Top COVID-19 Questions, Answered: An Interview with ASM Past President Robin Patel
Terms like social distancing, self-quarantine and pandemic are punctuating household conversations and raising pertinent questions. Robin Patel, M.D., Past President of ASM, Chair of the Division of Clinical Microbiology and Director of the Infectious Diseases Laboratory at Mayo Clinic, in Rochester, Minn. answers in an open interview about the novel coronavirus, SARS-CoV-2.
Can you briefly explain what this novel coronavirus is?
Coronaviruses are a large family of viruses. They're pretty common in people, and they usually cause just the common cold. They're also found in many different species of animals. Very rarely, animal coronaviruses can infect and spread between people. Examples of animal coronaviruses that infect humans include: Middle East respiratory syndrome coronavirus (MERS-CoV), severe acute respiratory syndrome coronavirus (SARS-CoV) and the one we're dealing with now, called SARS coronavirus-2 (SARS-CoV-2).
The disease caused by SARS-CoV-2 has been named Coronavirus Disease 2019 and abbreviated COVID-19. We first saw this virus in late 2019 in Wuhan, China. SARS-CoV-2 is a Betacoronavirus, like MERS coronavirus and SARS coronavirus. And all 3 have their origin in bats. [MERS-CoV likely jumped from bats to dromedary camels in the distant past before appearing in humans.]
What do we know about how SARS-CoV-2 is spread and why it's spreading so quickly?
SARS-CoV-2 is a respiratory virus; the primary way it's transmitted is human-to-human. It spreads very easily from person to person, and that's why it's spreading so quickly. When an infected person talks, coughs, sneezes or simply breathes out, they release respiratory droplets into the environment. These droplets are laced with viral particles that can move on to infect others. There has been some evidence of airborne and surface transfer of SARS-CoV-2. In some cases, viral RNA has been found in the air and on surfaces hours to days after contact with infected individuals. However, that RNA is not always infectious.
What are the incubation period and symptoms of COVID-19?
The incubation period (amount of time between exposure to the virus and development of symptoms of COVID-19) ranges from 1-14 days. It is most commonly 5-6 days, and in some rare cases has been reported to be longer than 14 days.
Symptoms of COVID-19 are varied. They include fever, chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, loss of taste or smell, sore throat, runny nose, nausea, vomiting and/or diarrhea. Most people don't experience all of these, and many people have absolutely no symptoms. Fever, dry cough and tiredness are the most common symptoms, if symptoms occur.
Serious symptoms include difficulty breathing or shortness of breath, chest pain or pressure or loss of speech or movement.
Anyone experiencing trouble breathing, persistent pain or pressure in the chest, new confusion, inability to wake or stay awake or bluish lips or face should seek medical attention immediately.
How can I protect myself from the coronavirus?
There are several ways you can protect yourself from SARS-CoV-2. The best way to prevent acquiring this virus is avoid contact with someone who has it. That's where face masks, hand hygiene and social distancing come into play.
How effective are masks and when should I wear one?
We now understand that face masks do help control the spread of COVID-19, and they should be worn.
There are a several types of face masks. It is currently recommended by the United States Centers for Disease Control and Prevention (CDC) that the general public wear cloth face masks. These masks can block viral droplets emitted when the mask wearer speaks, coughs, sneezes or exhales. The CDC recommends that masks be worn by everyone to prevent the spread of COVID-19 by people who are infected but don't realize it (since it's estimated that there are many asymptomatic or presymptomatic COVID-19 cases).
It is most important to wear a face mask in public settings when around people outside of your household, especially when you're indoors or in places where it's difficult to stay away from others. Be sure that your face mask covers both your mouth and nose, and don't touch your face mask while wearing it.
Wash your mask regularly in a washing machine, and dry it in a dryer or by air drying.
Healthcare workers need additional protection with a medical mask or an N95 mask, depending on the situation.
How often and after what activities should you cleanse your hands?
Wash your hands with soap and water for at least 20 seconds after going to the bathroom, before eating, after blowing your nose, coughing or sneezing or after touching a surface or object potentially contaminated with the novel coronavirus.
What is 'social distancing' and will it help?
Social distancing is a term that's applied to actions taken by public health officials to stop or slow the spread of a highly contagious disease. Social distancing measures restrict when and where people can gather in order to stop or slow the spread of infectious diseases. Such measures include limiting large groups of people coming together, closing buildings and canceling events, as well as deliberately increasing the physical space between people to avoid contracting an illness. Staying at least 6 feet away from other people lessens your chance of catching this virus.
