COVID-19: A cyclist’s guide, part 2. What we’ve learned.
Jason Gallagher, PharmD, FCCP, FIDP, FIDSA, BCPS
It has been a few months since I wrote about COVID-19 for Team Evesham, and after receiving a few questions on a ride today I thought I would provide an update. Reading my original post led me to reflect on both the massive changes that have happened in our society and on how much we have learned about SARS-CoV-2. One change that has happened on my side is that I’ve been appointed to the guideline panel for the treatment and management of COVID-19 of the Infectious Diseases Society of America, which I only mention because it keeps me in touch with new therapies as they are developed. I am not writing on their behalf.
Since I last wrote, New Jersey has experienced a horrific toll from COVID-19. In the US, New York City was affected most severely, and in NJ the northern counties had a much worse experience than we did in South Jersey. As of now though, we’re in pretty good shape – much better than the majority of the US.
As of mid-July, at Temple, we have had >2,600 confirmed cases of COVID and treated more than that, because 20-30% of people with likely COVID did not have positive tests (for 2 reasons – the test is not very good, and there were shortages). Philadelphia has over 24,000 cases as of 7/19. I have seen this first-hand, treating patients with COVID, including many who died. I’ve also had several friends and colleagues who were infected and recovered. Pennsylvania is dealing with an increase in cases now that needs addressing, but they are still in better shape than in the spring.
What we know
We have learned that the spread of COVID is primarily respiratory – coughs, talking, singing, and even breathing spread disease. Contaminated surfaces appear to play a smaller role than first thought. There is a lack of evidence for transmission by food, mail, sweat, or other bodily fluids. There is a debate about how exactly the virus is transmitted by the respiratory tract, which in public health parlance is a debate about “aerosol” vs “droplet” spread. Why does it matter? Aerosols stay in the air for hours, go through or around many masks, and can spread many feet from where they start. Droplets fall to the ground after a few feet- where the “6-feet distance rule” comes from. There is evidence on both sides of this issue, but in my interpretation it seems that it spreads as a combination of both, but is likely either primarily spread from droplets or short-distanced aerosols. Reasons include the increasing evidence that masks prevent transmission and may even protect the wearer from others (this is being looked into now), and that the infectivity is not as high as “true aerosol” spread with something like measles. A couple recent cases illustrate this. In one, infected people on an airplane wearing masks did not spread infection. In the other, two infected hair stylists wearing masks took care of >130 customers also wearing masks and nobody else was infected (the first stylist infected the 2nd).
Either way, what matters practically is that the virus is spread efficiently indoors in close quarters and poorly outside and at a distance. Increasing evidence that masks work well – even homemade ones – to block transmission and possibly even prevent acquisition is fantastic news.
There is a debate about how much disease spread comes from asymptomatic people, but there is no debate that it exists, and may be substantial. This is another area where semantics block effective messaging, since some people who are asymptomatic when they infect others ultimately develop symptoms later, and WHO doesn’t consider them asymptomatic in that case. What matters though is that not only can people with no symptoms spread infection, we know that they are probably most infectious during this time. That is very bad news and makes spread difficult to control. It is also why masks or face shields need to be worn all the time to prevent transmission between people. There is no ‘safe’ person unless you know everything about their contact history and their contacts’ contact history, etc.
Risks related to COVID-19 can be broken into two categories: risks for acquisition, and risks for mortality. The acquisition risks are logical and come from what I mentioned above – close quarters. If we are on a ride and you stop close to me at a light, I’m moving away – it’s nothing personal. This is also why the demographics of COVID-19 infection are changing. The average age of COVID+ patients has dramatically dropped in the US- young people are now the largest group of new cases in many states. This has brought the mortality rate down, but may be a temporary effect as they go on to infect older people.
Factors that increase the risk of death are things you have heard on the news. Age is the strongest risk factor – consistently, older people die at much higher rates than younger patients. It is really dramatic. Below is a graph from the UK showing the chance of death from COVID in the general population – not in people who are infected, but in everyone – as the pandemic progressed. This pattern has been seen over and over in studies.
Other risk factors include male gender, chronic illnesses, cancer, diabetes, immunosuppression, and others. High blood pressure and asthma do not seem to be the risk factors that they were first thought to be. Also, none of the medications that were originally concerns (“ACEIs, ARBs, and NSAIDs”) have turned out to be.
