Friday, May 8, 2020. Yesterday was a beautiful Spring day in New York. Sunny and mild with temps in the mid- to high-60s. The city remains quiet with this lockdown, although there is increasing traffic when you get closer to mid Manhattan.
Otherwise almost everything remains closed and looking abandoned and forlorn except for the food stores. In my neighborhood where the Mayor has closed off several blocks of the avenue for walking, there is a growing increase — not at all crowded — for pedestrians doing their exercise walks and running in the four lanes. Traffic can pass through on the sides at 5 mph. But it is occasional rather than frequent except for the delivery vans and most noticeably, FedEx, UPS, and USPS every late morning, double-parked and laying out the deliveries on the pavement.
Today and tomorrow we’re departing from our regular edit to deliver an interview JH and I had last week with Dr. Jay Levy, Professor of Medicine at the University of California, San Francisco. We met Dr. Levy, who is both a doctor and a virologist, through a mutual friend, and naturally fell into a conversation about Covid-19. It was so informative for both JH and me, that I asked the doctor if we could interview him, and he kindly agreed. We are running it in two parts — today, and tomorrow.
Enjoy — you will; it’s not depressing but, ironically satisfying. He puts it all into a perspective that is not only realistic but reassuring. And you learn.
The Interview, Part I.
JH: Dr. Levy, here in New York there’s an abundance of information being circulated from many different sources. And I think what would be practical to our readers, many who live here in New York, but also many of whom hail from around the country and the world, to help distill some of that over-information. WHAT is COVID-19?
Dr. Levy: This virus is a member of the coronavirus family of viruses. Its genetic material is three times larger than the AIDS virus but it has a very similar structure. For example, COVID-19 has a fatty and sugar cover making it quite sensitive to soap and water. The virus, like other viruses, is very small and probably would need over 10,000 to cover the tip of a pin.
JH: So, how do you get the disease from the virus?
Dr. Levy: To get the disease from this virus one needs a large enough amount to get by the first defense we have in our body against viruses called the innate or natural immune system. The innate immune system can be found in the nose, mouth, eyes and on the skin and is active within minutes up to days. When a virus comes in contact with those immune cells, it is destroyed quickly. We rarely have symptoms of that encounter.
If, however, a very large amount of virus infects the individual, the virus can spread readily in that person unless the second phase of an immune response, the acquired immune system, becomes active. It is like the second wave of the Army coming to defense if the first wave does not succeed.
Thus, we can also imagine that the innate immune system in young people is somewhat stronger than that in older people so a large infection does not take place. Therefore the younger people do not develop symptoms of the initial infection. The symptoms we know come later and are caused by the toxicity of the products of the acquired immune system that are made to combat the virus. If this second response does not succeed, we can save lives with the proper medical equipment and health care workers as our human response to COVID-19.
DPC: Why are some people able to be infected and not show symptoms?
Dr. Levy: Generally we are finding that young people — 10 to 20 years old — can carry the virus and show no symptoms. These young people can be a source of infection for older people who do not have the capability of controlling the virus replication. There are a few reasons given for why young people do not develop symptoms. One of these recently suggested was that the measles, mumps and rubella vaccine, given to all children at a very young age, has some genetic sequences similar to the coronavirus. So there may be an immune response against these childhood diseases that cross-reacts and helps the young people control COVID-19.
Another reason is that the immune system of older people is not as balanced as it is in young people. In some cases, parts of immune system overreact producing toxic substances against the virus to such a great level that they are harmful also to the patient. This response takes place because older people do not have regulatory immune cells in sufficient number and action to dampen down a hyperactive immune system. This type of condition will give you many of the side effects one is now describing in COVID-19 patients such as developing small clots in different organs including the brain. The blood clots are caused by the toxic products that the immune system is releasing to kill the virus. Unfortunately in large amounts they can be very harmful to the patient.
JH: What would you require before opening a community to activity? Are there specific sanitizing protocols besides the obvious that are important to practice?