Are some people at risk for getting very sick with COVID-19?
The disease course can differ between people. Some people have no symptoms, some will get mildly ill and others will get severely ill and even die. A well-known risk factor for severe disease is older age. In addition, people who have certain underlying diseases, such as chronic kidney disease, chronic obstructive pulmonary disease or COPD, have received an organ transplant, are obese, have serious heart disease, sickle cell disease or diabetes are at increased risk for severe illness.
How does COVID-19 affect children?
Although we have learned that children of all ages can become sick with COVID-19, most children don't become as sick as adults. However, in children, a multisystem inflammatory syndrome appears to be linked with COVID-19. This is a condition where different parts of the body become inflamed, including the heart, lungs, kidneys, brain, skin, eyes or gastrointestinal organs. Children with this syndrome may have fever and various symptoms, including belly pain, vomiting, diarrhea, neck pain, rash, bloodshot eyes or fatigue. We are still learning about this syndrome.
Are asymptomatic patients less contagious? Are presymptomatic people less contagious?
It's estimated that about 1/3 of people who get infected with COVID-19 will never develop symptoms (although that number may be higher or lower depending on the population and may change as we learn more about the virus). There's also a state called "pre-symptomatic," meaning prior to the onset of symptoms. It's estimated that a significant fraction — more than 1/3 — of viral transmission occurs before people who will get sick develop their symptoms — that is, in the "presymptomatic" phase. It's impossible to differentiate asymptomatic from presymptomatic people until time elapses. In both cases, the person looks and feels normal, although those who are presymptomatic will develop symptoms later. Infected people without symptoms are important sources of viral transmission.
According to a study published in Science, 4 in 5 people with confirmed COVID-19 in China were likely infected by people who didn't know they were infected.
Why is staying at home and 'social distancing' important even for groups who are not at 'high risk'?
Anyone can become infected, and anyone can transmit this virus to someone else. The goal is to prevent the spread of the virus. A low-risk individual, or someone who has minimal or even no symptoms, can pass the virus on to someone who is high-risk. That's what's really concerning about this. The person may not feel sick at all, and yet they can be a vehicle for passing this virus to someone who is going to get very sick or even die from this virus.
Contact tracing — how effective is it? Are we doing enough?
Contact tracing has the power to be effective, if there is widespread and quality implementation. According to a study in The Lancet Infectious Diseases (using a model based on real-world social contact data from the United Kingdom), even if people only moderately physically distanced themselves, a robust contact tracing effort could reduce viral spread by 2/3 and ultimately snuff out transmission.
Unfortunately, the current number of contact tracers at work in the United States is well below the number required to conduct adequate and efficient contact tracing for COVID-19.
Is it safe to travel at all right now? What is the safest way to travel?
Whether or not you should travel depends on how you're traveling, and who you're traveling with and will be in contact with while you travel.
Traveling in your own car, either by yourself or with members of your household, is safer than traveling by plane, train or bus in terms of acquiring COVID-19.
Even with physical distancing measures on an airplane, there is a risk of exposure to COVID-19, due to the sheer number of people sharing the same space. Close proximity to others in airports, train stations and security lines also increases risk of exposure. And you should consider what you'll do when you get to your destination.
We know that the virus can be transmitted from asymptomatic or presymptomatic people, so there's no easy way of knowing who might have it. Having all travelers wear a mask, properly cleaning surfaces in airports and on trains, buses and planes, and sanitizing your hands regularly can help. That said, if you're alone or with others from your household in your own car, there's little risk of acquiring COVID-19 there; it's pretty much like being at home. Traveling in a rental car, or with people from outside your household, is riskier than taking your own car and traveling only with your household members.
What is the testing process for COVID-19?
There are 2 main kinds of tests for this virus, those that test for the virus itself and those that test for an immune response against it. The first kind is used to find out if someone is actively infected. First, a specimen is collected. This may be a nasopharyngeal swab, a nasal swab, a throat swab or even saliva. For patients who have involvement in their lungs, lower respiratory secretions, like sputum samples, are tested. For some of these specimens, studies have shown that patients may collect their own specimens, instead of having a healthcare worker do so.
