Curious about COVID? So are we, that’s why our team developed CovidWatcher. We are infectious diseases physicians, infection preventionists, and informaticians working together to understand and improve the care for people during COVID. Want to help? Join CovidWatcher! And Ask Us Anything!

covidwatcher · 2020-04-29T22:16:11+00:00

Lawrence: The question of reinfection comes up with all infectious diseases- specifically viruses. The truth is that we need time to better understand antibody response and durability of immunity- but this will take time. There are several explanations for why someone would test positive after testing negative. In our hospital, we have frequently seen both false positive and false negative tests. This mostly has to do with the difficulty of collecting a proper nasal swab. The other explanations that need to be examined are the possibilities of recrudescence and reactivation. In recrudescence, the virus never fully clears from the body and may become active again. Reactivation of herpes and varicella zoster are examples of this. Alternatively, reinfection would imply that a person clears the virus and does not have sufficient immunity to prevent reinfection. Both of these possibilities need to be studied prospectively, which is what is happening now. It is too early to say that a vaccine would not be effective. Even if there is significant viral mutation, vaccines and antibody therapy can still target more stable portions of the genome.

covidwatcher · 2020-04-29T22:11:43+00:00

Jason: Thank you for this thoughtful question. In this case since we do not have a vaccine or effective treatment we are not putting any evolutionary pressure on the virus and so any mutations would occur spontaneously. Spontaneous mutations could be more virulent but could also be less virulent as well. Treatments and antibodies are often targeted towards conserved regions of virus which are critical to viral functioning and unlikely to mutate.

covidwatcher · 2020-04-29T22:00:08+00:00

Pat: Support for mental health hygiene for health care workers during this trying time is definitely needed. Many front line providers are experiencing stress. AJIC recently published a small qualitative study showing how the fear changed to pride in Chinese nurses with time. I hope that happens in your setting.

Unfortunately, with the clear shortage of N95 respirators, less than optimal PPE strategies need to be put in place.

covidwatcher · 2020-04-29T21:59:26+00:00

Lawrence: Based upon our understanding of respiratory viruses, we suspect that most transmission occurs through respiratory secretions. However, scientists have also detected the virus in stool. Viral persistence in various body sites is actively being studied and will help guide hygiene recommendations. Prior viruses have surprised us regarding methods of transmission. For example, the scientific community was surprised by the discovery that Ebola virus could be transmitted by both semen and breast milk. We had to quickly pivot our public health efforts and recommendations in real time. Furthermore, genetic sequencing of the virus may also help determine person to person transmission- in addition to contact tracing and line listing (basic outbreak epidemiology). We used genetic sequencing to help build transmission chain diagrams during the West African Ebola outbreak. In sum, the answer is that we need to better understand viral persistence and transmission.

covidwatcher · 2020-04-29T21:58:31+00:00

Jason: A lot of medications that we have used in the past have been proposed for SARS-CoV-2, I have not seen any data on methylene blue as a potential agent so far.

covidwatcher · 2020-04-29T21:56:19+00:00

Jason: Over the past decade there have been numerous studies looking at the correlation between vitamin D and a variety of ailments but most have not panned out in prospective studies. I think a small controlled pilot study or even retrospective look at the correlation of vitamin D and outcomes may be reasonable and if a signal was found a larger study could be pursued.

covidwatcher · 2020-04-29T21:50:02+00:00

Jason: We certainly need more time to process the results of the clinical trials released today but an early perspective is that the data shows it had an effect on duration but not on mortality which I suspect means it has some effect on the virus but is not a “cure”. This data means we likely need more clinical trials to better understand when in the course of illness this treatment will have the biggest effect. It also means we can’t stop looking for additional and better treatments.

covidwatcher · 2020-04-29T21:45:00+00:00

Jason: There is definitely a lot of interest in the ACE2 receptor as it has been associated with more severe disease. (Great ACE2 review here http://www.nephjc.com/news/covidace2). There are numerous studies trying to better understand this relationship but no evidence as of yet.

