious disease? So, a great study came out last week, it said basically 20% get serious disease.
Now again, with what I said earlier, that's in the context of limited testing, right? So as we test more and more and more people, just like the mortality rate is gonna fall, this percentage of like serious disease is also gonna fall.
So 20% I would say aga again is kind of a ceiling number. It's likely to be much lower.
And a lot of that is among the elderly, a lot of that serious disease is happening in the elderly population, not to say it can happen in other groups, but that's where it's mostly happening.
Um where there is an interesting wrinkle. What kind of want to uh focus your attention on is uh where you got a big inoculum, right?
So when I say inoculum, what I mean is lots and lots of secretions full of virus versus a little bit of a secretion full of just a little bit of virus.
And I'm right in their face and let's say I'm not wearing my n95 mask because it's soiled or I forgot to put on or I'm in a rush and then I'm kind of face to face and that person just kind of coughs or sneezes or gags and all of a sudden I get in my face kind of a shower of of these, of these particles full of virus.
That's a large inoculum. Compare that to me being at a conference and me grabbing AAA handle on a restroom and maybe someone had forgotten to fully wash their hands and they, and they got some virus on that, on that handle.
That's a small inoculum. So these are the two different inoculum.
What we know from the data is that when you get a large inoculum, you get sicker. And so the people at risk, I mentioned the elderly, but the other group at risk for serious disease are healthcare workers cause they're with the sickest patients and the sickest patients, patients tend to have the highest amounts of virus.
So that's just one thing to kind of keep in mind, what should I do if I develop symptoms? So if you develop symptoms and you're, let's say in the community, um and you get a little runny nose and then all of a sudden two days later you're coughing and you have a fever and again, a fever would be, you know, anything, 100.4 °F or 38 °C or higher.
So, those are the cutoffs. So, let's say you get a fever, you're coughing a bit.
Um The first thing to do is self quarantine. That means stay in, in your home, uh protect your household contact.
You know, you don't want your, your significant other kids or your parents to get ill as well. That means putting on a surgical mask.
That's where the mask is very useful. It's for people that are sick.
Um And make sure that you at that point, right. When you first get sick, you don't run to the hospital or the clinic.
That's the last thing you wanna do, right? So there's a good chance you might have something else.
So the last thing you wanna do is just immediately run to the hospital. What you wanna do is self quarantine.
Are you coughing more or less? Is the chest pain, more or less track all this stuff?
And if things are going the right way, like you're getting better, great, good, good job, you know. Um That's perfect.
That's what we wanna see if it's going the wrong way and you're getting sicker, maybe you're lethargic. You're, you're, you're not, um, uh, you know, feeling well, the cough is just so severe, so much chest pain.
That's when you pick up the phone and you call your hospital or your clinic and say, hey, I'd like to talk to a nurse or a doctor to figure out what I should do at that point.
They might say, hey, you know what, why don't you come in, we'll check you out and when you go in, of course, wear your surgical mask.
Um And if you don't have one, I'm sure that when you get there, they will have one for you. So that's what you should do.
Um What are the various types of masks and what is the correct way of wearing the mask? All right.
So there are two different types of masks that are out there. There's a surgical mask that's just kind of uh it's got two oops on it.
Um If you're in the general public and you have no symptoms, let's say you feel like me. Uh right now, uh then you should not wear a mask.
You don't need to wear a mask. It's really for people with symptoms.
So that's pretty simple. Um The other type of mask and, and that's really the only mask you should even be considering the other type of mask is the N95 mask and that's a mask that actually prevents um things from getting in the surgical mask, prevents things from getting out.
So if I'm coughing or sneezing, it catches all that inside the mask, the N95 actually protects things from coming in from the outside.
And so to wear it properly, make sure you have a good seal. We're actually gonna be dropping a video on this topic pretty soon.
So stay tuned for that and you wanna make sure you you're a clean shaver, so clean shaven. So there's no sort of facial hair like I have um so that the mask can sit really nicely and it's tested.
So if you're a healthcare worker, those N95 masks are for you and for in the general public, you should just be wearing the surgical mask only if you're sick.
So no need to hoard masks or any of that kind of stuff. Those N95 masks are in short supply in many places.
So really need to go to uh healthcare workers. Next question, why aren't antibodies from the recovered patients not being uh used uh as a treatment?
It turns out they are so pretty cool idea uh is to say, well, what if you have all these 54,000 people recovered? We know they're forming antibody to COVID-19.
Why don't we get that antibody kind of concentrate it and give it to people that need it. And in fact, that's what we do.
It's called kind of passive immunity and we give that in uh in many cases, uh measles is an example where if you're at high risk, we have measles antibody.
