Epidemiologists answer questions about COVID-19 and mutations

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

In today’s COVID-19 update, epidemiologists Ilse Levin, DO, MPH, and Harris Pastides, PhD, MPH, discuss some of the lingering questions around COVID-19, including what we know about the disease and its mutations, transmissions from holiday gatherings, the possibility of creating a "bubble" that works and when we can expect some normalcy.

Learn more at the AMA COVID-19 resource center.

Speakers

• Ilse Levin, DO, MPH, epidemiologist/internist, Mid-Atlantic Permanente Medical Group
• Harris Pastides, PhD, MPH, epidemiologist, president emertius, USC

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we're talking to two epidemiologists to help answer some of the many lingering questions about COVID-19. I'm joined today by Dr. Ilse Levin, an AMA trustee and a board-certified internist and epidemiologist, as well as a hospital-based physician for the Mid-Atlantic Permanente Group in Silver Spring, Maryland, and Dr. Harris Pastides, an AMA trustee and president emeritus of the University of South Carolina in Charleston, South Carolina. Dr. Pastides has also worked with national and international organizations, including the World Health Organization and the National Institutes of Health, on matters involving higher education in public health. I'm Todd Unger, AMA's chief experience officer, in Chicago.

Well, the last time we spoke with both of you was back in August, when the situation was very different. And at that time, we talked about how this was a novel virus and we had a lot to learn. So, Dr. Levin, why don't you start off by telling us what have we learned since August?

Dr. Levin: Well, we have learned that some of the basics to controlling this spread, like mask wearing and social distancing, can be very effective, but when we broadly reopen everything, we have seen the spread increase. We've also seen that with the holidays. We've had huge spikes across not just the U.S., but around the world, and we've also seen that certain medications work well to control the infection to some degree, once people are sick.

Unger: Dr. Pastides, anything to add to that?

Dr. Pastides: Yes, I would say on the pathophysiology side, we are again impressed with how wily COVID is and that it is able to adapt to our control measures, either by mutating or by somehow adapting to what we bring to it. And then on the public health side, we have reaffirmed all over again that once you let your guard down, whether it's for Thanksgiving travel or anything, just as you think you're about to come out of it, you realize you're not. So, we've got to be in this battle for a long time.

Unger: Well, speaking of wily and adaptation, over the weekend, we saw a strict lockdown in London and most of England Southeast, a decision that came after new evidence of a fast spreading variant of the virus emerged. Dr. Pastides, can you talk about what does this mean for transmission and spread, and have we seen other mutations with this virus?

Dr. Pastides: Well, yes, we have and I hate to be pessimistic, but there's no way that locking down London will avoid the rest of the world experiencing this variant, as well. What we're told is that the variant is up to 70% more transmissible. It may or may not, hopefully not, be more virulent or more deadly, but that means that the spread is going to continue, and in spite of, and I'm supportive of the control measures relative to the UK, there's just no way to keep it there. It's going to spread. And I do believe there have been other variants, as well. What we hope, though, is that the vaccines that are out today will be broad enough to be able to confer immunity against the original, if you will, and these new variants.

Unger: Dr. Levin, what's your perspective? And when you introduce this kind of uncertainty, how do we deal with that?

Dr. Levin: So, I think one of the most important issues with this new variant is how rapidly it spread. And what we have seen is that when governments respond quickly, they are much more effective. The longer we wait, the harder it is to get control. Once the transmission gets out of control, it is very hard to get that back under control by flattening and then suppressing the curve. So, I think it will involve planning out more, probably stricter guidelines on mask wearing, on social distancing, and controlled closures, but not across the board. What we've seen is that certain closures or decreasing the number of people present in one place at one time are more effective than closures across the board.

Unger: And this is going to be a pretty tough time. We've seen Boris Johnson in the U.K. accused of canceling Christmas for portions of England. With the holidays coming up, that's a big issue. Dr. Levin, talk about what do we see in terms of the effects of Thanksgiving on transmission and spread, and have we fully seen the impact of those gatherings and holiday travel at this point, to only be compounded by Christmas?

