We encourage everyone to listen to these interviews, Dr. Osterholm shared a true wealth of information.  I have listened to them several times to be sure I have learned what he has taught us.

Glossary

• Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses, and on it goes.
• Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
• SARS-CoV-2– the specific name of the new coronavirus
• COVID-19-the name of the illness that the new coronavirus is causing
• Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
• Epidemic– a sudden burst of an illness that comes and goes over a limited time
• Pandemic– an epidemic that bursts across the world not just one region
• Spreadability– how contagious is the disease, how many people will end up infected
• Symptoms- the experience of being ill, for example- fever, cough, headaches, loss of smell etc.
  • Asymptomatic– literally means “without symptoms”.  For COVID-19 it refers a person infected with the virus but has no and will have not symptoms
  • Presymptomatic– This is a person who was infected with SARS-CoV-2, and will feel sick, but hasn’t yet
• Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
• Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
• Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
• Personal Protective Equipment (PPE)- PPE are any item that covers any part of the body with the design and intent of keeping viruses in the environment from infecting the wearer of the PPE. PPE’s include all masks (which includes respirators), face shields, eye shields, gloves, gowns.
• Ventilator- a ventilator is a machine that can force a person unable to breathe to inhale and exhale and control both effectively.  They are sometimes called respirators, but during this pandemic the word respirator is now reserved for reference to a tightly fit mask.
• Live Virus Swab– this is the swab which attempts to swipe live virus from one’s nose or throat to see if you are currently infected.
• Antibody Test- (aka serology test) this is the blood test which looks for antibody to the SARS-CoV-2 virus to see if you have been infected in the past.

In this special COVID UPDATE from Real Answers, we expand on some of the many insights shared by Dr. Michael Osterholm in his interview with Dr. Lavin from July 8, 2020

Background

As most people know, and has been mentioned to readers of Real Answers, Dr. Michael Osterholm is a world renowned expert in the field of dangerous infectious diseases, has helped work on some of the most pressing challenges from germs to humanity, and his advice has been sought by the world’s leading institutions that protect us from harm from germs.

Advanced Pediatrics was beyond honored to be granted an interview with Dr. Osterholm, and so pleased the depth of his understanding was brought into our conversations on this pandemic in this space, Real Answers.

The interview reflects our understanding of the pandemic as of the day of the interview, July 8, 2020.  One of the first things we discussed is how the greatest strength of science is actually exposing what is not true.  Paradoxically, it is this process that allows us to gain understanding of some things that are true.  As a result, our understanding of new events, such as this pandemic, changes over time.

The interview was organized into 3 sections, and therefore, so will this COVID UPDATE.

The Biology of the SARS-CoV-2 Virus

I asked Dr. Osterholm what we currently know about how much this virus changes over time.  We know that at one extreme, the influenza virus changes extremely rapidly, with each infection, whereas the herpes viruses change no more rapidly than we do, which is to say not much, over time.

The answer is that all life changes.  We adapt as circumstances demand, and time brings change all on its own as well.  He noted that we change too, we are different today than some decades ago, for example.

It may help to remind ourselves how life changes genetically.  Life is built around two great forces- our genes and our experiences.  Life has a balanced challenge.  An essential aspect of all forms of life is that it makes copies of itself.  No copies, no reproduction, no life.  Copies must be exact enough to work.  We know that even minor errors in copying genes leaves a copy form of life that will not work.  An extreme example is the influenza virus, which makes about a million copies in every cell it infects.  The million copies of the virus explode out of the cell, destroying it (that’s the destruction of the infection at work), and each, if copied accurately enough, will infect another cell.  But the influenza virus gene copying is a big, big mess.  Out of a million copies, it is found that only 10,000 are working viruses.   This is in stark contrast to the herpes virus which only has a 7 changes out of 10,000 copies, which turns to be about the rate our cells mutate when we reproduce.

I mentioned a balancing challenge facing life.  It cannot mess up copying too much or their will be no descendants.

But at the same time, some errors need to be built into the process.   Without errors, there is no adaptability.  One set of genes produces one type of life, in deep detail, but the world changes, and if the genes cannot change at all, changes in the world can wipe out life.   A dramatic demonstration of this fact is that over 99% of species of life have already entered into the oblivion of permanent extinction.   Isn’t that humbling?  Life fails to adapt 99% of the time.  Meaning all the life we see around us are the small 1% or less of species whose genes did change enough to continue living, while not changing too much to stop reproducing.

With all that in mind, I asked Dr. Osterholm, how is this virus, the SARS-CoV-2 virus managing this balancing act?  Is it a crazy error-ridden mutation machine like influenza virus, or more like us and herpes virus, a slow changer?

More to the point, are the changes seen to date influencing its function, making it spread more, making it kill more?

The answer:  There is little evidence for either.  Perhaps, just perhaps, the virus is becoming more spreadable or contagious, but there is not much proof that the virus is more deadly.  Mutations are seen in this virus, but they reflect more the passage of time which brings change, with changes that are not impacting spreadability or severity, yet.

