Call Notes & Replay | In the Trenches: Pulmonary & Critical Care Medicine

Call Notes

• When I look at the presence of COVID-19, the disease caused by SARS-CoV-2, in Michigan, the case rate has gone up significantly. 70% of newly diagnosed cases are the B117 ("U.K.") variant. When you think about coronavirus in general, you want to think about what the word variant means. Mutations = a change in genetic code, an amino acid, for example.  This definition of variant is a bunch of changes in genetic code passed down to other viruses once that virus replicates.
• The worry is that perhaps the variants lead to more infection, more transmission, or are more deadly – but B117 is covered by the current vaccinations.

• We have to talk about real-world data and efficacy…SARS-CoV-2 positivity - it doesn’t mean you have COVID-19.
• Look at it overall: the immune system is trying to "scout" the illness - we're allowing the body to get used to seeing a certain aspect of the virus, and then the body knows how to defeat it. We want to allow the immune system to respond efficiently, effectively and clear the virus quicker. Most of the data published on whether vaccines are efficacious cover just one layer of the immune system: the antibody layer. When your body sees a vaccine or pathogen, it creates many different cells or molecules that recognize the pathogen (more on this below). It is just easier to look at antibody levels or neutralization when the antibody binds to the virus and allows the body to recognize its presence.
• Variants are different spike proteins – a different color, for example - so we're looking for neutralization of that (whether the antibody recognizes and binds to the spike). Look at T cells too. It doesn't matter what the variant is; the body still has the ability to recognize that an infection is around and clear it.

• Once the body recognizes the infection, it will make a B cell, T cell, dendritic cells that recognize the infected cells and the virus. Right now, we're looking at just the antibody part in the studies. But all of those contribute to immunity.
• Real-world data - if fewer people are being admitted to the hospital once they've had the vaccination and severe COVID-19 cases and ER/ICU visits/stays down, are the people in the hospital - where they vaccinated? Or, if people aren't going to the hospital, or if they are, are they in the ICU? Are they dying? If not, the vaccine is doing its job.
• Vaccines aren't a force field, but you can tell if they are doing the job by the answers to those questions.

• A contact in Michigan said that all the people he's taking care of w/ SARS-CoV-2 or COVID-19 in the hospital are unvaccinated.
• A friend in Nashville - of the 12 cases he's managing (more than he's had), only one had been vaccinated, and that person is the “least sick.” 
• The vaccines seem to be doing the job.
• With B117 in Michigan – it’s more transmissible, and that increases the fatality rate (just math - if more people get it, there are higher case rates, more hospitalizations, and more deaths).

Do we know what it is about that one that makes it more transmissible? 

• If the virus – mutations – latch onto cells tighter or if it has increased "survivability," it can replicate more, and if it can replicate more, there's an increase in the viral load… if the viral load is higher, it’s more easily going through the air, there’s more virus out there. Thus, it's more "transmissible."

• This is one of the first times we are studying mutations of the spike protein on a daily basis.
• Part of it is routine w/ RNA viruses like SARS-CoV-2 – so we can see if the mutations lead to increases in viral load, transmission, and fatality rates.
• When you see the virus select for more dangerous variants, that's bad. It just so happens that B117 is covered by our vaccines – the antibody level drops with some of the others, and there's fear, so we're studying booster shots for certain variants like the P1.
• It's easy to create boosters due to the way mRNA vaccines work. That should help with better immunity vs. the variants. We‘re becoming more efficient – we just need to know what kind of booster is needed based on whether the current vaccines cover the variants. 
• P1 is able to evade antibody binding. That doesn’t mean that T cells and B cells don't recognize it. The important question to ask is: "Are the vaccinated individuals getting these variants?" This isn't discussed in the media. The answer is: "It's very, very minimal." The next is: "Have they been in the ICU or died?" If they haven’t – real-world answer = if you're vaccinated, you're less likely to get the variants too, and that’s probably the case. 

• SARS-CoV-2 infection and COVID-19 are not the same. Once vaccinated, it's within two weeks of the first shot that you can see the split in SARS-CoV-2 positivity and COVID-19 cases. To generate antibodies and the supporting cells and molecules to neutralize the virus or pathogen normally takes 7-10 days. It's the same reason that most people are sick for 7-10 days - 7-10 days after that second shot is when your immunity is strongest. 

• The increase in cases is not just a lack of vaccination - it's people... a lack of responsibility and behavior (traveling more, not wearing masks, etc.).
• The level of vaccination for herd immunity depends on how contagious – the R naught - constantly changes because of the variants. That's why you hear a range of 70% - 80%. People don't understand immunology and get angry, but that's the deal. 
• I think it's about 70% vaccinated.