Dr. Levin: Sadly, I don't think we've seen the full effect yet. When people get sick with this, we're talking about weeks. And so as far as deaths go, I think we are still seeing those numbers coming in, and as we hit the holidays, so we have Christmas, Kwanzaa and New Year's coming up, and we just finished Hanukkah, so you have the potential for more travel, more family gathering. And what we did see is that large groups traveling and getting together for celebrations, we see larger clusters forming.

Dr. Levin: So, I think this is very concerning. What we have to do is learn from what happened with Thanksgiving and really change our behaviors. I see it as not canceling the holidays, but changing how we celebrate for this year.

Unger: How would you describe that, I guess, in terms of the advice you would give people about how to celebrate the upcoming holidays?

Dr. Levin: Just stay put. I would not travel to see family. If you do have to travel, then if possible, quarantining beforehand and working from home, avoiding any social gatherings beforehand, and then being very open with everyone who is going to be gathering about their symptoms and what they've been doing, and asking everyone in that group to comply with avoiding interacting with others beforehand, and perhaps going and getting COVID testing before getting together.

And then the other addition to that would be planning to stay in separate places, not stay in the same place, so you minimize your time together, and keeping those numbers still as low as possible. But when you are together, maybe separating out the table, separating out cooking the food. It's so easy for everyone during the holidays to spend time together in the kitchen, in the living room. And this means really spreading things out a little more and being more thoughtful of what we do, and still wearing masks. I think that's important even when you're in a private home. If it's not your home or if there are other people there who you're not with all the time, wear a mask.

Unger: Dr. Pastides, I think Dr. Levin was talking a little bit about this idea of bubbles. Many people have tried to create these. Is this a productive concept? And is there a way to go about creating a bubble that works?

Dr. Pastides: Well, it's a valiant effort, and I commend people who try to do it. And it's another one of these imperfect and incomplete control measures. I hate the fact that the public health and medical communities have taken on the aura of being the Grinch, but it is something, you know, I think we want to appeal to people, not only for their own wellbeing and their own families, but for our society and for our world as a whole.

You only have to look to epidemics that occurred in our lifetimes. I'm older than Dr. Levin, but I'll remember polio, and how seriously my mom and family took that. And in those days, you could actually see children, not to mention Franklin Roosevelt, who was a victim of polio. And we desperately wanted to avoid that. COVID is a little bit different. It's a lot quieter, unless, like Dr. Levin, you work in a hospital, in which case you are confronted with it every day.

So, I think these smaller pods and these smaller things are, again, a good, valiant attempt to try to stay with people who you are confident are healthy, but we need more testing. And Dr. Levin alluded to it, I think the countries around the world that are doing somewhat better than us, and this is not a competition, by the way, we want everyone to be doing well, they really afford everyone the opportunity for frequent, regular testing. Before you go back to school, after you come home, really regularly. And the countries, frankly, where the pandemic is raging more, are those where testing is not as accessible or affordable to the people.

Unger: In addition to testing, Dr. Levin, what should, first of all, physicians be doing to help the situation, and what counsel to federal, state, even local governments, to try to keep people safe until a vaccine becomes more widely available?

Dr. Levin: Masks are so important, and knowing which mask to wear when. We know that the bandanas are not helpful, but wearing that mask, making sure that both your nose and your mouth are covered. That's one of the things I see frequently, is not wearing it properly. Trying to keep that social distance, avoiding parties, bars, clubs. There's such a desire to get together, especially right now, and so changing that media of how to get together to perhaps video calls instead. I've taken part in those myself, with my own family. You have to come up with alternatives, but it doesn't mean you have to cancel what you're doing.

And I think it's important that doctors keep on that message of social distancing and wearing masks are really key. The other thing I would add to that, though, is getting the flu vaccine. We know, having watched the data from the Southern hemisphere, across the board flu cases were down in the Southern hemisphere's winter. And we see that they're down here. What we don't want is to have a combination of both flu epidemic, along with COVID, and having patients getting both at the same time and getting sick from both at the same time. That would just be devastating. So, I think it's also pushing that flu vaccine.

