Covid Factual Missive 6/6/20: Vaccines, Antibodies, Reopening and Zoloft

Hi, I’m back as Robin-Schoenthaler-the-Boston-cancer-doctor-who-writes-about-Covid.

Covid faded a little for me this week. I wondered if it’s even appropriate to be writing about Covid during a week like this one.

But I keep thinking about how the pandemic has revealed so many holes in the American medical system and so many inequities; and how one of the stark black-and-white truths we are seeing is that these deep-seated health inequities are not just morally unjust; they are deadly.

One tool in my toolbox is information. So, I write.

Massachusetts:
From a Covid standpoint, Massachusetts continues to improve. Many milestones this week: fewest deaths, longest-hospitalized patient released, twice-weekly Covid Town Halls slowing down, and our numbers of Covid-related emails finally thankfully dropped.

We are starting to staff our clinics and operating rooms again, and next week, as Massachusetts moves into Step 1 of “Phase 2 Reopening,” we’ll start doing the mammograms and heart tests and well-child-exams and even the colonoscopies we had to delay.

The hospital and our clinics are super safe places to be now — super clean, super regimented, super PPE’d, super spacious (waiting rooms with no waiting). No excuses on your colonoscopy now!

So where are we with the science about Covid? Every week we know more, and a little more refined. But more science reveals more questions — more caveats and maybes.

Antibody tests:
Do you recall how a few weeks ago I said antibody tests, rushed out without validating science in the wild west of an FDA free-for-all, weren’t ready for prime time? Well, they are now. The FDA has now verified that the tests are sufficiently accurate, they’ve pulled the bad ones, and they have a list on their website of the reliable tests.

You remember your biology: antibodies are the little soldiers your white cells make to deactivate viruses. You have to be infected with virus XYZ in your body in order to make antibody XYZ.

The Covid antibody blood test looks to see if your (usually hyper-competent) body made Covid antibodies — therefore “proving” you had Covid.

But here is the push/pull of science. There’s a lot of probablies and maybes before you get to “proof.”

What does a positive antibody test tell you? It tells you:

— you probably had this virus in you, ie you were infected (but in the lousy tests, they also pick up other coronaviruses)

— it’s probably been over a week since you were infected (testing less than a week after you’re infected won’t show antibodies)

— your body was able to make antibodies to fight it off

What a positive test does not tell you is:

— when you were exposed

— whether you are contagious right now (the only thing that tells you that is the viral swab)

— whether you will stay “immune” forever

This latter is a most important thing. We don’t know what a positive antibody test means in terms of immunity. Maybe it means

— you are immune now (probably)

— or will be for a year or two (maybe)

— or you will be immune forever (quite possibly not).

This obviously has huge implications in terms of immunity passports etc.

A negative antibody test is less illuminating. It tells you either

a) maybe you weren’t ever infected

b) maybe you were infected but it was so recent you haven’t yet made antibodies

c) you were infected but it was so mild you didn’t need to make antibodies

Takehome:
Current state of the science: interesting information but still a lot of maybes.

Vaccines:

The fastest vaccine development in the history of the world. Scientists have leapfrogged from concept in January to Phase 1 tests (safety) to planned Phase 3 trials (one group of patients will get the vaccine, one will not, then see how many people don’t get sick) of at least two vaccines in July and then two or three more.

And then what? We will have more science with caveats.

— Will the results come in quickly (what if some patients getting the vaccine live in a low-incidence area?)

— It was apparently safe in the 48 test patients (will it be safe in 30,000?)

— How well might it work? (like the polio vaccine — a few times and you’re good forever? or like the flu shot — once a year and it helps but isn’t a guarantee)

— Can it be manufactured in bulk (and be distributed quickly, fairly, cheaply)?

Takehome:
Lots of action, lots of questions, lots of maybes, and lots of hope.

Reopening:

Flying by the seat of our pants…..building the plane while we’re flying it….flying on a wing and a prayer….

Whichever metaphor you choose to use, we are reopening informed by guess and by golly and by rapidly evolving science.

Massachusetts is using epidemiological data and science and a high degree of caution to reopen. (Some other states not so much.) Some of the regulations will be too lax, some will be unnecessarily stringent, some will change, and some we will end up laughing at. There’s a lot of maybes.

For you and I, what do we think about when encountering other people in our widened reopening worlds?

— Are we outside?

— Are we far apart?

— Are we masked?

— Are we not touching the same stuff (eg serving utensils)?

— Are we not for heaven’s sakes sneezing or coughing or feverish!!!?? Because we of course stayed home if we felt even slightly sick, RIGHT?

— Are we washing our hands like surgeons despite all this hoop-la?

If the answers to all of these is yes, the science says we’re reasonably safe (ie, not 100% safe but not dooming yourself either).

My guideline: if I answer no to any of these — eg being close, being confined, not being masked, not being able to wash my hands, etc — I reconsider and reconnoiter.

Takehome: If I can’t remedy the situation so I’m safe — I go home.

Concerns re large group exposures eg demonstrations:

We don’t know what’s going to happen

Optimistically:

it’s outside, it’s summertime, there’s lots of masks, it’s mostly younger people; Europe’s outdoor gatherings/protests haven’t seen spikes

Concerning:

— dense crowds, shouting, singing

— Timeline:

a) Upticks don’t happen overnight

b) It takes at least a few weeks to see more cases

c) It takes at least a month, maybe six weeks, to see more deaths

We don’t know. We will learn. Right now it’s all a maybe.

Last Footnote:

In a heart-rending footnote, the FDA announced this week there is a national shortage of Zoloft, one of the most commonly prescribed anti-depressants in America.

These are hard times. Hard hard times. So much inside, so much outside, so much learning to live with the maybes.

Written by

Radiation Oncologist at Massachusetts General Hospital/Emerson Hospital. Writer. Teller. Mom. Currently Covid-Obsessed. www.DrRobin.org, @robinshome

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