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Get COVID-19 Answers From an Infectious Disease Doctor

June 10, 2020

Here is an edited version of a recent question-and-answer session with Dr. Faiqa Cheema, a Hartford HealthCare infectious disease specialist for Courant.com subscribers:

Q: What are the odds of a recurrence of the pandemic in the fall?
A: It is very possible to see a second wave of coronavirus that may coincide with the start of the influenza/flu season. We have to move forward, staying vigilant and revisiting our public health policies based on scientific evidence. We have learned so much in the past three months about the virus, but there is so much we do not fully understand. We are better prepared in regards to our testing, our PPE supply and early recognition of patients who can quickly decline and require intensive care.

Q: What is the likelihood of a vaccine being available by the end of the year?
A: Vaccine development is occurring at unprecedented speed as the scientific community has been racing to understand this new virus and the pathophysiology of this disease to discover new treatment options and also develop new vaccines.  There are approximately 100 vaccines currently in the development phase of which, about eight  in clinical trials. So far,  two frontrunners in this race are Vaccine #1 Oxford (UK) and #2 Moderna (USA) and we are still in the early development phase.

In my opinion,  it may be too ambitious to expect a vaccine to be ready by this fall. We need to focus on a strategy based on phased and cautious  reopening of the economy, broader-based testing and cohesive surveillance and contact tracing. Whenever the vaccine does come out, the US needs to make sure that it is  available to everyone, and affordable to everyone. Otherwise, the pandemic would take much longer to control.

Q: I am a 70-year-old man who is not experiencing any apparent health issues at the moment. I got the impression you had to go through a process to get approved by your doctor if you exhibited symptoms to even get tested. Is that still the case or should we just be going to get tested?
A: Current recommendations from the CDC and state Department of Public Health still remain to give high-priority testing for COVID-19 testing for the following individuals:

• Person with symptoms of potential COVID-19 infections including fever, cough, sore throat,  shortness of breath, chills, muscle ache, loss of sense of taste or smell, diarrhea, vomiting.
• Person hospitalized with COVID-19 symptoms
• Residents with symptoms of COVID 19 living in long term care facilities, including congregate settings, such as prisons and shelters.
• People without symptoms are only being tested if they have close contact with a confirmed case of SARS-Cov-2 for public health monitoring, contact tracing for purposes of public health surveillance

The rationale for this approach is most likely the high number of “false negative” results — test results suggesting no infection in those who are indeed infected — we would end up seeing.

Q: Do you think it would be helpful for health officials to offer drive-through COVID-19 antibody tests conducted outside, in cars, as many of the diagnostic tests were conducted. It seems like going into a healthcare clinic for the antibody test creates an unnecessary risk, while of course knowing who has the virus seems helpful overall.
A: Yes, I certainly see utility in doing drive-through antibody testing, however at this time we are uncertain what those antibodies would mean as well. Antibodies are proteins that help fight off infections and usually provide protection specific to the disease what we call immunity. This immunity can either be life-long or nearly non-existent.

We still have a lot to learn about SARS-CoV-2 immunity and much of our understanding of corona virus immunity comes from studying 2 other coronaviruses such as SARS and MERS (Middle Eastern Respiratory Virus) which have infected a relatively small number of people.

So far, here is what we do know about COVID-19 immunity:

1. Our immune system has never seen this virus and therefore we do not have any immunity against it.
2. Antibody test should never be used to diagnose COVID-19.
3. Most individuals infected with SARS-CoV-2 will have an immune response, some better than others.
4. It can be assumed safely that this immune response will offer some level of protection at-least for this year.
5. At this time we do not know how long this immunity will last and for how long.

Q: In the early days of the pandemic, we learned that the virus survives on surfaces anywhere between two and seven days. Paper, plastic, steel and glass have different properties. It stays in the cold more than in heat. You can wipe a packet clean with Clorox but do not always need to; plain paper towels will do the job. A shower that you take when you get back in the house from a public place will suffice to cleanse it. Sunlight is an effective deterrent of the virus. I have shaped my way of decontamination based on these beliefs. Are all these points still correct?
A: CDC updated its website in May to report that SARS-CoV-2 does not spread that easily via contaminated surfaces and is no longer thought to be the main way the virus spreads. SARS-CoV-2 is more readily  transmitted from human to human and occurs more exponentially if the human-human contact occurs in closed, crowded and poorly ventilated spaces. However, my recommendation at this time is not to get complacent and lax with our hand hygiene rigor and to still continue to avoid touching your face, mouth and eyes with your contaminated hands and use hand sanitizer or soap and water to wash your hands.

Q: I am going to visit my stepsister at her home in New York who is 76 with serious health issues. I am 75 and in good health, but wanted to get tested for COVID-19 before I went. I was told I am not eligible, even though I am over 65 and care for my 76-year-old husband who also has health issues (not COVID). Apparently, I can’t get tested because I myself have no symptoms, even though I am in the vulnerable group, age-wise. Why not?
A: So sorry to hear about your stepsister who is currently suffering from a serious illness.  We are not recommending testing of persons without symptoms because of “false negative” result — test results suggest no infection in those who are indeed infected. When people have no symptoms, they could still carry the virus and test negative by the swab-testing of their nose or back of their throat because at that time the concentration of the virus is low and can be missed by testing, giving a false sense of security. I certainly empathize with you and your family at this difficult time and can understand why you would want to be by her side.