Dr. Levin: As far as the physicians and nurses, as well as anyone else working in health care facilities, I think really taking that COVID vaccine when it's available is important. It's going to be a while. What we're seeing is that states are getting varied access. Where I live, I know we're seeing decreased access to what we had expected, and so it's really limiting which populations are able to get it right now. It's really the most at risk people working in hospitals and in retirement communities. But I think accepting it, being open about it, talking about the fact that you got the vaccine, and really trying to make sure that people understand this is safe. This is effective. It's something new, but it's one of those weapons we have in our arsenal to try and keep COVID from spreading.

Unger: Yes, it's given me great joy over the past week to see many of the physicians I know from the American Medical Association showing themselves getting the shots. And I know, just back to what we were talking about before, even despite how much I wanted to see my 86 year old mom, I've said, when we are so close to a vaccine, particularly for someone her age, it just doesn't make sense to take that risk and try to get together.

So, let's talk a little bit more about the vaccines. We now have the introduction of two authorized vaccines. How is this going to change the course of COVID-19, Dr. Levin?

Dr. Levin: Sure. So, I think it's going to certainly help, and long-term it will potentially be a game changer, but I think we have to plan for the fact that it's going to be a slow roll out. When we look at the numbers and we look at the size of the population in the U.S. and who is going to have access to these vaccines, we're not talking about the general public. So, while we are waiting to get that vaccine manufactured and out to the general public, I think that we need to keep up all of those protective measures, with wearing masks and social distancing and avoiding large family gatherings, or large gatherings in general.

And the other thing to remember with the vaccine is that you do need two shots. So, one shot gets you in the 50% range. That is not enough to get herd immunity. And so, one of the other issues with the vaccine is that we really do have to track that people are getting two shots to be effective. If we're able to get that widely across the population, then we have a good chance of really getting this under control.

Unger: Dr. Pastides, anything to add?

Dr. Pastides: Yeah, I worry about two things, the vaccine distribution, getting it to the places of in fact highest risk, not necessarily the nursing homes and the infirm in health care settings, or our health care professionals, but people who live in a dense inner city or more impoverished locations. American health care doesn't have a great record with the health disparities, and I worry that there will be disparities in the distribution.

And the other is the people who could have access, but who will reject the opportunity to take it. And I want to be clear, I don't think public health should look down on those people. We should respect the fact that they might have fears, concerns, or trust issues. Maybe they'll be a little bit toward the back of the line, but it's so vital that people like Dr. Levin, health care professionals, that our political leadership, as well, show by example that they and their families are being immunized. And there will be problems. We need to acknowledge that tonight on the evening news, there's going to be reporting of more side effects, and eventually some serious ones. And we hope not, but maybe even a death. Again, I hope not, but that happens with all kinds of therapeutics and things like that. So, we've got to respect people who are concerned about taking it.

Some in the minority community, because of bad experiences before, might be particularly averse to accepting the vaccine from the medical authorities. So, we've got to work together, I think with compassion and leading by example, because the alternative is that COVID, as long as it can prey on large percents of our population, it's going to be around for a long, long time. The more people who get vaccinated, the better off we'll all be.

Unger: I think that's exactly right. Dr. Levin, do you have any other thing to add before we close?

Dr. Levin: Yeah, I do want to talk about another group, in addition to what Dr. Pastides just said. The people who are incarcerated and working in incarcerated settings have an extremely high risk. We just saw in South Korea that they had another cluster outbreak in one of their jails. And given that that country has had some of the lowest numbers in the world and shown some of the best control, I think that's a good comparison, when we know here in the U.S., most of our large outbreaks came from incarcerated settings.

So, and when me think about this, we have to remember people are working in those settings and then going back out into the community. People are being released and going back out into the community, and they may be asymptomatic and spread it to the community. So, I see that section of our population as extremely high risk, and they should be getting access to the vaccine early. They should also have increased testing and access to treatment if they start showing symptoms.

Unger: Well, thank you so much, Dr. Levin and Dr. Pastides, for being here today. So many important messages as we enter a very difficult period, with hopefully light at the end of this tunnel. We'll be back soon with another COVID-19 update. And in the meantime, for resources on COVID-19, visit ama-assn.org/covid-19. Thanks for joining us, please take care. Happy holidays.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.