Dr. Osterholm also commented on the issue of durable immunity, observing that some immunity happens, otherwise no one could recover.  The question is is it durable, and if so, how long does that last.   Some findings suggest the immunity, and therefore protection, from having the infection is fleeting.  But we simply do not know for sure.

The Human-Virus Dance

All diseases, including infections, involve not just the cause of the disease, but each of us, and our communities.  How our body reacts, and how our nations react, help define our actual experiences of the disease.

And so it is with the disease, COVID-19.   In this section I asked Dr. Osterholm questions relating to how we as people make choices that influence how much this disease spreads and how much damage it does to all of us.

Has the Two Model Concept Presented in Real Answers Been Valid?

The first question had to do with a way I have tried to understand differences in the experience of the pandemic across various nations.  Readers of Real Answers will be long familiar with our sense that there are two major models, or strategies, in place around the world.  So this first question in this section had to do with whether my read of this difference was accurate and how sustainable one of the models could be.

For the purposes of our discussion I labeled Model One as the strategy of Identifying the Infected and then Isolating them to stop the spread.   Model Two is the strategy of shutting down the nation, isolating everyone.

Model One has been followed by many nations around the world.  If you go to www.endcoronavirus.org today you will see 48 nations have achieved essentially an interruption of the spread, they have stopped the virus, and the number of deaths per day has been brought down close to zero and held there for many weeks even months.

Model Two has been followed by us, America.   It is a damaging strategy, closing businesses, schools, cruelly isolating and it is not nearly as effective.  Even under severe national isolation we still had transmission of virus sufficient to kill over 100,000 of us, not the million or more who would have died without the lockdown, but far more than the zero deaths achieved in Model One.

In talking with Dr. Osterholm, it was confirmed that this view of the patterns of the Two Models is, as he put it, “Spot On.”  This comes as a very welcome confirmation, as this perspective was the result of my own reading of the patterns, how powerful and helpful to learn it is the view shared by one of the top experts in the world on such matters.

The implications of this confirmation are important, too.  First, it means we in the US have the ability to be like other nations that have more effectively reduced the spread and incidence of this virus and its disease, COVID-19.  It also suggests that such efforts are sustainable.  Imagine if we achieved working identification of enough of us who are infected that we could isolate those of us infected well enough so that we could not be suffering massive outbreaks, interruption of business, closed schools, as well as  so many deaths and impairments!

The Tornado Effect

We next spoke about the curious phenomenon that COVID-19 has not appeared across the United States all at once, it seems to appear in very discrete spots, here and not there.  Almost like a tornado, hitting my home and not yours.

Dr. Osterholm observed that we don’t know why it pops up discretely, but this is a common happening with onset of viruses spread by breath.  Influenza coats the nation every year, but it begins in spots.

He did observe densely lived places make it more likely to appear and spread: cities, nursing homes, crowded workplaces, prisons, rehab centers.

But never mind the discrete beginnings, this pandemic will coat the whole nation, every county.  Dr. Osterholm has said over and over in many interviews, we will almost certainly go from about 5% of us infected to about 60-70% infected.  We are likely at 10% today, that means all the suffering we have seen has come about at 10% infected.

If we continue to fail to slow or halt the spread we will go to 60-70%.

Why does that matter?  Because if we do go to 60-70%, Dr. Osterholm offers a very tragic reality- most of us will experience having this virus take the life of someone we love, someone in our family or circle of friends.

Across this whole interview, I found this moment the most sad, truly tragic, and frightening.  No one should doubt, we are in the midst of a very dangerous disease, we are all at risk.  The notion that each of us are likely, if we survive, to experience a loss is hard to comprehend, and yet it is very real.  Unless we find a path to have our nation do what others have done and substantially slow the spread, for a year or two.

The Super Spreader Phenomenon 

Tied to the “tornado effect” in which the virus initially shows outbreaks in very discrete spots, is  another, different phenomenon.

Dr. Osterholm described the super spreader phenomenon.   This appears to reflect that fact that if I come down with COVID-19, and if you do, neither of which I hope happens.  Both of us may be in a room with 200 people (I don’t advise it!), you may spread it to 5 people, but I may spread it to 100!  I would be the super-spreader.

This is a very real property of the SARS-CoV-2 virus, and a property not shared by all viruses.  Influenza virus does not work by super spreader, for example.  We don’t know why, in this example, you would not be a super spreader, and I would. We do not know why, but we know it is very much for real.

One theory suggests it is random.  In our example, your coughs and sneezes only contain virus in large drops, or droplets, that fall rapidly out of your mouth and nose, this is the droplet idea, and why staying 6 feet apart helps.   Whereas, for me, in this example, my breathing and coughing generates tiny drops, or aerosols, that can hover in the air for a long time and distance.   That is the droplet-aerosol discussion.  But we don’t know if this is why there are super-spreaders.

Because there are super spreaders, a small number of people who happen to be super-spreaders explain an outsize number of cases.

An important point, Dr. Osterholm notes that super-spreading happens no matter your age, no matter your health, at the same chance if you are old or young, healthy or not.

