Emerging Details of COVID-19

Mark Pochapin, MD, led a recent Q+A webinar with Doreen Addrizzo-Harris, MD, and Harmony Reynolds, MD. Below are excerpts from the conversation, which took place on July 8, 2020.

Mark Pochapin, MD: Many people say the current virus spread is a result of increased testing. Is that possible?

Harmony Reynolds, MD: No, I don't think the virus spread is due to increased testing.

Early in the pandemic, I was meeting with patients on video through virtual urgent care. There were so many people who clearly had COVID-19, but we weren't bringing them in for testing. Our capacity was limited, and I didn't want them to use public transportation and potentially spread the virus to other people because we weren't even really on lockdown yet. There was a ton of infection we didn't detect.

MP: Something we’ve learned about COVID-19 is its asymptomatic shed, where someone can actually harbor and affect another person without having a single symptom or fever. Does it make sense to take temperatures for entry to places since many infected patients do not develop an elevated temperature for several days?

Doreen Addrizzo-Harris, MD: Twenty percent of patients—even those who are feeling sick—won't have a fever. Asymptomatic patients don't.

Temperature checks are just one tool in our toolbox. In order to combat this virus, we need multiple tools and a temperature check is just one.

Instead, we need to combine temperature checks with wearing masks, very good hand hygiene, social distancing, with asking about a whole list of symptoms, including not just pulmonary symptoms, but GI symptoms, as we see about twenty percent of patients are presenting just with GI symptoms. And, checking yourself is also very useful. You might pick up a slight increase in temperature before you start to feel sick.

Temperature checks are one of several methods to limit the spread of disease.

MP: Our Center for Human Genetics & Genomics was able to sequence the COVID-19 genome and determine that New York was hit with a strain from Europe, not China. Does that mean the virus is mutating? Will that make a vaccine impossible?

HR: First, I believe a vaccine will be possible.

A virus is like a little package of genetic information coded in a bunch of proteins, and it gets into a cell and hijacks it. In order to multiply itself, the virus needs to copy that genetic material, but it's sort of a fast and dirty replication. Think of a lousy Xerox machine—it makes mistakes. And in that process, it's definitely going to mutate.

Scientists will identify certain proteins that the virus can’t function without—and if the virus can't function, it won’t copy itself and will die out. Vaccines are directed preferentially at that kind of a protein. When you see a picture of a coronavirus, you’ll see all of these little spikes on it. Vaccines are often directed at proteins that are on the outside of the virus, because the circulating antibodies need to recognize the outside of the virus, not just the inside. But will the spike protein change? Probably. We might need a new vaccine periodically, like influenza, which we update every year because it mutates so quickly.

MP: When can a COVID-19 patient expect to develop antibodies? Is that person then immune to the virus?

DAH: There's still a lot we don't know about antibodies. They are being studied very closely.

We do know that antibodies begin to form several weeks after exposure to COVID-19. There was a hope that they would, like other SARS viruses, last for a year or two. There are cases now, however, where antibodies are waning several weeks after having the virus. 

We tell patients: “Just because you have antibodies does not mean that you cannot get re-infected.” You may be less symptomatic or even asymptomatic, but you can potentially still spread the virus to other people. So we still don’t know how much having antibodies protects you from repeat illness.

HR: Some doctors suspect that if you can't detect antibodies, they may have truly disappeared, or it’s possible that your B cells [which produce antibodies] are just waiting around because they're not seeing the virus, but will ramp up and make antibodies again if necessary. There’s still so much we don’t know.

MP: Certain communities appear to be at an increased risk for fatality because of COVID-19. Is that due to genetics?

HR: We’re still learning. When it comes to race and ethnicity, the NYU Langone data presents an interesting disconnect with the numbers you’ve seen in the news. In New York and large cities, the black population has had a greater burden of death. And that is, of course, a huge concern, but Black patients at NYU Langone actually do better than patients of other races. I think that might be because we treat everybody the same, and we have protocolized care. We're really attentive to everyone. There are so many complicated factors at play. Some are environmental, but some are not.

I don't think we know enough about genetics, but we are getting samples. We've got sixty-five hundred samples of patients who have COVID-19, and there's been this incredible bio specimen machine getting the samples in and then farming them out to the labs that are going to research them. And a big question is genetics.

MP: Do you think we will see a resurgence during the flu season?

DAH: We may not have to wait until the fall for a spike. It could be sooner. We need to see what happens over the next few weeks, particularly with what we're seeing across the country and growing number of states spiking that are geographically closer to the Northeast.

But on a positive note, we are much more prepared to deal with COVID-19 patients. Our testing capabilities are unbelievable right now at NYU Langone. We have many protocols in place, Remdesivir and several other drugs are going through clinical trials, and we'll be approaching the patients as a known entity this time around.

Navigating the flu season and COVID-19 during the same timeframe will be challenging. And of course, we'll probably test for COVID-19 and flu at the same time. I think we will be much better prepared if we have a second wave of cases and hopefully that will correlate to better outcomes for all patients.

HR: It’s going to be so helpful that wearing masks has been completely normalized. In prior flu seasons, you never saw people wearing masks—there were lots of people who went to work, even though they were sick. That's just the way people lived and worked, but nobody is going to accept that now.

MP: When you wear a mask, it says to the person next to you, “I respect you.” I think every mask should say “I respect you” on it. Remember if we’re smart about protecting each other by wearing masks, keeping our distance and washing/sanitizing our hands, we can prevent COVID-19 for ourselves and for others. And ultimately, it’s about kindness and caring about others.

DAH: Let’s talk about the post-COVID monitoring of these patients and this center that we're forming at NYU Langone.

HR: We just don't know what the long-term outcomes of this disease will be.

New York was an early epicenter of the virus. We're going to have a big group of patients who have recovered, so we're planning to follow survivors. It's a collaborative effort between the pulmonary and cardiology divisions, with Rany Condos, MD, leading the study along with Glenn Fishman, MD, and me. We're collecting bio specimens and the Biobank will be involved, and Hersh Chandarana, MD, a radiologist, will use a new type of MRI to follow these patients looking at the lungs and the heart.

We really need to get a full picture of how COVID-19 survivors progress over time in order to tell everybody else what they can expect to see.

Mark Pochapin, MD, is the director of the Division of Gastroenterology and Hepatology and vice chair of clinical affairs within the Department of Medicine

Doreen Addrizzo-Harris, MD, is a professor within the Department of Medicine and associate director of education and faculty affairs within the Division of Pulmonary, Critical Care and Sleep Medicine

Harmony Reynolds, MD, is an associate professor within the Department of Medicine and associate director of the Cardiovascular Clinical Research Center