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Steve E. Bishop, M.D.

By: Steve E. Bishop, M.D. on August 19th, 2020

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COVID-19 Update 8/19: Risk Factors, Good Long-Term Immunity News, and More

COVID-19 | Facebook Live Recap

 

On this week's COVID-19 update, Dr. Bishop discusses recent data related to risk factors and hospitalizations, some good news regarding the potential for long-term immunity, the importance of metabolic health right now, and more. Watch the full video below and read on for a recap. 

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Risk Factors and Hospitalization: Metabolic Health

The CDC put out a couple good infographics this week. The first one is about the risk factors for doing poorly and getting hospitalized with COVID-19. It's a reiteration of all the stuff we already knew, which is that having any sort of metabolic disease (hypertension, overweight, diabetes, pre-diabetes, anything of those in that family of things cornea artery disease) all of those increase your risk significantly for getting hospitalized with COVID-19. 

If you have any of those things, please talk with your doctor about starting to treat them and get them under control. For metabolic disease what that generally is going to mean is making big changes in your lifestyle both in terms of what you're eating but also  your exercise habits and other things along those lines. 

If you’re a PartnerMD patient, talk to your doctor here with us and we have a number of wellness programs that we would love to connect you with and we can help you out with those things. 

Risk Factors and Hospitalization: Age

The second infographic is talking about the risks related to just purely age for hospitalization and mortality. Again, it reiterates what we already knew but provides a little bit more concrete data that I think is really helpful. What we've been saying all along is that other than things like metabolic disease and underlying chronic medical conditions, one of the biggest risk factors is purely your age. 

This second graphic really shows that starkly. So the reference population is the 18-29-year-old group.If you look at this infographic, people who are under 18, their risk of hospitalization or death is anywhere from four to nine times, or nine to 16 times, lower than the reference population, which is that 18-29 group. 

But if you look over at the 75 and up group, and especially that 85 and up group, their risk of death is actually hundreds of times higher. Between two and 600 times higher than people in the ages of 18-29. The same kind of increased risk applies, not quite to the same degree but eight to 13 times, for the risk of hospitalization compared to the 18-29 year old. 

Other than metabolic disease, age is absolutely the biggest risk factor. The older you are the higher the risk is and, really, ages 50 and up is where the risk really starts to take off for sure. And the risk to children, based on this data, again much much lower compared to the 18-29 group, which itself is already quite low.

Good News on COVID-19 Immunity 

Something else I want to share with you guys is an excellent study that I think is really good news that came out. It hasn't been completely peer reviewed yet but it’s about COVID-19 immunity and how long it lasts after infection, including asymptomatic and mildly symptomatic infection. 

This study actually looked at patients who had mildly symptomatic COVID-19. And for several months followed them and looked at their immune systems and found they have antibodies that persist and T-cell immunity that persists. 

We talked a few weeks ago about the multiple components of the immune system. There's two main branches, the innate immune system and then the acquired immune system, and within the acquired immune system there are both B-cells and T-cells. B-cells make antibodies. T-cells create killer cell types that go around and destroy virally infected cells and help coordinate the immune response.

What they found is that these people had persistent memory versions of these two cells, which is really good news and that they actually increase over three months, even among people who had very few to no COVID-19 symptoms.

That's great. That is not what I expected, and I think a lot of people did not expect that result. I think a lot of us were concerned that people who had mild infection might not have robust immunity to the virus after that mild infection.

But it seems like that's not going to be the case and that they may in fact have good immune responses that are lasting. Immune cells that are memory cells, so memory Bs and memory Ts, tend to last a very long time, potentially as long as decades to a lifetime, so that is very good news.

I hope that as they continue to follow that and these people, we will continue to see evidence that these memory T-cells and B-cells do stick around. 

So I think that's great news on the immunity front, which again, you know we're waiting on a vaccine and that's great, but that means you still take some time yet. If we can develop some sort of herd immunity in the meantime through the fact that people may get mild or asymptomatic infection and have lasting munity, I think that's great news and everyone should share that information. I hope that that's an encouragement to people. It certainly was an encouragement to me when I saw it, so lots of good stuff.

