CoV Q&A Part 1 05.11.2020

Good morning, everybody. Great to be with you again. I'm going to do a few question answer sessions. We've been getting lots and lots of questions sent to us through social media and I've asked for you all to ask your questions and you've actually answered by asking lots of questions. So I'm just going to go do this for a couple sessions, go through some of these questions and hopefully this will be helpful. So one of the first questions was talking about testing. People are referring to some of the headlines about testing. You know, when the tests become positive, why some people are positive, then negative, then positive again. I think this is a little more complicated than what the media is telling us. The testing itself is kind of complicated. For example, with the nasal swab, it depends how you do it. Is it a nasal sample, is it an oral sample, is it a lung sample, is it a induced sputum sample? All these have different levels of accuracy. It also depends on the manufacturer who does it. The other thing you have to realize is with the swabs that are checking for viral particles, actually active disease. This is the test we're typically doing when we're looking for active disease. People's degree of infectivity can change and the test itself can change based on whether it's a first morning sputum spit sample versus A later on. So for example, if someone's laying down overnight and they collect dry mucus in the back of their throat, the they get up and swab and spit and produce that. That's going to be a little more accurate than if you take a sample towards the end of the day. So there's so many nuances with the testing accuracy. I think a way to think about this with some of the getting it and not getting again is typically during a flu season, we have influenza A and influenza B and then different strains of influenza A and B. H2N3, H1, N1, H3N2. And so we all know someone who got sick, who got flu A and then a month later got flu b or got one type of H2N3 and then later got an H3N2. And we don't know what these viruses are, but they just got reinfected and we assume it was the same flu. Again, we're learning that this virus is mutating and we're learning that there's some new strains, so maybe they're just getting reinfected with older strains. And there's another question as well, as far as that question of reinfectivity. If someone gets Reinfected, is it going to be as significant, as serious? And that's another question that was later on in here. And I think the way to think about this, if you get infected with SARS, COV2 is the actual name, and get COVID19 and then it mutates a little bit and comes back. It's no longer for your body, a novel virus. And that's a big concept I haven't heard anybody talk about. The idea of novel is that you've never been exposed to it. We have never been exposed to it in the history of the world ever before. But if you get infected and it mutates, it's no longer a novel virus. So if you get reinfected, then you might get sick again by this mutated strain, but it's not going to be as bad as the original novel virus. That's a really important talking point. So next question. Numbers are still increasing despite many people staying at home. There's a lot of crowds in grocery stores. Do I think there's been a lot of contagion in these places? Should we avoid going to grocery stores? Do I think I need to be concerned about food safety in the near future? These are three big different questions. One of my things was always, you know, like in New York City for example, when they said stay at home, the subway stayed open. Well, the basic workers still have to go to work and pick up trash and provide food and work at Amazon and the grocery stores in order for people to eat. So what happened was it still spread rapidly in New York City. You know, we had the people going home here in Virginia, the kids went home. People are still going to grocery stores. And if y' all remember, right before the stay in place orders kind of went out, grocery stores were packed, people were in two hour lines. That was a massive spread. So as long as we're going in public, that's going to happen. We're just slowing. The only way to actually stop this is for everybody to stay at home and be boarded in their homes for two to four weeks, which is what they did in China. They literally actually some places would weld people in their houses and buildings so they couldn't get out. Are we going to do that in America? Absolutely, positively not. So there's always going to be some spread and we want a small degree of spread to happen so that it goes around so we get herd immunity. That's just going to happen. As long as people leave their homes for any reason whatsoever, that's going to happen. That's not Preventable. So instead of having massive spreads, we have slower spreads, which is again one of the three major purposes for this whole lockdown in the first place. As far as food safety in the future, my biggest concern for food safety is not the people delivering the food to your house, it's supply chains being cut. The average food in your grocery store travels about 1500 miles to get to your home. And when the butchers and when the pork manufacturers out in the Midwest no longer have, when they're literally sacrificing a third, a quarter of their beef, I'm sorry, of their pigs, of their chickens, you know, that's going to affect food, food access in the future. So my biggest concern with food safety is actually the supply lines being cut, which makes right now finding local sources for your food, local farmers, a big, big deal. And with us, we're getting a lot of food from local farmers through fall line farms, getting our milk from local farmers, and literally it's the farmer touches it, they put it at a drop off spot, we pick