I've noted confusion about what testing means. There is more to testing than just collecting the specimen. The actual testing for this virus, and for many other infectious diseases, is done in clinical laboratories. SARS-CoV-2 is an RNA virus, so most often, highly sensitive molecular tests are used to pick up the specific RNA of this virus and not other coronaviruses.
Before the outbreak, we had no tests for this virus. Initially, clinical microbiology and public health laboratories had to develop their own tests. Today, we also have tests made by companies and sold to laboratories to perform. Testing is more broadly available than it was back in March, but we continue to have supply chain shortages. Many laboratories have multiple tests in place just to make sure that at least 1 of them has enough supplies to be run at any given time.
To test for viral RNA, there is typically a first step, where RNA of the virus is extracted from the patient specimen; a second step, where that RNA is converted to DNA; and a third step, where the DNA is amplified with primers that are specific to SARS-CoV-2. There can be subtle variations to this.
This is not a trivial type of testing. Testing should be performed by trained laboratorians to make sure it's done correctly. Because these tests are, by design, quite sensitive, if quality processes are not in place where testing is performed, results can be falsely positive. In addition, some tests are more sensitive than others. And we've learned that not every infected person will test positive for viral RNA with a single test. Results can depend on the way the specimen is collected, the type of specimen collected, the timing of specimen collection relative to timing of acquisition of the virus, the person's immune system and the specific test being performed, among other factors.
Who should get an antibody test? What are the benefits of getting one?
Antibody tests are markers of past infection with COVID-19. For example, if in the past you came in contact with someone who tested positive for COVID-19, and then you experienced symptoms, such as cough, fever, difficulty breathing etc., that could have been caused by COVID-19, but have now recovered and were never tested, antibody testing could provide an indication that you were indeed infected. In this way, antibody testing is useful for epidemiologic studies to determine what percentage of a population has been previously infected. Antibody testing can also facilitate contact tracing and help identify potential convalescent plasma donors. At the current time, the American Society for Microbiology is working with the Infectious Diseases Society of America to develop guidelines around the use of serologic testing for COVID-19. A big challenge is that we don't know if infection confers protective immunity — that is, whether once you've been infected, you can become infected again. This means that people should not currently get tested to determine whether or not they are protected against COVID-19.
Additionally, antibody tests should not be routinely used to diagnose acute cases of COVID-19. Our bodies need time to make antibodies. It takes a week or 2 before detectible SARS-CoV-2 antibodies are produced. That means that during the acute stage of infection, antibody tests are likely to be negative and can be misleading.
However, there are select clinical situations when antibody testing might be used to facilitate a diagnosis. For example, if someone presents with symptoms late in a disease course, and tests negative for SARS-CoV-2 RNA, antibody testing could be considered.
How has the COVID-19 pandemic impacted laboratory testing?
Since the early Spring of this year, clinical laboratories have been experiencing supply shortages related to COVID-19 testing, including COVID-19 test kits, reagents and/or machines. But now, shortages are also affecting diagnostic testing for infections other than SARS-CoV-2. Laboratories are reporting shortages of all types of supplies, including culture and transport media, swabs, pipettes, pipette tips and collection tubes, to name a few. These limitations are hindering diagnostic testing for a variety of non-COVID-19-related diseases including, but not limited to, sexually transmitted infections, pneumonia, cystic fibrosis, urinary tract infections, gastroenteritis and surgical site infections. The impact of such supply shortages could be catastrophic and lead to inadequacies in patient treatment and care, ineffective infectious diseases management and increases in antibacterial resistance, if something does not change soon.
The American Society for Microbiology or ASM is committed to helping address these supply chain issues. In partnership with the Association for Supply Chain Management, ASM has developed an online platform to monitor shortages and demand for COVID-19 and non-COVID-19 testing supplies in real-time. ASM intends to illuminate the problem and facilitate solutions to ongoing, unprecedented and ever-changing shortages by collecting and making this data publicly available. It is ASM's goal that this initiative will help make critical changes to the United States testing strategy for COVID-19 and other infectious diseases moving forward.
What does EUA mean?
In the United States, tests for SARS-CoV-2 have what's called an EUA. EUA stands for Emergency Use Authorization. Under section 564 of the Federal Food, Drug and Cosmetic or FD&C Act, in times of emergency (like the current COVID-19 pandemic), when there are no adequate, approved and available alternatives, the FDA Commissioner may allow the use of unapproved medical products or authorize unapproved uses of approved medical products to diagnose, treat or prevent serious or life-threatening diseases or conditions caused by chemical, biological, radiological or nuclear threats.
