The United States currently has the highest number of cases and deaths in the world with over 11.5 million confirmed cases of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and over 250,000 deaths.1,2
In this new phase of the 2019 coronavirus disease (COVID-19) pandemic, which will feed in the results of the phase 3 vaccine and publish clinical practice points to provide guidance on new therapies, a new question arises: how to do it continue?
We interviewed Dr. George Abraham, MD, Chairman of the Infectious Disease Board of the American Board of Internal Medicine, President-elect of the American College of Physicians, Professor of Medicine in the Medical School of the University of Massachusetts, Worchester, Massachusetts, and Chief of Medicine at Saint Vincent Hospital in Worchester, Massachusetts for a glimpse of where the United States is now on the 2019 coronavirus disease (COVID-19) pandemic, vaccine development, barriers to patient care, and the evolving roles of infectious disease specialists .
Some studies have shown that less than 10% of the population have detectable antibodies to SARS-CoV-2. Recently, however, there has been a lot of discussion about “immunity to organic flocks” in the context of disease control. Can you give more insight into this concept?
Dr. Abraham: The generally prevailing 10% herd immunity3 and [its contributing factors have] was the subject of debate. One of the challenges we faced was the accuracy of the determination of antibodies in a person using our current antibody tests. If there is a 10% prevalence in the population, we now know, based at least on preliminary data from vaccine trials, that we need a prevalence between 50% and 70% to have herd immunity.
When plasma was transfused from someone recovering from a more severe illness [compared with mild disease]People seemed to respond better to therapy.
There could be a subsection of people who could have very mild to asymptomatic illness, possibly those who have very low antibody levels, and we don’t know if they do [levels] will be enough. First, it is reasonable to assume [these individuals] will not be protected and may be prone to a second infection.
Second, we don’t know how long these antibodies last, and therefore we don’t know how long the duration of immunity will be conferred, even in those with detectable or robust antibody levels. Third, the underlying problem that our tests are not accurate enough to detect mix-ups with other non-CoV-2 coronaviruses plays a role in determining the answer to this question.
What tools or resources can clinicians working with populations who are reluctant to acknowledge the severity of the pandemic and disease be helpful in communicating the reality of the dangers of this disease?
Dr. Abraham: This is such a pertinent question, but one that is difficult to answer because everything we say probably seems awkward only because you can convince a person who does not believe in science that there is scientific principle behind it [COVID-19], and that it is not about a person or the source of the infection? If [this disease] is laboratory-born, a natural mutation, a conspiracy to destroy our economy, or a race-based question, or all of these different challenges that contribute to it.
I think we try, often with limited success, to at least push through the argument that [the disease] is based on science and there are no other ideological differences that determine our decision-making in this situation.
Just using the scientific principles and staying away from politics, religious aspects, ethnic aspects, or any other ideological aspect that might dilute the strength of the conversation would make it much more believable. Forget everything else in the puzzle. Because unfortunately [these] Other factors have played some sort of role in watering down the conversation and pushing it away from science. It’s just an airborne virus. If we do not cancel the transfer, there will be a person-to-person acquisition of diseases and will continue to occur.
More than 40 vaccines are in clinical trials worldwide. Over 90 preclinical vaccines are currently being studied. What are some key findings, inclusion and exclusion criteria, and outcomes that clinicians should look for when reviewing preliminary study data?
Dr. Abraham: For every vaccine we develop, we have a population with different characteristics. From these traits, we clearly know that there is a gender difference, with men being more prone to serious illness4 and complications than women. We know that age is a bigger factor; The CD4 / CD8 responses in elderly patients are much lower5,6 or they have a much weakened immune response compared to those who are younger and therefore [older individuals] tend to have more severe illnesses and other complications. We also know that socio-economy plays a big role.
The first thing [that physicians should be looking for] is where [these data] studied in appropriate, diverse populations. Second, how high are the antibody responses? Are they enough to induce the immunity we expect from taking the vaccine so that we can actually fight infection when challenged and never actually get infected? And third, how long do these antibodies last in the system? So how often is the vaccine given again? Is it 2 doses one month apart or 6 months apart? Or is it a single dose? Is it given annually, every six months, every 5 years, every 10 years?