During this part of the conversation, Dr. Osterholm confirmed, as we have suggested, that this virus, the SARS-CoV-2 virus, is more contagious than influenza.

Finding the Dosage that Infects to Find out Just What Situations Spread the Disease

Dr. Osterholm shared very, very exciting and important news- he has assembled a group of people from around the world to answer an amazingly crucial question:

How many viruses must you breathe in or enter your eyes in order to get infected?

Let’s say the answer is 10,000 viruses.   Now, we can go to the grocery store, grandma’s house, school, and see how many viruses will you breathe in during your time there.  If the answer in one situation is 10 viruses, we can say, maybe we can do that activity without much risk.  If the answer is 1 million viruses, doing that activity will likely make you sick.

We will know also about situations- distance, indoor/outdoor, etc.

We will finally be able to know what is really safe, what is really dangerous to do!   Dr. Osterholm will be publishing results ASAP.

Questions that Come from You- the Families of Advanced Pediatrics- Thank You!

Does Age Change Contagion?

I asked Dr. Osterholm, does the chance a person will catch COVID-19 OR spread COVID-19 change with age?  Do children spread the disease more slowly than adults?

The answer was short and clear:  We do not know.  We do not have enough information to say if this is so or not.

I would add, therefore, beware of those who claim this is known.  We of course hope children are less likely to spread this virus, but we do not know this yet.

If a School, or any Building, Drops Its Volume of Attendance of Students, or Workers, from 500 to 250 a day, will that Change the Risk of Infection?

A key action that could drop the chance of infection spreading is to boost air flow in the building.

But to the question, we have no idea today if this strategy will work.  Since it stands to reason that fewer people in a room will lead to less spread, it is worth trying.  But we do not yet now if it will work.

The Path to Schools Must be Through A Safer Nation

We owe it to each other, and certainly our children, to secure our ship of state.   As confirmed above, we know there are highly reliable approaches to securing a nation, to slow the spread of this virus so that hundreds of thousands will not die, and to keep a nation safe long enough for a vaccine to be at hand.

If a nation can do this, and it is done by Identifying the Infected and Isolating those Contagious, then our nation can too.

The question of when to open the schools needs to follow the question, when will our United States of America secure itself, not just slow the spread, but really interrupt it?

When we do, we can go to school.  We can go to work.  We can stay alive and well.

Until we do, we will be chasing after bad situations, straining to create situations in which schools will be less dangerous, work will be less dangerous, while the virus continues to rage.

BOTTOM LINES

Biology

1. This virus, the SARS-CoV-2 virus, is mutating, i.e., changing over time, but so far none of its changes have made it more or less contagious or more or less deadly.  Nothing we have experienced is the result of any mutations since its appearance.
2. The key question of whether getting the disease COVID-19 endows one with lasting immunity remains unknown to date.  And, readers should also know, we have no reliable antibody test available in Cleveland to say if you have the antibody following infection.

The Human-Virus Dance

1. Human choices, our choices, CAN define our experience with the disease, will define how many of us will die, how many will be hurt, how shut down our world needs to be.  It was confirmed that many nations have succeeded in essentially halting the spread of the virus, bringing their daily death count down to, and kept at, nearly zero.
2. Since nations can choose to substantially stop the spread of this virus, we can too.  If choose not to, which we have chosen so far, then doing anything will be dangerous.  If the virus is allowed to spread unchecked, then going to a friend’s house, seeing one’s parents in their home, going out to do anything indoors, going to school, anything, will cause many more to sicken and come to harm.   It also means we can choose to slow the spread to the point we can do all these things, without causing needless death  and suffering.
3. Should we go to 60-70% of the nation infected, most of us will experience someone we love, someone in our family, a loved friend, losing their life to this virus.
4. This virus spreads by the unusual phenomenon of super-spreader, a person infected who infects many, many, whereas most people do not.  Super spreaders are NOT older, sicker, than non-supers.
5. This virus is clearly more contagious than the influenza virus.
6. Osterholm’s center, CIDRAP, has assembled a world class group to find out, how much viral dose will cause disease and how much viral dose happens in various situations.
7. We already know- being outdoors makes a BIG difference, being 6 feet apart makes a BIG difference. Period!

Questions from You, The Families of Advanced Pediatrics- Thank You!

1. We have no idea if children are less likely to catch or spread the SARS-CoV-2 virus.  We know they do not get as sick as adults if infected, but do not know if it spreads well.
2. We do not know if having half as many people in a school or building will reduce the risk of infection.  It is worth a try, it makes good sense, but we do not know if it will work.
3. The path to opening schools should be by a nation slowing its spread of the virus.  Yes opening schools is important to the mental health of our children, to the work of parents, but not at the cost of life or harm.

I close with all of us thanking Dr. Michael Osterholm, a true hero of science.  A clear eye, seeking facts that will save lives, and willing to speak to the community about what we do and what we do not know.

To your health, stay well, stay safe,
Dr. Arthur Lavin