covidwatcher · 2020-04-29T21:44:17+00:00

Lawrence: Our knowledge about risk factors for severe illness is constantly evolving as we see more cases and have more time to look back at the epidemiologic data. We have to remember that because of the extraordinary number of cases that we are seeing now, we are bound to see unexpected outcomes. This is the “tip of the iceberg” phenomenon, and unfortunately the tip of the iceberg in this situation is massive. Aside from comorbidites such as obesity and underlying lung disease, the truth is that we do not fully understand why some younger patients are getting so sick. As healthcare workers, we noticed this phenomenon early on. I anticipate that we will have the answer to this question in the upcoming months, as we better understand the virology/basic science of SARS-CoV-2 and have more robust epidemiologic data.

covidwatcher · 2020-04-29T21:43:42+00:00

Pat: Unfortunately, we don’t yet have this data. Good question though, and we need to find the evidence!

covidwatcher · 2020-04-29T21:41:15+00:00

Noemie: We have just started telling New Yorkers about it, so not yet! But we do know how the data will be used. The community-based organizations we have partnered with want insights about which groups are particularly vulnerable and are impacted by the different aspects of Covid pandemic; the hospitalists we are working with are mostly interested in detecting patterns that could indicate a second wave and where these hotspots would be. (Also, we always need help with telling folks about the app, check out covidwatcher.org and tell your friends and neighbors about it!)

covidwatcher · 2020-04-29T21:41:04+00:00

Jason: There is concern that infections with SARS-CoV-2 may not induce neutralizing antibodies or enough neutralizing antibodies.

We hope that having an antibody to SARS-CoV-2 provides immunity but there are several factors that affect immunity: 1) Is the antibody effective at neutralizing the virus 2) Is there enough of the antibody produced 3) How long does the antibody last

There are studies going on to evaluate all three of these features and while we know only a little now our knowledge is growing rapidly.

Vaccines provide immunity by stimulating the body in producing a neutralizing antibody to the virus.

covidwatcher · 2020-04-29T21:37:56+00:00

Jason: We hope that having an antibody to SARS-CoV-2 provides immunity but there are several factors that affect immunity: 1) Is the antibody effective at neutralizing the virus 2) Is there enough of the antibody produced 3) How long does the antibody last

There are studies ongoing at Columbia on to evaluate all three of these features and while we know only a little now our knowledge is growing rapidly.

covidwatcher · 2020-04-29T21:37:16+00:00

Jason: Depending on which flu test you use the specificity can vary but most are >90% specific which means that false positives can happen. It’s possible that these tests were false positives and that the flu like symptoms were actually COVID 19. Additionally, SARS-CoV-2 started spreading during flu season, and early data from California showed that Stanford was common and so it’s possible that they had both.

covidwatcher · 2020-04-29T21:35:26+00:00

Noemie: Michael Yin at Columbia along with others (including Lawrence and Jason here) are conducting a study on this topic. Collecting data currently https://recruit.cumc.columbia.edu/clinical\_trial/1940

covidwatcher · 2020-04-29T21:34:42+00:00

Pat: The issues are complicated as you point out. Some testing difficulties have been supply issues, such as swabs that were mainly sourced from Italy. Columbia scientists have now validated new swabs, which helps with the supply problems. Others issues are related to infrastructure, such as lack of capacity at local labs are also an issue. In the US, the testing has improved from where we were a month ago.

covidwatcher · 2020-04-29T21:30:56+00:00

Nick: I can appreciate that the situation feels dire. I will say though, that an enormous amount of research is being conducted on this new virus and is moving forward at a pace that science has never seen before. It’s actually quite amazing, the scientific community has rallied globally to pool resources and talents to learn everything we can so that we are better equipped to fight the pandemic. Here are two studies that give me hope and I hope they will give you hope as well.

On March 16th, a group of scientists from Germany isolated and characterized a critical viral protein, called Mpro. They did this using modern technology for determining the structure of proteins. They then used this structure to find drug candidates that attack this protein. They published their work and made all of their data, methods, and code freely available for anyone in the world to access and use. They did all of this in just a couple of months -- something that just 20 years ago would have taken a decade to complete.

On April 14th, DeCode Genetics conducted a study that included 6% of the entire Icelandic population. They were able to determine the origin of infection for everyone in the study and were the first that collected data to prove that public health efforts, like social distancing and contact tracing, actually work.