The researchers use slightly different methods, all with the end result of trying to generate enough antibodies in the person who is being injected with the vaccine, so when [these individuals] are actually challenged with illness; they react enough never to get the illness.
Some drug companies recently released detailed information about their study protocols, including the conditions under which studies might be stopped prematurely and how participants will be monitored. How can doctors better navigate this data when it is available?
Dr. Abraham: I suspect most of them [companies] Studies are published in the medical literature that contain concise information that you have found relevant that would help solve the problem. Otherwise we will certainly see analyzes by scientific staff who compare and contrast these parameters. First, company transparency is a response to the demand from the scientific community that all companies make this information transparent and public, as it is vital that we know or understand what population they are being tested in and what results have been achieved to date or their challenges and complications.
But if anything, complications would be extremely important because if the person receiving the vaccine is relatively healthy at the time of vaccination, are we actually inducing or making them more susceptible to the disease? Are we protecting them from the disease in any way? All [these] They will be questions that a patient will ask us before receiving the vaccine.
So I suspect we will see medical publications summarizing this information. I think I should look through some of these publications to filter out this information and summarize it in some sort of tabular format [along with comparisons with] Different vaccines would probably be the best way to quickly process information and then discuss some things to talk about with their patients.
For infectious disease specialists, how do you see their role evolving after the pandemic has subsided?
Dr. Abraham: Excellent question, and I think this is one that we are dealing with. Traditionally, one of the criticisms of our country’s response to a pandemic has been that we are so deeply rooted in acute medicine that we really haven’t invested in public health and preventive care because we see something could happen, but as a distant dream . I think this pandemic taught us that this is not a distant dream, it could be a reality and it could be devastating if we are not prepared.
The role of the infectious disease physician has been not just treating acute problems, but infection control in most facilities, monitoring infectious diseases, community prevalence, and facility prevalence. How would you mitigate outbreaks within the facility and keep people safe? And when a pandemic like this occurs, how can the facility continue to safely care for people who may be seeking elective or routine care, as well as care for the sick? And so this one [questions do not have] A related high economic value, based on how our reimbursement system works. Hence, from this point of view, hospitals have been reluctant to invest in infection control, infection control practitioners and infectious disease doctors [to prepare] for that kind of eventuality.
I suspect that in the future, due to this pandemic, hospitals will wake up to the fact that this is no longer a distant reality. The question is not if we will, but when we will have the next pandemic. Hopefully this was a wake-up call that hospitals and the health system will invest in developing and maintaining an Infectious Disease Doctor and / or an Infectious Disease Service in every facility that provides care to ensure safe care.
Editor’s Note: This interview has been edited for length and clarity.
1. CDC COVID Data Tracker. Website of the Centers for Disease Control and Prevention. https://covid.cdc.gov/covid-data-tracker/#cases_casesper100klast7days. Updated November 20, 2020. Accessed November 20, 2020.
2. COVID-19 dashboard of the Center for Systems Science and Technology (CSSE) at Johns Hopkins University (JHU) Coronavirus Resource Center at Johns Hopkins University of Medicine. https://coronavirus.jhu.edu/map.html. Updated November 20, 2020. Accessed November 20, 2020.
3. World Health Organization. Coronavirus Disease (COVID-19): Herd Immunity, Lockdowns, and COVID-19. https://www.who.int/news-room/qa-detail/herd-immunity-lockdowns-and-covid-19. Updated October 15, 2020. Accessed November 20, 2020.
4. Griffith DM, Sharma G., Holliday CS, et al. Men and COVID-19: A Biopsychosocial Approach to Understanding Gender Differences in Mortality and Recommendations for Practice and Policy Interventions. Prev Chronic Dis. 2020; 17: E63. doi: 10.5888 / pcd17.200247
5. Chen Z, Wherry JE. T cell responses in patients with COVID-19. Nat Rev Immunol. 2020; 20: 529- 536. doi: 10.1038 / s41577-020-0402-6
6. Westmeier J., Paniskaki K., Karaköse Z. et al. Impaired CD8 + T cell cytotoxic response in elderly COVID-19 patients. mBIO. 2020; 11 (5): e02243-20. doi: 10.1128 / mBio.02243-20
This article originally appeared on Infectious Disease Advisor