• As long as vaccinations are going up, it’s meaningful. That’s certain.  Up to 2/3 of households have deferred care of some sort. 
• 65+ - 75% have had at least one shot – those people utilize healthcare the most, and they feel safer. For some strange reason, people are ignoring the people w/ the highest experience in life. They've been around for all these illnesses - e.g., polio - that needed vaccinations to clear them. Let's follow their lead. Why aren't 20-49-year-olds getting vaccinated? They are ignoring what the 65+ population is doing.

• About 20%-30% of people won’t want to get vaccinated (or they don't believe in it), which is ridiculous. Unless the pandemic is ongoing or people close to them get really, really ill or dies, then that's when someone says, "OK, I need to get vaccinated."
• Can you change their minds?
• I’ve changed a few minds, but there are some people that won’t change their mind unless someone close to them gets really sick or dies.

• As coronavirus changes, there will be more infections. Kids can spread it. An expert the other day said that kids are contributing to the spread in certain areas of the country.
• I don’t think it’s in California, which strangely has the lowest case rate in the country. Perhaps as schools go back, I wonder about how kids are going to deal with it. I have a little bit of fear for my kids, but we'll see.

• COVID-19 is an autoimmune response to the presence of the virus – once antibodies and cells get made to recognize what the spike protein looks like, they can bind to anything that looks like that. The molecules stick around in the lung(s), brain, bloodstream, etc. 76% of patients that have had COVID have symptoms 6 months later. Being a specialist in pulmonary, I've got some really severe patients with significant inflammation in the lungs  (full of white blood cells, can't exchange gas). I put them on heavy immune suppression to calm down the response. I can see improvement there through scans. Something like "mental fog" is harder to manage because we aren't sure if we know what it is.
• There's a thought that vaccination helps with long COVID.
• When you say 76%... I mean anyone with COVID-19 - hospitalized patients. But you don't need to have a super severe case to end up with long-COVID.

• If there's a silver lining to the pandemic, it's personalized medicine – understand the way in which cells interact w/ one another – I can't tell you how one patient will do versus another. We must individually take care of each person – [COVID-19] is very personal.
• The more severe they are, the less likely they go back to normal. I have a couple of patients that need a lung transplant, others that have scarring in the lungs, which leads to a reduction of lung function. 

• I don’t know… it could be that depression and anxiety are secondary to the quality of life lost – able to jog, exercise, then SARS-CoV-2, severe COVID-19, can’t run, pissed, don’t feel good about themselves. Some of the post-COVID syndrome could be neurological or mental health dysfunction. 

• ACE-2R receptor is expressed there, where spike protein binds to. No brainer if spike can bind to epithelial everywhere, then if have inflammation secondary to that binding, it can mess up a lot of things. Cellular communication leads to disease… it’s caused by the pathogen, but it’s the immune system’s response to the presence of the pathogen. Tempering that reaction is important and hard to do because it's hard to recognize when people get the infection.

• It depends on your exposure to crowds. I get tested every other week or so. If there's an outbreak, undergo testing in an easy way. Testing now is pretty easy. I know where to send patients and can send someone to their house. How often depends on exposure history – MI or NJ, or NY, I'd probably be getting tested every now and then.

• Over half experienced some kind of post-COVID, asthma, stuffy nose, can’t smell or taste as much. Those are the complaints that I hear most often. Nobody has said, "I had it, and it was fine." I've heard, "I was fine, but I can’t smell or taste…" I see my post-COVID patients once a month.
• The activity revolves around their symptoms. Many are younger, so I'll test/assess exercise capacity – can you run or get on your Peloton? Did you do a 10, 15, or 30-minute class? I get labs and more objective information for the ones I follow via telemedicine ("tele"). We check for inflammatory markers - if they are up in the first place, how are they trending?  

• Tele is now ~20% of my practice. It allows me to reach farther: TX, NY, FL, etc. I can do that relatively well, so long as there’s objective information to follow. It’s an important aspect of health care now. Once you see a patient in person, you can monitor them.
• The difference is compassion – I can be more compassionate, more empathetic, and explain things more easily in person. I have materials that allow for a robust explanation in the office. Via tele, it's harder to do that. 
• The other thing about virtual is that I can see their environment or space - if there's construction in the house, pets, etc. It helps with building a rapport.
• I don't know what the "right ratio" (of in-person and tele) is. If someone says they do, they're lying. It's person and disease-dependent.
• 80/20 might go up as my practice expands. I think 25%-45% could be tele. An older doctor doesn't want to do it at all, and I just take those. I think we'll see it increase over time and for monitoring chronic diseases.
• The intensity of the visit is not as high, but I'm comfortable prescribing over telemedicine. 

• I think people in the medical business need to take advantage of it. If there's going to be a delay or excess demand, it could be the time to start a practice on their own.
• If I know patients are backlogged and want an appointment, I'll fit you in via tele or whatever. People in healthcare - physicians in general - need to pay attention to what sounds like an opportunity.

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Thomas Tobin

Managing Director


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Justin Venneri
Director, Primary Research


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William McMahon
Analyst


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