Your Questions, Answered. 

  • Where in Richmond can you get same-day, rapid COVID-19 testing? BetterMed and Patient First are booked for days out. MedExpress and CVS can do the same day but only the swab. KidM ed can do rapid testing but they don't see adults.

This is a huge and growing problem everywhere. As far as I know, BetterMed and Patient First are the only places where you can get same-day testing for the general public in Richmond. There is a place called Primary and Urgent Care that’s in Fredericksburg, and they also have an antigen machine, which is the one of the Sophia machines, where they can do the same-day test. 

Those machines have become incredibly hard to come by because the U.S. government is actually, for lack of a better word, they are confiscating them all and redirecting them to nursing homes.

I'm not necessarily opposed to that, but it is creating a testing problem for the general public. These Sophia machines...we've been trying to get them here at our practice for a number of weeks and the U.S. government is now directing them all to nursing homes so that they can do rapid testing in nursing homes. 

From an ethical and public health perspective, I think that makes a lot of sense, just because of what we just talked about with the hospitalizations and death rates for people who are in those age brackets that would be in nursing homes are so much higher than everyone else.

I think it's the most ethical thing to do. That being said, it is creating testing bottlenecks for those of us out in the main community. That's a long answer to your question, which is to say that there really aren't any good options for same-day testing. 

The best thing you can do is to book an appointment as soon as you. Try the place in Fredericksburg if you're willing to drive a bit but there's not a lot else out there that I'm aware of. If anyone else is aware of anything, please share it in the comments because I haven't seen it.

We have a limited ability to do testing here at PartnerMD on a rapid basis for antibodies, but we are only doing that for symptomatic people and people who are members. It's not for asymptomatic testing or screening unfortunately because we have so few of those rapid antibody tests available to us again because we're still waiting on the FDA to change some of the CLIA regulations around that. 

  • What is the quickest and most affordable place to get a COVID test in the Richmond area? We have young friends who have been living on a small boat in the Bahamas who need to disembark back here in the US and then fly back to France and need to take a COVID test in order to return home. We are trying to help them navigate the US system of testing

Same thing kind of that we just discussed. I think other than booking an appointment at one of those places mentioned above, you can always go online to Pixel by LabCorp, and they will ship a test to your home. You can test yourself at home and ship it back if your time frame is not quite as tight. 

This might be the best case for your friends who need to disembark from their boat. They can probably order a test and have it shipped to wherever they're staying here in the states. Do the test. Ship it back. And when they get the results, they can give that to the French government.

  • Are nose tip swabs reading false positives consistently? 

Not that I'm aware of. There are false negatives frequently with any of the nasal swabs, meaning that you can do the swab and it comes back negative but that's not a hundred percent certain to mean that you don't have the virus. It just means it’s not showing up on the swab at the same time. 

I know there was a particular brand of machine from a specific manufacturer that was having an issue with false positive results, but I am not aware of any of those machines being used locally here or around any of our practices. False positives are extremely rare with any of the nasal swabs. 

False negatives, however, are very common. That’s just a limitation of the technology and the molecular testing technology. It's nothing about the test or the manufacturer or anything else, it is just a limitation of the science. 

What is your assessment of college and university openings so far? Is congregate dorm living feasible at this stage of the pandemic?

I think it depends a little bit on what your overall perspective is on this AND what your perspective is on the individual risks of the students. Then the risks of professors is sort of a separate question I think. 

So let’s just talk about the students for a bit. I think the overall risk to the students, in terms of congregate students living in dorms, being around other young people, the risks of them acquiring the infection are moderate to substantial in any kind of congregate dorm setting. 

Now, the risk of them doing poorly with the virus in terms of getting hospitalized or dying is extremely low. So in that regard you can think of it very similarly to influenza or other similar respiratory viruses in that, yes, they are more likely to get the infection by living in those settings, but they're very unlikely to have a bad outcome from the infection itself. 

