Coronavirus in Context: Eric Topol Explains the Emerging Research

; John Whyte, MD, MPH

Disclosures

March 25, 2020

This transcript has been edited for clarity.

In this One-on-One, WebMD's Chief Medical Officer Dr John Whyte turned the tables on Medscape Editor-in-Chief Dr Eric Topol and interviewed him about how he interprets preliminary COVID-19 research that's making the rounds on social media as well as the role that technology could play in curbing the pandemic. 

John Whyte, MD, MPH: Hello. I'm Dr John Whyte, chief medical officer at WebMD. Welcome to "Coronavirus in Context." My guest today is Dr Eric Topol, a renowned cardiologist, geneticist, researcher, founder of a research institute at Scripps, and Medscape's editor-in-chief. Thanks for joining me, Dr Topol.

Eric J. Topol, MD: Of course, John. Great to be with you.

Whyte: I want to talk about some of the recent studies that have come out, even in the past day, where we're seeing out of Italy that in over 99% of deaths, the person had some comorbidity: 75% had hypertension, 35% had diabetes, a third had heart disease. Are you surprised that that number is so high—99% of deaths?

Topol: Well, I don't know that it really is. First of all, once you get past age 50, you see a lot of comorbidities But we also know that there have been some young people who have succumbed in Italy. In fact, there was a White House press conference yesterday finally alerting to the fact that young people are not necessarily spared from COVID infections. So I know you're queuing into the people who are vulnerable—that is, the aged—because they have comorbidities, but some of these comorbidities don't make much sense, like hypertension.

And there's no good explanation to link high blood pressure. That could just be a proxy for age. The ones that do have some reasonable connection would be things that would impair the immune system—age, especially advanced age. For example, chronic obstructive pulmonary disease, because we know that the real problem here is that the virus skips into a lower respiratory tract, and once it does that in a vulnerable patient... So I don't know about this 99% number. I mean, it's dreadful.

What I do know, John, which is so disconcerting, is that the number of deaths in Italy now surpasses that in China. And we don't have a good explanation for that. The fact that we just tossed it on to, "Oh, well, they're older in Italy and they had comorbidities"—it doesn't make much sense, really. There's something else that we don't know yet.

Whyte: What do you think about the role of cardiovascular disease? The American Heart Association has talked about it. It's listed as a condition that puts you at increased risk. Do you think it's the same for the person who has a stent versus someone who has decreased ejection fraction? What might be the etiology there in your mind?

Topol: Great question. I already mentioned hypertension, which a lot of people lump into cardiovascular disease. But almost everyone, if they live long enough, will have hypertension. So I don't know that it really is important. But as you allude to, heart failure, diminished heart function, is certainly one for which you would connect the dots because those patients are just more vulnerable. It isn't clear that just coronary disease that's not obstructive—like you mentioned the stent, or having had a prior bypass operation or open heart surgery—is a comorbid condition that would set up for this.

Mixed Information on Drugs

Whyte: You've been very involved in your career in postmarket surveillance. I interacted with you during my time at the Food and Drug Administration. What about the preliminary data, much of it unreviewed, that we're seeing out of France, relating to the use of NSAIDs, and the impact that it might have on coronavirus? Is that something we need to start talking to patients about or is it too early to tell?

Topol: You know, it's really interesting, John. There have been these two drug classes that have been put into confusion mode. One is, of course, ACE inhibitors and receptor blockers. And the other are the NSAIDs. What's amazing about both is that it's just chaos, because there are no data to support either harm or potential benefit in either.

Whyte: And for the ARBs, they've been saying both. For the ARBs they've been saying it could actually be protective.

Topol: This is a false alarm. There have been people who say to stop taking ACE inhibitors. And now a group in France, backed up to some degree by the WHO, say not to use NSAIDs. There are no data that I have seen, and I try to get my arms around this, that would support that. There are theoretical things, like today we heard the chloroquine story. It's theoretical. There are no data to show that chloroquine compared to control truly is effective treatment. We're in a panic state. It's a crisis. We're getting a lot of things that don't have data or even a basis for making this proclamation.

Whyte: Well, there's another study out there from China that says if you have blood type A, then you're more at risk of dying if you develop coronavirus. And if you're blood type O, you will do better. And this is getting a fair amount of circulation. So how do readers interpret this information when they see it on social media? It's even being reported by some news outlets. We can't change our blood type as we might be able to a medicine. So, what do you do? Is it needless worry?

Topol: At this point, I think so. First of all, there have been all sorts of studies over the years, decades, where this blood group associates with that [outcome]. Associations are not cause and effect, and they're frequently spurious. So we just don't know yet. First of all, the data have not been peer reviewed. Second, many of these assertions about a link between a blood type and an outcome didn't hold up, didn't get replicated. So these are suspect because the blood surface antigens are just not that big of a determinant, typically, for outcomes, particularly with the COVID infection. So we'll have to see. It's possible. I'm not ruling it out. But I think we should be a doubting Thomas at this juncture.

#flattenthecurve

Whyte: You're an active tweeter. You're very active on social media. I follow you and others. And we have all this conversation about bending the curve. You tweeted a little earlier today about how if we don't have protective equipment we're not going to bend that curve even with social distancing, because we won't have enough clinicians to provide care. But others have been talking on social media about how, depending on where we are on that curve, why aren't we seeing ERs being overwhelmed? Why aren't we seeing people in gurneys outside hospitals? What's your comment on that, where some people, especially younger people, are doubting the seriousness of this epidemic, this pandemic?