it up. So our personal supply chains not being that effective, we still have access to chicken and beef locally. And that's why I think you can mitigate this issue by just finding local sources. Next question. Someone has concerns about people in Midlothian getting sick, having symptoms and reappearing coming back. Did they get it again? Then the WHO has concerns about getting infected and not actually having immunity. I think this is an older question because the WHO then retracted that statement. When that statement came out, I thought it was very uninformed statement to make. You can't just assume because someone gets infected again that they're reinfected with the exact same virus. You know, again, a typical flu season, a typical head cold, there's always someone's kid, someone's family who's sick the whole season, right? One kid gets sick, the whole family gets sick and this happens for the whole season. There's always just people who get the flu once and get it a second time. That happens all the time. That's because the virus, like the adenovirus or a typical coronavirus will mutate. That's going to happen with this one as well. If it's a coronavirus, which it is, the question doesn't mutate enough. That becomes novel again. And that rarely happens with flu. And that's when you have pandemics that does happen, like with this COVID 19 so I think the biggest issue is just once you get it, you will have a degree of immunity. We shouldn't assume this virus is different than every other virus in the history of humanity. It's probably very similar. It's just we've never seen it before. So there will be a degree of immunity that'll stick around for a while. If it mutates a little bit, you might get reinfected, but it won't be as severe as the first time because it's no longer novel for you. Maybe that's the concept that people should be talking about. It's only novel once. Something's only new once. After that it's a second or third time. And so without some kind of antigenic shift or drift. Which is what? Without some kind of antigenic shift, we're not going to see any major issues with this as far as we know. Again, this is all influx and change. Next question. And I'm trying to keep you short, less than 10 minutes. So, next question. There's some questions about hydroxychloroquine, its efficacy. I actually did a video on this a couple of days ago, so I'm not going to go too in depth on it. But there are studies for and against hydroxychloroquine, just like they are with many drugs. There's only one FDA approved currently right now, which is Remdesivir. So that's the only one the FDA said actually works. And its efficacy, it helps. But we're looking at 8% mortality versus 11% with, I'm sorry, 11% mortality without versus 8% mortality with remdesivir, which is a absolute 3% reduction or a relative 30% reduction. So that's the only FDA approved. And that's the whole part of the process when you get a drug, you get studies, multiple studies. The reason Remdesivir went through so fast is because this had already been studied in the past. It wasn't a brand new drug, just like hydroxychloroquine is not brand new. So I don't think it's as much as a pharmaceutical conspiracy per se. It's just this is the way research works. You have studies for and against, and then you get enough of these and someone justifies a randomized trial. And the randomized trial, which is what happened with Remdesivir, shows, hey, it actually works or actually does not work. And we do not have that with hydroxychloroquine. So the best practice is to save it for those who are sick. And it's really interesting because there's been a pullback. The government initially said it was useful and they said it wasn't, and they said it was. And you're going to see that back and forth. I think that's the reason we should let well educated practitioners make these decisions, not news media outlets or administrators. Because ultimately the practice of medicine is a practice and it occurs at the level of the practitioner and the individual, not the level of government organizations or news media outlets. You should let the professionals look at the studies and determine for the patient if it's appropriate or not. And it's not appropriate for everybody. Until we have an RTC trial, we will not know for sure about hydroxychloroquine. I think that's the biggest take home point. So someone else is curious about my question about returning to school. And schools opening seems kind of dangerous. Since it seems less dangerous than previously expected. Do I think it's safe to return to school in the fall? What are my thoughts? Well, the thing about it is once the kids go back to school, we're going to see a massive spike. You know, we could try to do what they're doing in China, which is where we do almost like shift work for school. So some kids, they do this in Brazil as well. Some kids go to school from like 7 till 11. Then they go to school from like 11 or 12 to like 4 to 5 and from like 6 till 10. I mean, they do that in Brazil for schools. They're doing something like that and that's normal. That was not, that was something they were doing decades ago in Brazil. They're doing that in China. Are we going to do that here in the United States? I don't think that'll fly with most parents who work when kids go back to school. The question ultimately is what's the downside for kids going back to school in the fall? They get sick. I get that. But the kids, if you look at the data, kids are not. If you're less than 18, the odds of you dying from this are less than 0.001%. So it's about like a typical cold or flu for kids. So you kind of sort of want them to get immune so they won't spread to their parents, so they won't spread it to grandparents. We're actually losing that right now with the way we're doing it