Dr. Levy: Before opening a community I’d require sufficient hospital facilities to handle large number of sick patients including the need for lung ventilators and kidney dialysis. We need sufficient beds in the ICU. We would want sufficient PPE and protective clothing and masks for frontline doctors and nurses to be handling patients.
JH: And what about testing?
Dr. Levy: Yes, we also need sufficient testing so that the extent of spread of the virus can be assessed by contact tracing or other means. An increase in infections would indicate if further restrictions need to return to the community.
I would require continuation of 6 foot distancing in the beginning of the opening activity — no meeting of groups with over 10 people and they all should have masks. Masks should be worn in public spaces in which many people are present.
DPC: What about when you are just taking a walk in the park?
Dr. Levy: If it’s an open space, and you’re not in groups, there’s really no need to wear a mask. But if someone is bicycling by you or running, breathing heavily, there are going to be aspirations coming from their mouth. And you may not think to turn your face away. Frankly, if I am not wearing a mask I hold my breath.
So for that reason alone I think it’s a very good idea to wear a mask. By wearing a mask you are also advertising the fact that you are playing a role in protecting others; this is your way of being a good humanitarian. But essentially, it’s also protecting you.
JH: Right. And what about washing one’s hands for a full 20 seconds, and wearing gloves when you go out?
Dr. Levy: As you know, I’ve been involved with HIV from the beginning. In the very early days, my lab did many studies to look at what could one do to get rid of HIV — which shares the same physical properties of a coronavirus. It is also a virus that has a lipid/ sugar coating. So soap and water will take care of it immediately. If you get a sudsy soap solution and cover your fingers and and thumb while washing, you’re doing a terrific job. And not to worry too much about counting the seconds. But again, one does have the public which I think feels better hearing specific instructions. However, this virus is extremely sensitive to soap and water.
DPC: And also heat too, no?
Dr. Levy: High heat, no question about it. Boiling and actions like that, yes. The virus is completely taken care of.
DPC: I’m perplexed to see how many people wear gloves while shopping. Especially when many return home, unpack their groceries, and proceed to touch every surface in the house — all while still wearing that same pair of gloves. Don’t dirty gloves transmit the virus just as well as one’s unwashed hands?
Dr. Levy: Absolutely correct. If you wear, let’s say, latex or plastic gloves, you feel you are protecting yourself. But the fact is, you are now going to forget to wash the gloves. And if you use the gloves in the supermarket, you’re only going to pass perhaps the virus to surfaces and products that you touch. I would say the gloves are not at all needed. The most important thing — well really, the two key things — Wash your hands and don’t touch your face.
Now we understand that if you have a mask, it will remind you not to touch your face. Fine, but washing your hands, not touching your face, and keeping that six feet of distance are three rules to really help maintain very good protection for the whole community. Unfortunately, people tend to not adhere to all three.
JH: Some people — my wife included — are adamant about wiping down all deliveries with a disinfectant, including door handles multiples times a day, as well as other high traffic areas. Are we taking it to the extreme? Mind you, we have a newborn in the house, so if we didn’t we probably would be a little more lax about…
Dr. Levy: Let me put it this way, it depends on who you are living with. I have a very close friend from medical school whose wife is so worried about getting the virus that if he takes a walk outside, meeting no one, and he comes back, he has to take off all of his clothes and take a shower before he comes into the house. These are very educated people. But they’re not virologists.
You have to be reasonable. If you take care of your groceries and then wash your hands, you are protected. We don’t know what is going to be involved when you touch bags and cartons and such, or tabletops. Most likely, the virus is not a problem. Door knobs, I feel could pass it. But if everyone simply washes their hands as soon as they come in the house, they will be safe. And also not spread the virus.
DPC: It seems every year there’s some kind of a virus that people get shots for, etc. etc. What makes this Covid-19 so different? Could it have been made in a laboratory or escaped from a laboratory working with this virus?