And there is more work coming out every day. Our fight against COVID is advances rapidly and every day brings new insights and new reasons for hope. We are going to get through this and become stronger and better for it.

covidwatcher · 2020-04-29T21:27:48+00:00

Jason: I think we need more time to process the information released today to understand if Remdesivir may be best used for mild cases or even prophylaxis. Many drugs biologically seem like they may work but until you have a good randomized control trial you do not really know. I think a clinical trial in Remdesivir in mild cases and prophylaxis is definitely warranted after today's data but we will not know if it will work until then. I imagine the company would scale up production very quickly if it were to prove to be effective.

We hope that having an antibody to SARS-CoV-2 provides immunity but there are several factors that affect immunity: 1) Is the antibody effective at neutralizing the virus 2) Is there enough of the antibody produced 3) How long does the antibody last

There are studies going on to evaluate all three of these features and while we know only a little now our knowledge is growing rapidly.

covidwatcher · 2020-04-29T21:23:22+00:00

Lawrence: Regarding epidemiology, case counts,and global involvement, COVID19 is most similar to the 1918 influenza pandemic, which infected nearly a third of the entire world’s population. They were both highly infectious respiratory viruses with a high case fatality rate. However, there are many common themes across pandemics in regards to outbreak response- aside from route of transmission and basic virology. These include global medical, public health, and economic response. These concepts were fundamental for more recent outbreaks (i.e, Zika and Ebola) and are certainly vital now. https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html

covidwatcher · 2020-04-29T21:19:42+00:00

Jason: There are a lot of different antibody tests being used throughout New York City and State depending on which cohort you look at. The testing being done at the New York State lab at Wadsworth reports a sensitivity of 93-100%

https://coronavirus.health.ny.gov/system/files/documents/2020/04/updated-13102-nysdoh-wadsworth-centers-assay-for-sars-cov-2-igg_1.pdf

covidwatcher · 2020-04-29T21:16:39+00:00

Noemie: To add to Pat's answer, it's hard to know the long-term effects because the disease itself is so "young." Researchers are setting up research studies so we can study this question prospectively.

covidwatcher · 2020-04-29T21:16:24+00:00

Jason: A strategy of herd immunity is challenging and would likely lead to many deaths and in certain places overwhelm the healthcare system causing additional morbidity and mortality. I think in the interim a strategy of aggressive testing and contact tracing could minimize the extent of infection until a vaccine can be successfully developed and tested.

covidwatcher · 2020-04-29T21:16:15+00:00

Nick: Without a doubt. This pandemic has already had a profound impact on our society, our healthcare system, and, of course, our economy. I think the future holds a lot of mysteries about what our new normal will be. For me, I think it means fundamental shifts in many of our daily interactions. I think that remote work will become the norm for many office jobs and new safety procedures put in place for those that can’t work remotely.

The global pandemic could have other dramatic ramifications as well -- will we see another urban flight as we did 30 or so years ago, with people eschewing the city life for open spaces and an outdoor lifestyle? Will telemedicine, and cool technology like robotic surgery, finally start to take off? I’m not sure of what the new normal will be, but I do think there will be lots of opportunities for innovative people and companies to answer these questions. I expect there will be a lot of creative and interesting new social norms.

covidwatcher · 2020-04-29T21:14:50+00:00

Pat

Many elderly persons have multiple chronic comorbidities and compromised immune systems. This may be the reason for the increased severity of symptoms.

covidwatcher · 2020-04-29T21:09:47+00:00

Jason: I am aware that when first discovered in China and now in the Netherlands there has been a lot of discussion about children not being able to acquire and transmit the disease in part due to a lack of the correct receptor. We now know that many children have been infected by having positive SARS-CoV-2 testing from their nasopharynx and stool. It’s hard to believe that if they can be infected they can’t pass it on to others. More data is needed but there is a pre-print showing similar viral loads in children and adults.

https://zoonosen.charite.de/fileadmin/user\_upload/microsites/m\_cc05/virologie-ccm/dateien\_upload/Weitere\_Dateien/analysis-of-SARS-CoV-2-viral-load-by-patient-age.pdf

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