Doctor Calling | Dr. Nitin Desai

Sanity in Reopening the Country

August 13, 2020 drnitindesai Coronavirus, Covid-19, Health & Care

The world has seen an unprecedented event called the COVID-19 pandemic.

This pandemic comes with a number dating the year it started (2019). The amount of anxiety and fear this pandemic has created is unprecedented compared to Spanish flu or prior plagues the world has experienced, maybe because of the information age and the internet. Society, political, and religious leaders are struggling to make sense out of this pandemic.

First, let us talk about what is known. This pandemic is from a novel virus that has spread across all continents and has cost human lives all over the world, sparing none. The spread was assisted by population density and mobility. It is highly contagious and more lethal than what we initially thought it would be.

Second, we have a lot of unknowns.

To list a few:

Is this pandemic going to continue and resurge every season or year?
Is there a danger of this becoming endemic in certain parts of the world like Malaria?
What are the drivers of this pandemic other than population density and mobility? How effective are measures of mere social distancing and lockdowns?
Does the COVID virus have the potential to mutate?
Will we have an effective vaccine for COVID?
Are treatment therapies for the acute illness of COVID able to save lives and limit morbidities like neurological or pulmonary complications?

Public health measures are currently focusing on tracking acute infections and behavior of the pandemic. PCR antigen testing of this virus proves this is an acute infection. Testing is becoming widespread and evolving for rapid on the spot testing via saliva, nose or throat swabs, and fingerstick blood tests. This is promising for isolation and quarantines. These are patients in the first group: known infection, treated via home care or hospitalized, and survived. Most or some of them will have natural immunity for some time.

The second grouping of patients is those who are not known to be infected. If they are checked for a reliable antibody testing with Ig M and Ig G titers, we can establish if they have some immunity and were infected in the past without their knowledge. If they acquired immunity in an acceptable range of antibodies titer ( unknown), they are hopefully less vulnerable to COVID reinfections.

The third grouping of citizens is those who are not known to be infected and who test negative for COVID antibodies. These folks are non-immune and are vulnerable to COVID infection. They are in need of stricter social distancing and measures to prevent COVID exposure. They can be considered fortunate in hope of an effective vaccine yet to be established.

How do we apply science to reopening the country?

Learn from Asia and Europe as they are ahead in timelines of the initial epidemic and second waves. Gather epidemiological data and apply this to scientific models of predictions.
Initial case tracking, preventive measures for isolations and self quarantines, as well as sick care at hospital settings based on technology, data, and scientific application thereof.
Establish guidelines on herd immunity and future vaccine-based immunity. CDC guidance based on FDA approved serological testings and clinical trial data as they emerge.
Establish public measures on social distancing based on immunity status, subgroups of immune vs. vulnerable vs. high-risk individuals. Population density and mobility are key drivers and will guide how facilities and events will occur in the new world order.
Establish trusted registries of citizens who are immune via natural way or vaccination. Consider immunity passports via technology that is readily available and trustworthy.
Public health guidance as to the new designs and architecture of places with high population density for living, travel, and gatherings. Do we provide safe or immune zones vs unknown/high-risk individuals zones? Do staff serving those sites need immunity status? Will the new building plans or renovations follow airlines and airports with separate lines and zones for terrorism threat like the movement of people.
Hotels, office buildings, closed spaces like churches, etc. will need to be redesigned or renovated for social distancing needs. Consideration of new airflow engineerings like industrial-grade filters or negative pressure areas like a hospital isolation room or operating theater may be the future.

Closing remarks:

As science evolves around the COVID-19 pandemic, more knowledge and guidance will need to be applied to our next new normal and world order. Technology will play a key role, starting with mobile devices, to blockchain to Artificial Intelligence and Machine learning in the digital age.

Immunity Pass Around the Corner?

August 3, 2020 drnitindesai Coronavirus, Covid-19, Health & Care

As society has begun its push to reopen amid pandemic concerns, interest around the concept of “immunity passports” has been growing in recent weeks.

The idea is based on other viruses in history and facts acquired over the decades surrounding natural immunity. Those who’ve already recovered from COVID-19 have a status of sorts that shows they’ve likely developed immunity to the virus and can move more freely in society, even as others still require social distancing and must keep controlled measures in place.

Is that a practical idea?

Would businesses and public places adapt to the idea of allowing folks with so-called “immunity” to move more freely than others? Would restaurants and gyms open up freely for those with immunity?

What is the science?

Someone who gets infected with COVID-19 will potentially have an immune response, raised antibodies, and other immune cells that can fight COVID-19. They will likely be immune to reinfection, and they also won’t be shedding virus particles themselves that could infect vulnerable or high-risk individuals.

Let’s think about what we know about the recovery from viruses, such as coronaviruses in general, or any infectious disease with very few exceptions. When you have an antibody present, it likely indicates a degree of protection. Think about diseases like measles, chickenpox, or hepatitis b. We can make a reasonable assumption that it would be protective, but natural history and epidemiological studies over a period of months to years will tell us definitely if that is the case.