If your student is a normal risk, healthy person, I don't think there's any reason to be overly alarmed about them living in a dorm, because even if they do get the infection they're not likely to do poorly with it. And they'll go have immunity to it after that, most likely, based on the data we’ve seen. 

Now the risk to professors and teachers is a different question. It's the same thing we are facing with the local school systems for kids, which is that the risk to the children seems to be very small, not zero,but very small. But the risk to the teachers is more substantial.

I think for teachers and professors alike, if you are part of that 50 and up crowd and definitely the 60 and up crowd, if you can teach virtually you should do that. And I think that the school system should give those teachers the option to teach virtually if they are concerned that they're at high risk.

For the younger teachers or otherwise healthy teachers. I think that that's a one-on-one decision. I think that most of them would be perfectly fine to go back to teaching in person, assuming they're doing all the other normal things that the CDC is recommending - washing hands, don't touch your face, wear a mask, all that stuff. Do all those things and I think the risk is pretty low in general, what I’d say is it is comparable to the flu.

For the older teachers or teachers or teachers with metabolic diseases especially, the risk is much higher, and I think there should be more choice and I think the school systems and the university systems need to tease these things out and figure them out.

So again, students have a high risk of getting the infection and a low risk of having a bad outcome. 

Teachers, if you're interacting with large groups of students, there is a much higher risk they're going to get it. For professors, same thing. 

If you have metabolic diseases or other underlying conditions or if you're much older, then you have much higher risk of doing poorly with the virus and you probably want to stay virtual or have contact only with a few students at a time, not huge groups. 

We should try to normalize things as much as we can for as many people as we can, while also being cognizant of protecting the vulnerable. That’s kind of where I’ve settled at, realizing that it may be some time before we get a vaccine or develop herd immunity. Normalize what we can.  Minimize the risks where we need to. And protect the most vulnerable wherever we need to do so. 

  • Can the state force us to have a vaccination?

I'm assuming you’re talking about an eventual COVID-19 vaccine. That's a really complicated question that does not have a simple answer. 

I did a little bit of research on this, because I'm not an attorney and I'm not a legislator. I'm not an expert on that issue. That being said, the short answer to your question is yes they can.  There is legal precedent for this going all the way back to outbreaks of smallpox. There's plenty of legal precedent for the government, when there is a pressing public health need, to mandate vaccines in certain instances.

This was done also recently in New York when there was an outbreak of measles in that area, where religious and other exemptions were declared invalid and kids were required to get vaccinated for measles. 

So there's plenty of legal precedent for this, so I think the short answer to that question is yes they can. I  think the longer answer to that question is that probably is not a good idea for a number of reasons, both politically and practically. Forcing people to get vaccinated against their will using the force of law always brings all sorts of thorny issues and really should only be done in the most extreme of circumstances. 

If our scientists develop a good vaccine that works and has a reasonable side effect profile, I think many people would be perfectly happy to take it. Everyone is going to have their own personal opinion on that, and I think that’s what it comes down to. 

I’m not sure with the vaccines they have in trials right now, I’m not sure it would be scientifically sound or reasonable to force everyone to take it against their will. 

I think if they came out with the vaccine that was 100% efficacious and had a very small side effect profile, say 2-3% of people, I think that would be a much more reasonable candidate to say ok look you got to get this vaccine. But given what we have, which is a vaccine that is maybe efficacious, we don’t know, and it has a pretty high side effect profile - 50 to 70% of people are having pretty significant side effects, I'm not sure that it's either wise nor prudent to require everyone to get the vaccine right off the bat.

Not to mention the supply issues and everything else. Even if we require it we may not be able to actually deliver 300-plus million doses of vaccine in a short period of time. I suspect this will come about in a piecemeal fashion whenever we do get a vaccine. It will probably be required by certain groups before others, say healthcare workers will probably be required to get it, not necessarily by the government, but by their employers. 

So same thing with school children and teachers, I think you're more likely to see those groups come under mandatory vaccination requirements, not necessarily to force of law but because of employer policy and things like that. 

Any of these things may require changes to the law if it's things like public schools requiring the vaccine. That may require changes to the law, so I suspect before there's any mandatory vaccine rollout, I would think that there would have to be some changes to the law. 