With many viruses, there is a “dose effect” (the trade word is “inoculum”), where a higher amount of “dose” of virus leads to worse disease than a lower inoculum. Personally, I think this is likely with COVID-19, but it is a difficult thing to prove. It is another reason why wearing a mask is important though, because even poor masks will decrease the amount of transmitted virus.
On the treatment front, there is good and bad news, depending on your perspective. Hydroxychloroquine has been extensively studied now and is a failure. That is a shame, because it is cheap, well-tolerated on the whole, and widely available. But it doesn’t work, and not a single randomized study has shown anything positive with it.
Two therapies have shown to be effective and are now recommended. Remdesivir is an antiviral that has modest effects. It was the first drug to show anything positive for COVID-19 and shortened hospital stays in a study from 15 days to 11 on average. Dexamethasone is a steroid that has been shown to decrease mortality in hospitalized patients – the first therapy shown to do that in a controlled study. However, note that both of these drugs are for hospitalized patients with severe disease, and steroids seem to make COVID worse if they are given to the wrong patients, so don’t ask for them from your doctor.
There are other therapies being studied, but they are mostly for hospitalized patients with severe disease. I’m afraid I don’t see anything useful coming for outpatients – where most people are treated. Also, in general, we do not have good therapies for acute viral infections. There is no miracle drug like penicillin coming for COVID. If you hear about anything new (or old) found to be a cure, be skeptical.
This is the good news. Vaccine development is happening much faster than I expected, and under Dr. Fauci’s proposal, the government invested in several of them “at-risk”, so they are being developed as they are being studied. That means that they are working on producing vials of vaccine for us at the same time they are figuring out if it works, not waiting to see success first. The risk is financial – if it doesn’t work, there will be billions of dollars of worthless vaccine lying around. Normally, companies do not take this risk, but the government assumed the risk by guaranteeing purchases. It should shave many months from the time from approval to availability.
There are many vaccines being developed – over 150 the last time I checked. At least 4 are deep in development, and one may even be available by the end of the year or early next year. The NYTimes has a great site tracking this: https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.html?searchResultPosition=4.
Vaccines are tested in thousands of people before they are approved so they show safety and efficacy. They may be like the flu vaccine and not be perfectly effective, but even if they blunt severe COVID to make it moderate COVID, that is a victory (and they may be more effective than that). We are fortunate in that several of the vaccines being studied were already being worked on for other coronaviruses (SARS and MERS), so some of the technology was already developed and they just changed the target to SARS-CoV-2.
There is no data at all looking at the interaction between bicycling and COVID-19. With rates where they are in NJ now, I feel comfortable in group rides. People breathing as they ride will likely disperse any virus quickly into low concentrations that don’t worry me, but nobody has studied this. I believe that the greatest risk of transmission for our club is at the beginning and end of rides, at rest stops, and when we stop and congregate. We need to keep our distance in these scenarios – it is important.
Looking ahead – One man’s opinion
The state of viral spread in the US is grim right now, and now increased deaths are starting to follow increased cases, as it usually takes a few weeks to die from COVID. It is not true that increased testing is the reason we are seeing more cases, though it is true that it reveals more of them. You can tell that testing doesn’t explain rising cases for 2 reasons – the percentage of positive tests is increasing (it would go down if testing explained everything), and the hospitalizations and now deaths are increasing also.
It is a sad state of affairs, and it was preventable. New Jersey is proof. As bad as the news of record daily cases in the US is now, it is still reversible. The shortage of testing in March and April meant that far fewer cases were identified, so the wave of infections in NY, NJ, Philly, etc may actually have been even worse than Florida, Arizona, and Texas are seeing now. But those northeastern states shut down to prevent transmission to a greater degree than is occurring now, and that is worrying.
Personally, I think it will take mass vaccination to get past COVID-19. I am very encouraged by the data that I have seen with three of the vaccines being developed, and I would sign up in a second for any of them right now. I hope that our current climate does not prevent effective vaccine use by the public, though I am concerned about this. To me, this is an easy equation. Any vaccine that gets approved will be much less harmful than COVID-19, a disease that kills 1 in every 100-200 people it infects, and that I have seen kill people my age (43). I’m not counting chickens yet, but at least there are some good looking eggs!