Where do you think we get it? We get it from other people that have had measles or vaccine and have an immune response and we gather that up and we give it to people that need it.
We're, we're exploring that. I think we, I'm not exploring anything but the uh the manufacturers are, are uh looking at this as a possible treatment.
And so that's not even in FDA um at, at any point in the pipeline yet, but it will be. And so that's one thing to look at.
Um as a side note, they actually looked at breast milk uh to see if moms with COVID 19 were giving or transmitting the virus to the babies.
And it turns out that actually in a series that they looked at the babies were not getting COVID-19 uh disease or, or the virus uh through the breastmilk, but they did detect COVID-19 antibody in breast milk.
So actually one more reason to think about breast milk uh as a good thing is that in that scenario, they were seeing that the breast milk had the antibody and that was thought to be passive immunity for the baby.
So that was a pretty cool thing. Uh Next question, are there any updates about the vaccine for the virus?
So pretty interesting updates for sure. So there's a company called Moderna.
Moderna has an MRNA vaccine that's out there. And the way it works is it, when I say it's out there, let me rephrase, it's out there in studies.
And so it's still in phase one, that vaccine will not be ready until 2021. So let's be very clear on that.
Uh And so for you and I to get the vaccine, we're looking at next calendar year. Um But Moderna has this vaccine, it's in phase one.
it's an MRA vaccine and the way it works is the um the RNA gets injected into the cells, these cells, like if it's my hand, it kind of the pick up the M ram RN is inside the cell, the antigen presenting cell, it then transcribes and translates this into or translates this into um a protein, a protein sits on the surface and then that protein is causing this immune response.
So it's a great way to get an immune response out of someone. It's a, it's a vaccine that works in a very elegant way.
And it's kind of a relatively new technology. Uh again, still in phase one, there are other types of vaccines out there that are being looked at, but they're not even at phase one yet.
So this is kind of the one that's, that's furthest along. Next question, what methods are used to diagnose the virus?
What are the clinical and laboratory criteria to suspect the virus? So, again, put your heads in the shoes of, let's say I'm in the, er, and I'm told there's a patient that just called in, they're feeling sick, they're now headed this way.
First thing I would do, make sure I go out to the parking lot, hand them a surgical mask and make sure that they don't just walk around the, er, uh, exposing people.
That would be a nightmare scenario. Right.
Second thing I make sure I myself am protected. Right.
So I've got my N95, my eye protection, contact, gloves, everything and I go out there and look and make sure that they're safe.
I bring them in and then I wanna check their vital signs. Are they severely sick or not?
And the, the clues there are the respiratory rate fever. Um I wanna make sure I immediately uh do things like uh send off a rapid flu test.
It's still flu season right now. Right?
It's March. So we're in the middle of flu season.
The most likely thing someone has is the flu or one of the other viruses. It could be Adenovirus, it could be R SV Rhinovirus, any of those.
Um I also wanna make sure I send off like a viral panel. If my hospital has that, I wanna get a chest X ray.
If I'm concerned, maybe even a chest CT and a chest CT is actually one thing I wanna kind of focus on here. There is evidence that chest CT in this context is very sensitive and more sensitive than PCR.
In fact, we're gonna drop a video about this topic very soon. So stay tuned for that.
But basically in this context, s CT has a sensitivity in, in an endemic setting. So actually, let's say we're in China in endemic setting.
Uh The sensitivity is above 95% you're missing just maybe one in 20. By comparison, PCR has a sensitivity of 30 to 70%.
That's much, much lower and very concerning, right? Because in that setting, you're missing out of 100 30 to 70 people, you're missing them and when you miss them, you might be sending them out back in the community to get sicker, which is really worrisome because there are treatments like I mentioned um and also they're exposing more people.
So again, we're not doing our job in terms of combating that are not factor. We're really kind of causing that, that transmissibility to really ramp up.
So that's the worry with missing people with just PCR. So chest CT is a great modality.
It's been shown in a number of studies now to be effective and much more effective at picking it up early on. So take a look at that video.
It's all about how to read chest CT S to look for those findings. Um Other things you would do CBC blood culture.
And then ultimately, of, of course, you'd wanna, if you're suspecting it you wanna send off a rest, your blood PCR for COVID-19, you'd wanna detect it if you can.
So that's out there and you want, of course, make sure that your laboratory can do that and supports you. Um What's the risk to healthcare workers?
Next question in uh, in endemic settings? Like China, 15% of healthcare workers got really ill.
Went to the ICU, some of them died. That is very, very worrisome.
right? Because if 15% are getting sick, that means your healthcare workforce is either a gonna be panicked and they won't, won't want to come to work, right?