Q: Are scientists looking into the reasons someone can have the virus, but not get sick? The genetic or biological implications of asymptomatic carriers would be significant and it would be interesting to find out how this happens.
A: I prefer to call it “pre-symptomatic” rather than “asymptomatic” transmission. Transmission of the virus occurs 24-36 hours BEFORE onset of symptoms, making it much more challenging to track and contain. Therefore, physical distancing, avoiding congregate settings and wearing masks have played a critical role in reducing transmission of the virus. A study published in the Lancet scientific journal reported that 1 meter or greater physical distance reduced risk of acquiring COVID-19 from 12.8 percent to 2.6 percent. Wearing a  face mask reduced risk of COVID-19 infection and transmission from 17.4 percent to 3.1 percent. We still do not know the genetic predisposition of who develops little or no symptoms but can still spread the virus and if age, gender and race has any role to play. Great questions for current scientific research.

Q: About vaccine distribution, once it’s available, will there be some kind priority format allowing the “most at risk” to be inoculated before others?
A: I agree, there should be a national COVID-19 vaccine plan regarding how and when everyone will be vaccinated. So far we have not heard any announcement  or headlines on this endeavor.

Q: I continue to hear conflicting information about the safety of handling and consuming fresh vegetables and fruits (including berries which are not easy to thoroughly wash)in regard to COVID-19 transmission. Being over the age of 65 with an autoimmune condition, I would like to know if these foods pose any risk for transmitting COVID-19 and if so what are the most up-to-date recommendations for handling and eating these foods, and are they safe to eat raw?
A: Transmission of the virus from handling or consuming unwashed fresh fruits and vegetables is thought to be low and recommendations are to wash them with water before consuming it, to the best of your ability without it being a source of mental anguish.

Q: Can a person who has already had the disease still be contagious and can he/she get it again?
A: The ideal scenario: Once infected, a person is completely immune for life is correct for a number of viral infections like the chicken pox virus. Immunity after a viral infection can range from lifelong to nearly nonexistent. We do not yet know once you recover from COVID-19 how long your protection with antibodies will last.

It is very unlikely once you have recovered from COVID-19, you will be contagious to spread the virus to others at-least for this season and also unlikely that you can contract the virus again for the year 2020.  The World Health Organization has received data that some people who have recovered from SARS-CoV-2 virus may experience re-activation of some of their prior COVID-19 symptoms after recovery. We need more data to determine why the virus behaves so differently in some infected, recovered people.

Q: Should someone (35 years old) who has been to a protest march in in Connecticut  last week be considered a higher risk to contract and/or spread the coronavirus?
A: As an Infectious Disease specialist, I have concerns about the protests as we are still in the middle of a global pandemic but as an American citizen, I understand that peaceful protest is an important right of any American citizen.  I advocate that partaking in protests does increase risk of acquisition of infection and we are prepared to see a possible increase in the number of infections. We advocate as health professionals that if you attend a protest that the following guidelines are followed:

1. If you have any symptoms of COVID-19, please stay home.
2. Wearing a mask is necessary protection in a pandemic and should cover nose and mouth.
3. Carry a hand sanitizer with you to wash your hands.
4. Stay 6 feet apart from other protestors, if possible.
5. As temperatures rise, wear a hat, sunscreen and carry water for hydration.

Q: My guitar teacher is resuming one-on-one teaching next week, at his home for a half-hour session per student. I’m the first student of the day. Should I have qualms about resuming these once-weekly sessions? And any particular caution appropriate? 
A: I am happy to hear that you are resuming your guitar lessons. My advice is to perhaps check with your teacher if these lessons can be given in an outdoor setting (patio) vs. an enclosed room, where it may not be possible to stay 6 feet apart. If this is not possible, you can take the lessons indoors (if you are the only student for the 30-minute class), wear your mask for the 30-minute duration and sit 6 feet away from your teacher. Don’t forget to pack your hand sanitizer in your bag.

Q: Is it acceptable to let younger kids play outdoors with one or two friends, supervised by parents? Is it still best to limit a child’s “playing circle” to one or two friends, or is it OK to let them play with anyone? What do you think of sending kids to camp when the state guidelines are observed? The kids (and their stressed-out parents) are more desperate than anyone for reopening. I would trade all the businesses in the world for camp.
A: As a mother of two children, I completely empathize. I am also struggling to keep my children entertained and often wonder whatever happened to the days when we played all by ourselves making mud pies and crafting imaginary play. It all comes down to your comfort with risk tolerance.

I can speak for myself: I am not allowing my children to play one-on one with their friends in close proximity. I do let them ride their bikes with their friends in the neighborhood and they are given strict instructions to wear their masks when closer than 6 feet from their friend.