That's a very long-winded answer to your question. The short answer is yes they can. The long answer is that I’m not sure that they will and I'm not sure that it will be practical to do so in the short-term.

  • This research looks promising, but what does it mean for how to develop T-cell memory from a practical standpoint? 

This is what we were just talking about earlier but what does it mean for how to develop T-cell memory? 

There's nothing you need to do to do that. That is a natural part of a viral infection. The immune system develops both B-cell and T-cell immunity to pretty much any viral infection, so there's nothing specific that has to be done. If you get sick or get the infection, you will develop T-cell immunity, so it seems, from the data that is coming out. 

Which is good news because I think a lot of people were concerned that not everybody was keeping the antibodies for a long amount of time, but it seems that even though the antibody levels may change, the memory cells, the memory Bs and T-cell responses, are sticking around even in those that had asymptomatic infection.

Again, I think it's really, really encouraging news, and I hope that that continues to panned out and further researched.

  • I have a friend whose main symptom is severe body pain between her shoulders and up her neck. She has some chest tightness and a headache. No other classic COVID symptoms (fever, cough, loss of smell). Have you seen COVID patients with these symptoms? Her doctor wants her to get tested before seeing her but that will take at least a week to schedule and get results. What do you recommend patients that may have COVID take for their symptom management while they wait for results? With doctors wanting testing done first and testing taking so long, I'm worried non-COVID related illnesses aren't being treated timely. Any thoughts?

Yeah, I have a lot of thoughts on these issues. First, yes, we have seen people with atypical symptoms, which is similar to the flu, right? Some people don't get a lot of high fever/cough, but they have these body aches, muscle aches, fatigue, these are common flu like symptoms. And it's similar to COVID-19. Some people only have those symptoms. Some people just have a runny nose, so it's extremely variable in that way. So yes, I have, so I think it's reasonable that the doctor wants here to get tested.

The issue becomes, as you said, the testing turnaround time, which is very slow for most patients. For most people. if they're otherwise generally healthy. taking something like an anti-inflammatory to help with body aches and pain and headaches and low-grade fevers would be perfectly fine. I would treat it just like the flu or a severe cold. Take any of those things that are meant for symptom management, like Aleve, Tylenol, or anything like that is perfectly fine to do while waiting for COVID-19 testing, especially if you're not very sick. If you're only mildly ill, I think that's fine.

Getting into other treatments, potential treatments, I think that's something that is between her and her physician based on whether they do in fact have COVID-19. That being said if someone is minimally symptomatic and they are otherwise pretty healthy, I wouldn’t necessarily do anything for treatment other than anti-inflammatories or something like. If they are young and healthy, I would say just ride it out and use anti-inflammatories to manage those symptoms that way. If the person is older or has underlying conditions, like metabolic disease, then it’s worth having a conversation with the doctor about other treatments. 

On the follow-up question about non-COVID related illnesses being treated in a timely manner, yes this is a huge problem. Lots of studies have come out in the last couple of months showing that hospital admissions for heart attacks, strokes, cancer diagnosis and treatment, all these sorts of things, are our way down compared to historical norms, which doesn't mean that these things have disappeared. It just means people are not seeking care for them, so there's a lot of undiagnosed heart disease going around, a lot of undiagnosed cancers going around, that will have a long-term impact on our population as a whole. 

Not to mention just the routine illnesses that we deal with all the time. Depression, anxiety, aches and pains, muscle joint problems, all of this stuff. The diabetes and high blood pressure, all that stuff needs to be managed and it’s not being managed the way it should be due to COVID-19. That’s a big problem. 

Can you comment on best practices for metabolic health that might help prevent a bad Covid outcome. Big question I know — what are your top ideas?Also, isn’t PartnerMD developing a metabolic health program? Will this be rolling out to Maryland? I go to the Owings Mills office.

Yes, so to answer your second question briefly, yes, we have a metabolic health program that is  called MetabolizePMD. I run that directly with our health coaching staff, and it will be rolling out to the Owings Mills office in October. You will start seeing ads for that to sign up in early September. Our health coach, Yvonne Bull, up there will be helping me roll it out to the Owings Mills office in September/October.  