Dr. Levy: The full genetic sequence of the virus has been known since China provided it in early January. The sequence looks like other coronaviruses, some of which cause the common cold. COVID-19 has no genetic additions or mutations that would suggest someone has manipulated the virus genome in a lab. It has natural mutations that seem to have come together to make the virus more virulent or deadly than other members of this viral family.
To imagine this virus escaped from the lab denies the fact there are no examples of a virus escaping a lab and causing an epidemic. In our work with HIV there have been no transmissions of HIV itself in a laboratory setting after more than 30 years At most, there was a researcher who accidentally injected himself with the monkey AIDS virus and that virus did not grow well or affect that person.
In order for a virus to really cause pandemics such as COVID-19, it must do more than pass from an animal to another animal. It must go to a human and be sufficiently adapted that it can pass from human to human. Most animal viruses that pass to another animal do not adapt sufficiently to then infect and cause a disease in humans.
DPC: What is cause of the diseases in the heart, kidney and even brain – particularly small clots?
Dr. Levy: A disease syndrome that one sees with Ebola and several other viral infections is called sepsis. As I mentioned before, that condition >observed with COVID-19 involves a hyper-responsive immune system which we know as an inflammatory response. Sepsis includes the release by a variety of immune cells in the body of cellular products that cause irritation and inflammation in tissues. This can give rise to blood clots in small and large blood vessels cutting off normal blood flow and destroying the tissues — again, a part of a syndrome called sepsis. That may become severe or finally lead to septic shock in which many organs in the body shut down. This final inflammatory condition is extremely dangerous and can cause death. The latter is an important potential result of the coronavirus infection and requires intensive care.
The key is we’ve had coronaviruses in our life for a long time. This is now called SARS-2, because it is very similar to SARS that was a real public health challenge almost two decades ago. Thus far, it looks like the death rate from SARS-2 (COVID-19) will be about the same, 4-9%. But more people are being infected so that number is high.
DPC: You think it could go that high?
Dr. Levy: Yes. But we will see — as people practice the recommended actions for protection, less people will have the severe illness that must be treated in hospitals. And, hopefully hospitals will be prepared to handle the cases. We all hope that the infection rate is reduced sufficiently so this SARS pandemic can be controlled as we did SARS-1. It does seem that COVID-19 is transmitted a bit better than SARS-1. So, in the United States we are facing much larger numbers of this coronavirus infection than we did with SARS-1 that was effectively contained.
But again we will see. And that gets into the really big point. As has been emphasized from the start, we need to have better testing so we will definitely know the extent of infection by COVID-19 and then the directions needed to contain it. If indeed we knew that there are many hundreds of people who have already encountered this virus, the challenge becomes much better understood. With appropriate antibody tests, we can know how many people have been infected and remain without symptoms. A much larger number would reduce the fatality rate substantially although, as we are seeing, that number is still high. But at this point, we do not have a way of knowing the full impact of this pandemic in the United States.
JH: Because we only know those that have it. So if 80% of the population has it with no symptoms, it changes the mortality rate significantly.
Dr. Levy: That’s right. And I think the 80% is correct.
JH: Where it’s either asymptomatic or with hardly any symptoms.
Dr. Levy: We have that situation with HIV, but it’s extremely low; actually with AIDS, a person infected may not show symptoms for up to 10 years. Then 1% or less of the infected people may remain healthy for many years even without therapy. With all viruses there are situations in which infected people do not know they’re infected, and show no symptoms. That is scary with this virus, because if you are in that early stage where you are just infected and you don’t show any symptoms you can be secreting the virus and causing new infections; no one will know that.
I summarize the developmentof COVID-19 infection as 5/10/10. In general, the first five days after a COVID-19 infection the virus is getting established and one begins secreting virus. The next ten days one will either have symptoms, or will not — but may still secrete the virus for a while. In the last ten days an infected person may have symptoms and have a chance to recover. That is the key. At that time we have to get the most vulnerable into the prepared ICUs and the best care.