In the current review of literature and guidance, as it stands today, immunity is likely, but not certain. We as a medical community should move carefully in supporting such immunity concepts as the science is not yet confirmed.

While it is still unknown whether the presence of SARS-CoV-2 antibodies confers immunity, it is important that scientific communities around the world are looking at tests specifically for the broadly neutralizing antibodies that would provide that immunity. This could be a game-changer in the COVID-19 pandemic and effect on society at a global level.

Serologic antibody tests can not only confirm suspected cases after the fact, they can also reveal who was infected and didn’t know it. Up to a quarter of people with a SARS-CoV-2 infection may unknowingly spread the virus because they have minor or no symptoms.

In the treatment of acute COVID-19 infection side, serology tests are being used to screen donor blood for antibodies to SARS-CoV-2. Plasma containing the antibodies from recovered patients is then transfused to very ill patients in an experimental treatment known as a convalescent plasma transfusion. Early results from a small number of Chinese patients, published in JAMA in late March 2020, were promising. The US Food and Drug Administration (FDA) is coordinating a national effort to develop blood-based, antibody-rich COVID-19 therapies. They include convalescent plasma and the hyperimmune globulin derived from it, which ideally will provide passive immunity to people who have been exposed to the virus. This angle of natural infection of COVID-19 favors the hope that natural immunity from COVID-19 is likely.

COVID-19 is a new viral disease and pandemic of epic proportions. We have many unknowns but there is hope. With the global attention that is being paid in terms of suffering and investment of the scientific community including clinical trials for testing, treatment, and future vaccines, I stand optimistic.

What’s Up with this Virus, Doc?

June 25, 2020 drnitindesai Coronavirus, Covid-19, Health & Care

Todd is a long term patient of mine who recently saw me on a telemedicine follow-up appointment. His usual greeting is “What’s up Doc?” This time, he added, “with this virus?” Todd and Dean are brothers, Southern gentlemen, and so-called working class. They both ask the most pertinent questions from their “gut.” I chatted with Todd in simple words, but here is what I want people to read and understand amongst all of the new information, uncertainties, confusion, media scare, and more.

This new “novel” corona group virus began infecting humans from animal transmissions in Wuhan, China. Population density, mobility, international travel, and easy transmission via air droplet and contact turned it into a pandemic.

This pandemic has been handled in different ways across the globe. Sweden tried keeping everything open to create a “herd” immunity. Natual infection created immunity in a large portion of the population but they paid the price with a higher mortality rate compared to other countries. Countries like South Korea and Japan, where there are cultural and geopolitical differences, measured far better than other places at the price of privacy with contact tracing. They did massive testing, isolations, and strict personal hygiene and protection by using masks and other PPE. Their results are worth noticing compared to the handling of the pandemic by places like the USA, which had poorly handled public health measures and oversight, including limited testing.

The world has seen viral diseases under control with effective public health strategies, mass vaccination, and other measures. For example, the eradication of smallpox, controlling measles, mumps, and other diseases that once plagued our world.

COVID-19, caused by SARS-COVI- 2, is a disease unlike others we have managed. Humanity, with its scientific advances and global attention to this pandemic, has promises of a full blast effort to develop effective vaccines and effective treatments for COVID-19. The science to understand the epidemiology of this virus is constantly evolving.

The world is awaiting how this pandemic will phase out, and so far the news has not been good, with new “hot spots”, second waves, and what poorly managed reopening efforts have shown.

Improved personal hygiene and social distancing have shown benefits with other infections in hospital settings. As an example, our local hospital has shown a one hundred percent hand hygiene score has dramatically lowered the infection rate of another infectious disease, C. Difficile Colitis.
People are currently practicing safety measures within their judgment and are awaiting effective treatments and hope for natural immunity or vaccines protecting them in the near future. The world economy has taken a dive with lockdowns and long term effects on the economy, and the health of people is speculated to be taking a big hit. My patients are scared to go to the hospital emergency room as they feel threatened that they will get infected with COVID-19. Essential care and preventive care are suffering from being given limited access to health care for multiple reasons.
As we understand this virus better with science, ongoing clinical trials, treatments, and vaccines available, we will be near normal or at a better “new normal” hopefully soon. Meanwhile, we have to protect our most vulnerable citizens like healthcare workers, the elderly, and folks with multiple medical conditions and low immunity.

Let us not forget that with any infection, including COVID-19, the host response is very variable and some patients are doing well with minimal symptoms. The science is unknown why some healthy patients are doing poorly. Public health authorities and the CDC will have to continuously manage trustworthy and sound guidance for managing and preventing this disease.

I told Todd and Dean that a healthy lifestyle, not smoking, and having a good nutrition and exercise regimen will go long way in immune response and the ability of our body to fight this or any infection. I advised them that it is time to be smart and not be scared!

Dean said, “I knew some of these but wanted you to tell me straight like it is, and that’s why I come to you” in his Southern drawl. Until the next time they show up to me on a video call or visit, I will be prepared for my next response to their “What’s up — Doc?”

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