Regarding camps, we are going to pass on routine camps for this summer but that is related to my own personal preference, instead we are going to let them participate in camps that have outdoor activities like tennis and golf in smaller groups.

Q: A lot of people are arguing about whether masks are helpful or not. Can you explain how masks help the person wearing them and help the people around the mask wearer?
A: SARS-CoV-2 spreads primarily from person-to-person through close contact and large droplets and causes COVID-19. Until there is a safe and effective vaccine or a reasonable treatment option becomes available, we will continue to rely on non-pharmaceutical interventions, including measures that can mitigate spread of the virus in community settings. This includes physical distancing, wearing masks and broader based testing and surveillance.

Wearing a mask is the most inexpensive way to reduce spread of the virus. It prevents your respiratory droplets and  saliva from remaining contained, thereby protecting others around you. It is important that the mask should be secured properly, not requiring constant adjustments that can lead to contamination of the outside of the mask. The mask should cover your nose and mouth when outside or within 6 feet physical distance of another individual.

Current data published in the scientific journal Lancet shows that use of face masks was protective for people in the community and can protect against COVID-19 infection and reduce  transmission from 17.4 percent (no mask) to 3.1 percent (wearing a mask). Cloth masks are advised for the community instead of medical grade masks and are just as good in providing protection. We advise that medical grade masks should be saved for all frontline workers.

Q: I know that outdoors is better than indoors, but how dangerous is it to be indoors with others as long as people remain 6 feet apart or wear a mask?
A: Increasing evidence shows there is  increased transmission of the virus in crowded (close proximity), enclosed and poorly ventilated spaces for prolonged durations. Outbreaks related to outdoor activities are linked to “super-spreader” events involving large crowds. We need to follow Gov. Lamont’s and state guidelines on recommendations on safe numbers for indoor events.

Q: What experimental outpatient treatments trials are in process for moderate early COVID symptomatic high risk patients and which facilities do you know are conducting them?
A: There is a lot in early stages related to possible treatment options for COVID-19 and despite the unknowns, one thing remains clear that there is no approved treatment for COVID-19.  To date, the mainstay of treatment remains supportive ICU care. A drug called remdesavir has recently received a lot of headlines as a possible  game changer. Remdesavir is an antiviral drug that in recent studies has been shown to reduce the number of days you would be sick with the virus if given early)  and had no impact on the really sick patients in the intensive care unit.

At this time, a larger clinical  trial is still needed to answer some important question such as:

• Who are the patients who would benefit most from this medication?
• How effective is the drug?
• What is the best duration of treatment 5 days versus 10 days?
• Can this drug be given in combination with another mediation?

Currently, Remdesavir is being distributed by FEMA based on State and regional COVID-19 cases.

Q: I understand that the accuracy of various antibody testing varies tremendously. Are there any specific types of antibody test — or tests distributed by certain companies — that are more accurate than others? Why is there such variation in accuracy for this test; is that common?
A: It is very common to see variability within antibody testing. In early March, the Food and Drug Administration relaxed regulations related to rapid COVID diagnostic testing capacity that led to floodgates being opened and approximately 160 tests were available of which only a handful were regulated and validated for accuracy.

Since March, the FDA has improved its requirements for these diagnostic testing and we anticipate perhaps the diagnostic testing field may see some marked improvement with improved accuracy. Ideally, we want to see an antibody test that has close to 100 percent specificity (very specific for  SARS-CoV-2) and does not  cross-react with the other many coronaviruses (MERS, SARS and the common cold coronavirus) and as close as possible to 95-98 percent sensitive.

Q: What safety precautions should dentists use?
A: Dentists should follow precautions and guidelines provided by the state and the CDC. If an aerosolized-generating procedure is not being performed, a surgical mask and eye goggles should suffice and an N95 mask is not necessary. However, information pertinent to infection control practices continue to  evolve and my advice is to always stay up-to-date by following the Connecticut Department of Public Health guidelines.

Q: How long after potential exposure to the virus will enough virus be present for me to test positive if I have it?
A: COVID-19 viral replication occurs 24-48 hours prior to symptoms, peaks at Day 3- after onset of symptoms and then begins to decline especially if you test upper-respiratory airway specimens.

• The ability of the nasal swab to pick up the virus depends on some important factors.
• Specimen quality (if the virus is not transported appropriately).
• The technique of how the swab was conducted.
• Analytic sensitivity of the type of test used to pick up the virus (viral swabs from nasal passages give better results than specimen from the throat).

False testing can be seen if testing is done too early, before the peak of viremia ((the presence of viruses in the blood) or if testing is done too late after peak of viremia. The third reason for false negative test is  poor specimen collection.

We now know that some people can continue to shed the virus in their nasal passages up to 4-6 weeks. Scientifically, we understand that you can still shed the virus even after recovery and not be spreading the infection and perhaps we are picking up possibly “dead, inert” virus that is not very potent.

Dr. Faiqa Cheema is a Hartford HealthCare infectious disease specialist.

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