That's terrible. They might go on strike like some people did in Hong Kong and say we're not gonna go to work until you get us proper PPE the personal protective equipment and only then will we come to work?
Um or you simply have to quarantine people and say, look, we've got so many exposures here, we have to quarantine half our staff to see who's really, you know, got sick and, and who isn't.
And if you're quarantined, half your staff, you don't have much staff left. So this was really concerning when I saw this 15% is a really worrisome number.
And I think we should all focus on this number more than anything else because we need to make sure our healthcare workers are safe through this process.
If they're not safe, none of us are safe and you don't want a scenario where N95 masks are getting hoarded by regular folks that don't need them and healthcare workers don't have them.
So we have to make sure that they get properly supplied in those settings so that we, we have a hospital that's staffed with the right people, nurses, physicians, respiratory therapists, et cetera.
Um The risk factors for why this number was so high, 15% was they didn't have the PPE but also they were fatigued, they were working double shifts, they were falling asleep, they were unable to kind of care for themselves like they needed to, to prevent the virus from getting in.
And that's something that we have to look out for too is is fatigue that sets in as we start stretching our healthcare workforce through uh kind of out.
So one of the things that healthcare providers can do to prepare, know the phone number of your department of public health, talk to them, call them, understand what their protocols are, understand what your hospital protocols are, you know, do you understand what rooms in the hospital are positive pressure versus negative pressure?
For example, many or s operating rooms are positive pressure if you go in there with a COVID-19 patient, because you're concerned they have some abdominal pain.
Uh you're actually exposing a lot of people because that positive pressure is moving the virus out of that person's kind of mouth and into the room and into other people.
So that's a dangerous scenario. Um You need to find out if you can order RT PCR many states in the US.
Actually, believe it or not still to date, have not done any PCR testing. So we need to make sure if, if, if that's possible how you do that, what paperwork you fill out, et cetera.
Um And then again, I mentioned chest CT, learn the classic S CT findings. It's better than RT PCR in early disease in that high endemic setting.
And so learn the findings and we have a video specifically about that. So if you're on the front lines, you should definitely check that out.
Next question. What can I do as an intern to protect myself?
Um I mentioned some of this wearing PPE the right way making sure you don't have facial hair if you're wearing it N95, washing your hands, taking breaks.
And then if you are starting to feel ill quarantine yourself, the last thing you wanna do is keep working and exposing others.
Um And also you don't wanna expose yourself to a secondary inoculum, right? You don't wanna get more of the virus if you already are trying to combat the virus.
So making sure you quarantine yourself and stay safe. Um A couple more questions I'm gonna answer cause II realize we're getting at the end of this uh how long can it survive without the host?
The virus can survive and transmit for hours up to a day. On a nonporous fite.
So something like, let's say a cell phone, a doorknob, these are non porous fites up to a day can survive and transmit. Um There are special cleaners that the EPA has mentioned.
Uh a couple of days ago, they, they sent a list out for what you should be using in your hospital or really anywhere to clean these surfaces so that you're not transmitting them.
Um And final question, uh this come up a lot in terms of the effect of heat on the virus. Uh as the summer months approach, you know, as we get into kind of April through, let's say even November, these are the low months for Coronavirus.
Normally Coronavirus typically peaks December through March be it's because the viruses prefer kind of cooler drier environments rather than warmer, more humid environments.
Having said that that's for Coronavirus is normally we don't know for COVID-19 if that's gonna be the case. And in the past when we've seen this going back to like the Spanish flu, what we saw is that there was a, a kind of a diminishing of the virus, but then it resurged late and we saw 100s of thousands of people affected in that resurgence.
So by no means if, if let's say this ends up going down a little bit in April or may, we should not be doing a victory lap instead, we should be thinking about the fact that this maybe just kind of endemically circulating and then kinda Resurge uh especially because this is hemispheric, right?
So what's winter in one hemisphere of the planet is, you know, the summer of the other hemisphere? So this could just kind of bounce back and forth a bit, causing worse disease in some areas and maybe less disease in other areas.
So, uh I'll end there. What I will say is um this is an evolving situation, we, you know, wanna have your backs and give you the best information.
There are a lot of different stakeholders here with lots of different questions. Um I do wanna say that uh if you have questions that weren't answered, put them in social media, we will definitely kind of go through them.
I'll go through them answering all those questions as best we can. Um We might even do one of these again.
But um we wanna thank you for participating and spreading good information and most of all, you know, go out there and, and don't overreact, don't underreact, but just kind of react as appropriately as possible.
Um And on that note be well, thank you.
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