Big ideas and broad strokes...I've been talking to a lot of people about this. Broad strokes are to change diet and lifestyle. 

So what does that mean? Metabolic syndrome and metabolic diseases are primarily driven by excessive carbohydrate intake, excessive body insulin levels - which is a result of high levels of carbs, especially processed carbohydrate intake. So the big big ideas are to avoid high carbohydrate foods, avoid added sugars, and start to lose weight and get diabetes under control. 

Lower the blood sugar, lower the insulin levels, and these things will have a major impact on high blood pressure, heart disease, and being overweight. All these things will start to come under control as you cut out the processed foods, the high carb foods, the added sugar foods, and really start focusing on healthy proteins, healthy fats, green vegetables, and eating whole foods, the way they come from nature rather than packaged and processed things. 

Those are the broad strokes. Obviously there is a lot more nuance involved, but those are the broad strokes. Just changing the diet is 80% of the battle in relieving metabolic disease. Exercise comes in second, but it's not a close second. 

After you have sort of conquered the diet piece, the nutrition piece, then starting to exercise, doing aerobic exercise, doing resistance or weight training, these are extremely important for improving metabolic health. That's following the 80/20 rule - 80% of the problem is the diet, 20% of the problem is lack of appropriate exercise, so we really focus on nutrition in MetabolizePMD.

  • What’s the latest on budesonide as a treatment for COVID-19? 

I do want to put a link to something a patient sent me about budesonide as a treatment for COVID-19 has come up of late as well. Again it's one of those things that, like a lot of other potential treatments, sound reasonable. They are relatively safe and reasonable to pursue. They may or may not help. There just is not a whole lot of data. 

Dr. Bartlett has published his protocol and a couple of case reports here, but unfortunately that is just what it is, it's a couple of case reports, which means it’s just a couple of patients. Before we can really say using X drug or X treatment really helps COVID-19, we need trials. 

I think the same thing with budesonide. Now things like Plaquenil, etc., they have quite a bit more data than budesonide does at this point. That being said budesonide is a very safe drug to use for asthma. It’s an inhaled steroid and makes a lot of the theoretical sense of why it would be helpful in treating COVID-19, because it reduces lung inflammation, which is one of the main problems after you get a COVID-19 infection, especially in people who are getting sick with it, they have a lot of lung inflammation. I want to see more data before we would be able to say this is definitely something you should do. But again, it's another one of those things that’s been on the market a long time.

If you and your doctor think it's a reasonable thing to use or try, I think that’s perfectly fine to do that. I don't think there's any reason to avoid it if you and your physician think it might be helpful to you. Because again it's an FDA-approved drug and using it for this purpose would technically be off label. However, we use off-label things all the time, and I think it's the kind of thing where it’s unlikely to harm, might be helpful, okay to think about and talk with your physician. 

  • Any supplements you recommend in addition to dietary changes?

For most people, the major supplement they probably need is Vitamin D. Getting 20 minutes of sunlight a day is very helpful and then taking a Vitamin D supplement is probably helpful for a lot of people. We talked a lot about Vitamin D last week, and one it’s primary roles  is to regulate the immune system and inflammation in the body, so making sure you have sufficient Vitamin D is important.

Vitamin C is helpful, too, maybe not quite as much as D, but I think making sure you're getting some Vitamin C everyday is fine. Probably whatever you’re getting each day in your multivitamin is sufficient.

Most Americans are very deficient in Vitamin D, so I recommend sunlight 20 minutes a day and then take a supplement for many people, not everybody. 

  • Can you recommend an infrared thermometer for home and work use?

I don’t have a specific brand. I think any of them are fine. I would caution to make sure of where the manufacturer is coming. If you can get one that is manufactured in the US, that's probably best but most of them are fine. 

Infrared thermometers are great. They're a little hard to come by periodically. It took us quite a while to get all the ones we needed for our practices, because they were kind of on shortage.