That gets into the other point. The common cold doesn’t do very much to the lungs, unless you get a subsequent bacterial infection leading to pneumonias. But when COVID-19 gets into the lungs, it creates an inflammatory response. It appears that it is really the immune system trying to get rid of the virus that causes the most lung damage and difficulty in breathing.
A lot of people don’t realize that all of the symptoms that you get from a cold and other respiratory infections is not due to the virus. It’s due to the immune system trying to get rid of the virus. You create all sorts of secretions that are toxic — that makes you have a fever, makes you have joint pains; It is the immune response acting against infection.
DPC: So the symptoms are actually not from the virus, or the germ itself, but from your body’s response to fighting the virus?
Dr. Levy: That’s it. The virus isn’t going in and killing off many lung and muscle cells directly. It is the immune response that comes in. As I mentioned before, a young child may hardly show symptoms because of their early quick immune response.
Again, in most of the coronavirus cases, particularly in young children, the innate immune response immediately takes care of the infection and this asymptomatic state is not recognized. Nevertheless, the infected person will eventually show signs of the response of the acquired immune system such as production of antivirus antibodies. That is where the antibody test can help us know the extent of this virus’ spread in the United States.
DPC: But still that infected child can transmit the virus to his or her parents or grandparents …
Dr. Levy: Yes, while the child’s innate immune system is in its battle to control the virus, COVID-19 is able to replicate for a while, and that is how children can transfer the virus to adults.
JH: So this leads me to the next question. We have a newborn in the house. Is it a good idea to be keeping him at home or is it okay for me to continue to walk him in his covered bassinet and maintain the 6 feet of distance? Or is it better to be safe than sorry and isolate for a few more days inside the house?
Dr. Levy: Let me ask you, is your wife nursing? If she is, I would say that giving the child outside air can be really helpful. And yes, as long as that child is going to be washed and clothed and so forth in a safe way. Joining a parent on a walk is also good as the exercise can help the parent’s immune system.
JH: Now, it’s hard to ask some of these questions surrounding the virus without getting political, but we’ve all read reports of certain later stage COVID-19 patients and their doctors who are vouching for the efficacy of hydroxychloroquine and their miraculous recoveries.
Don’t these cases have some validity to them? Of course I understand that the scientific community requires empirical data, but if you have a number of independent doctors using this technique and it’s working, according to both patent and doctor, is that not considered evidence, even if early stage?
Dr. Levy: It is evidence on some level, Jeff. But for a physician to say the drug is helpful needs the support of real results from a a clinical trial. You need to have the true data to justify it. Most importantly, as we as doctors know, the Hippocratic oath states: “Do no harm.” We now know that hydroxychloroquine can be harmful and in the trials recently completed there were even more deaths in people taking the drug than those that did not.
On another note, some people who try to avoid any contact with any microbe, even may have a house built with antibiotics in the roof and in the walls. This action can leave themselves open to developing asthma and autoimmune diseases because the immune system is responding too much to a common substance.
JH: Thankfully, not.
Dr. Levy: They will have children who will probably have bad allergies, because a young child should be exposed to lots of different things in the environment at a young age. Their immune system learns that this is normal, and not to overreact.
DPC: I read recently that Morgan Stanley had made a claim that this virus is going to return and be worse at the end of the year. Now, that’s a banker telling us this, but I know they get their information from experts, too. But does that make sense?
Dr. Levy: Are they talking economically or…
DPC: They were talking about how it’s going to infect more people and kill more people.
Dr. Levy: Unfortunately, if the current behavior of people who were sheltering in place, using a mask, washing their hands etc. is not continued the public health experts do expect the virus to return. We recognize that a balance needs to be made between public health and economy. We can only hope that the experts will get this right. We’ve learned from history that, in the 1918 flu epidemic, the infection was controlled so well that on November 21, 1918, they opened up everything. Then in January of 1919, the death rate doubled from the virus. So let’s learn from history and be careful.
Part II coming tomorrow …