with schools now. I'm not saying what we did was wrong. I'm saying that's just how, how these, how herd immunity develops. Sweden has chosen to not close down schools and they're actually going to have Hermia herd immunity by the end of the summer. So My thoughts on the school thing, I don't know. Do we just stay at home for the rest of the year? Does everybody homeschool for the rest of the year? You know, how's that going to affect families? How's that going to affect anxiety, depression, mental health? There's all these things. I think this needs to be ultimately determined at the local level, at the local level of the local counties, regions, states, because they could only they can take local data and apply it. You can't take New York City data and then tell schools in Des Moines, Iowa, they can't meet. So, but ultimately you're right. If kids go back to school, we will see another spike. And that's what typically happens when kids go back to school. From the summertime, within two to four weeks, kids start getting sick. That's what happens after spring break and fall break. That's what happens all the time. That's what we usually see. It's just this will be with the COVID 19 spreading around. Last question for this session would be when should we consider antibody testing to see if we have COVID 19? Are the current tests good and should we wait a couple more weeks to get more specific ones? The question about that is none of the tests as of today are FDA approved for diagnostics. They're basically research tests that have been approved for, for epidemiological purposes, just to see, you know, how prevalent this is in the area. The sensitivity and specificity depends on which test. There's dozens of tests out there. LabCorp in our area is the one that does both IgG, IgM and IgA. If you do all three of those, the sensitivity is probably 95% plus or minus. So it's actually probably pretty good. But we're still learning which manufacturers do which tests. I'm waiting to get some labs from a manufacturer that their igg is to spike proteins 1 and 2. It's to the capsid, it's also to the nuclear protein. And they have igg A and M to all of these. So they're actually checking 12 different antibody epitopes and that's. That test is about 98 to 99% sensitive. I'm waiting to get some stuff from the manufacturer on that one, but they don't work with insurances. So if people want to use their insurance, you're kind of going to get stuck with the LabCorp Quest BioReference lab test, which again, we're looking at anywhere from 87 to 93%. If you do one IgG, you're looking about 87% sensitivity. So ultimately diagnosis is a clinical thing. If you have the typical symptoms for this and minor symptoms, which are the major symptoms, flu like illness and the minor symptoms are GI, upset, nausea, loss of smell, low grade headache that lasts weeks, this feeling of shortness of breath even at rest, that comes and goes. These are some of the atypical symptoms that are unique. For COVID 19 if you have some of those, then you probably had this. And do you believe the testing if it's negative? Well, you have to know the prevalence in your area then to determine if the test is accurate. I've talked about this in other videos, but in New York City where there's a high prevalence and it's negative, well, you probably didn't have it in Virginia where we don't know the prevalence yet because we've not. Our state hasn't kind of put any that data out yet. Let's say it's, you know, 1% or 2% and it's negative, then it's probably negative because it's not around here a lot. But we don't know the prevalence because we haven't done it yet. And that's the problem with the testing. A lot of these tests, their accuracy is based on prevalence. So if one in a million people have a disease and the test is negative in a low risk person, it's probably believable. If the test is positive in a low risk individual, it's probably a false positive. You know, that's, that's where a lot of people don't get. You have to actually know the prevalence of the disease in your area to be able to appropriately interpret the accuracy of the lab testing. And that's, that's why a test done in New York City with a certain sensitivity and specificity may not apply to Richmond, Virginia for example. The other thing is a lot of these tests accuracy are based on internal validation. That is if I do the same test in the same lab, I get the same result back. The accuracy is good. But accuracy does not refer to reliability. If I do this test and where I live and it's positive, is that an actual case? It's a little nuanced, but the point is, is I think the testing would be useful right now for people who had symptoms that are older and have high risk factors to know if they're clean, to go out younger people that have no risk factors, that are young and healthy. I mean, it doesn't really matter because you're low risk. Doesn't matter. You know, if you're 1819, 2025 if you're less than 50 basically and have you're not obese you have no comorbidities, you're healthy, you eat a clean diet then the risk of this is pretty pretty low. So would a negative test keep you from going to work for the next three months? Probably not. If you're my parents are in their 80s and your test is negative stay at home if you get this you might die so I think ultimately it depends on the test is more useful for finding out for high risk individuals whether or not they can go back out for low risk individuals it's nice to know it's data but ultimately does it change your behavior if you're a low risk individual and the answer is most likely going to be as we move forward no. So anyway more questions I'll go through later on hopefully this was helpful. Continue to ask your questions and we'll get to them as we can. Stay safe, be well and have a great week.