EUAs are based on the best available evidence at the time and remain in effect until the emergency ends, or new evidence causes the authorization to be withdrawn. EUAs are not the same as FDA clearance or approval.
When SARS-CoV-2 emerged in late 2019, we didn't have any diagnostic tests or treatment options at our disposal. EUAs have now been issued for a number of diagnostic tests, and even candidate drugs for the treatment of COVID-19. We are continuing to learn about SARS-CoV-2 testing. As of today, June 30, 2020, there are 94 individual EUAs for molecular diagnostic tests and 24 individual EUAs for antibody tests for SARS-CoV-2. Not all tests are equivalent. The FDA has removed some tests from the market due to poor performance, and recent evidence has caused the EUA for hydroxychloroquine to be withdrawn. EUAs do not guarantee the safety or efficacy of a particular product and are not long-term solutions.
What is the most effective treatment available for COVID-19 right now?
Supportive care, including oxygen supplementation and intubation and mechanical ventilation, if needed, are important treatments for severe COVID-19 infection.
There is currently no specific FDA approved treatment for COVID-19, with many candidate drugs being pushed through clinical trials.
A repurposed injected antiviral drug, remdesivir, has received EUA for COVID-19 treatment. Remdesivir targets the machinery SARS-CoV-2 uses to replicate itself inside of our cells.
EIDD-2801 is another antiviral drug being evaluated for SARS-CoV-2, but unlike remdesivir, is administered by mouth. It's an investigational drug; clinical trials to evaluate its efficacy are ongoing.
Dexamethasone is a corticosteroid used to treat a variety of inflammatory conditions. Data from a large, multicenter, randomized, open-label trial in the United Kingdom has indicated that dexamethasone reduces mortality of COVID-19 in patients who require supplemental oxygen. These results, while encouraging, are preliminary and unpublished.
Convalescent plasma, plasma harvested from people previously infected with COVID-19, is also under study.
Because so many clinical trials are ongoing and new data is emerging on a regular basis, recommendations for treatment are regularly updated.
What is the most promising vaccine in development right now?
The global impact of this novel virus has been significant, and so have efforts to stop it. More than 140 COVID-19 vaccines are under development worldwide. These numbers are unprecedented. Although the large number of candidate vaccines will likely increase our chance of success in finding a vaccine that is safe and effective, vaccine development is complex, and vaccine trials take time.
There are a variety of delivery platforms and vaccine types being evaluated for COVID-19. These include genetic vaccines, which use SARS-CoV-2 genes to provoke an immune response; protein-based vaccines, which use SARS-CoV-2 protein(s) to provoke an immune response; viral vector vaccines, which rely on another virus to deliver SARS-CoV-2 genetic material to our cells and provoke an immune response; and whole-virus vaccines, which use a weakened or inactive form of SARS-CoV-2 to provoke an immune response.
It is difficult to say, at this time, which vaccine is the most promising. In an effort to expedite the production of a successful COVID-19 vaccine, the United States government has developed a program called Operation Warp Speed to fund research for promising candidates. Companies such as Moderna, BioNTech (Pfizer), AstraZeneca, Johnson & Johnson, Merck and Vaxart are part of this program.
If I have symptoms of COVID-19, what should I do?
The symptoms associated with this virus are not any different than symptoms associated with other viruses, so you can't tell from your symptoms alone whether you have this specific virus. Other viruses that are circulating at this time, like influenza virus and adenovirus, can cause similar symptoms.
If you think you have symptoms of COVID-19, call your healthcare provider for advice, and stay put. You don't want to infect anyone else. If you're severely ill or have emergency warning signs, seek care immediately. Examples of emergency warning signs include very severe difficulty breathing, persistent pain or pressure in the chest, new confusion or unexplained drowsiness, blue lips or face.
If I've been around someone who displayed symptoms, what should I do?
Many people have been around people who have respiratory symptoms. As I mentioned, respiratory symptoms can be caused by a number of viruses. Just because someone around you has symptoms, doesn't mean they have this virus, SARS-CoV-2. I think in a case where you're worried about exposure, you really need to assess the situation on an individual basis, based on details of exposure and local spread of the virus.
If I test positive, what should I do?
If you test positive for SARS-CoV-2, you should stay home to avoid infecting others, and you should contact your healthcare provider for advice.