Topol: Let me unpack that because I think you've asked two important questions. First, the issue about the curve. The point I'm trying to make is that if we don't take good care of all our doctors, clinicians, and healthcare workers, not only will they become infected, but they may get sick and some may even die. So the point is that each of those healthcare workers cares for tens of patients.

Whyte: Right.

Topol: If we don't make this the highest priority, we lose the ability to care for even the non-COVID patients. And let's not forget about them. You know, in the hospital, it's not that we're seeing COVID patients as much as all the other patients.

Whyte: Sure.

Topol: So if you take them out, and we're going to have a shortage pretty quickly, now we get to the second question, which is: How come, except in specific hot zones, Seattle and New York City, most everything looks kind of business-as-normal. We're at the earliest point of this country's growth curve, this serious hit that we're going to see. And it will double every couple to few days. So just roll this out for another 10 days, which is how long it will take to be like Italy. It may not be as bad as the Lombardy region, which was hit really severely.

We're going to see a lot more cities, a lot more hot spots. And we're going to see in those particular hospitals that emergency rooms will have a real problem keeping up. I mean, I communicated with a physician in Spain yesterday who had over 50 admissions to the hospital, no less the ones that all came to the emergency room. We're learning with COVID and Syria, where they're seeing that in select hospitals. You know, it's not even distribution.

The Role of Technology

Whyte: You're a leader in tech. You talk a lot about innovation. What are we not doing now in terms of utilizing some technologies that we need to be doing?

Topol: There are two parts to that one. We should have tested millions of Americans by now. We had plenty of advanced warning. Not only did we know what was going on in China, but the first case in the US was diagnosed on January 21, which was 2 months ago. We haven't really done any testing until just in recent days, to any degree. If we are tested at scale, random, and broad-based—you know, not because you're very sick—we could have gotten on top of a lot of this.

We're facing perhaps the worst crisis in public health that we'll ever see in our lifetime. Eric Topol

Whyte: Would you have tested nonsymptomatic people? Would you have done community testing?

Topol: Absolutely. We would do as many millions of tests possible to see where our hot zones are going to emerge before they do. And the tests are cheap. They're easy. We were not prepared. We should be testing every healthcare worker, because that's part of the protection for them, as well as for all the patients that they touch and see.

The second part of the story is that there is a great tool that we can use, which is digital mass surveillance. Most of us have a smart watch of some kind, and there are tens of millions of Americans. We've already shown that the heart rate from that data can be exquisitely helpful for picking up a flu outbreak before it actually happens. We published on that. Yesterday we saw a big report on just using body temperature with a smart thermometer. So with digital tracking at scale, hopefully we will pick up the outbreak before it happens, because if we get it at the earliest possible time, we can do very precise isolation and prevent that exponential growth in that community.

Whyte: Should we be using location services? Should we be tracking people?

Topol: Absolutely.

Whyte: You don't have any issues of privacy or a concern about that?

Topol: This would not be the time for privacy concerns. Normally that's a biggie for me. But right now we're facing perhaps the worst crisis in public health that we'll ever see in our lifetime. I hope it's the worst, because people who think that this isn't going to get bad in this country just are not really paying close attention to the lessons learned. It isn't just China. And it isn't just Italy, and Spain, and many other places. There isn't any exception here. The only one that's positive to some degree is South Korea, because they were all over this and they did—

Whyte: —mass testing: 20,000 tests a day.

Topol: Good isolation, quarantine lockdown, or preventing the free movement of people. So they have contained this, but even then, John, we're starting to see that pick up again with more cases after they had shown a flattened curve. So we aren't learning the lessons here about taking this seriously.

Whyte: What about Japan? Japan had some cases early on. They haven't necessarily instituted the same mitigation strategies. We're not seeing that many cases right now. Is it because of where they are on the curve, or do you think something else might be going on there?

Topol: I can't imagine that it's anything beyond that this is an eventuality—that is, as you say, it's delayed. But we started the same day that South Korea did; within 24 hours, we had our first case. So we'll have to see. There's a kind of incubation phase. And, of course, we don't know enough about this asymptomatic carrier story. We know it's not uncommon in the young and even in children. But these are the unknowns. And the Japan story is part of the unknowns: Wait to see what happens.

‘A Lot of Unknowns’

Whyte: We want to get information out there but it's not necessarily peer reviewed. We've gone back and forth on how long people can be asymptomatic and infectious. We've had ranges of different numbers about how long the virus can live on surfaces. Is that helping or hurting? We're so early on and people hear from so many different sources. I've joked that everyone's an armchair infectious disease doctor, an epidemiologist with no training. Does it help or hurt?

Topol: It's kind of good. If everyone did convert to become a citizen scientist, that would help, because that means they're tuning in to what's going on. The issue about the viability of the virus, whether it's in the air or on different types of surfaces like plastic, steel, or copper... There was a nice paper in the New England Journal of Medicine that was peer reviewed, that gave us a lot of insight, like, in the air we're talking about minutes, but on surfaces it could be even 72 hours—particularly plastic, interestingly.

What we don't know about is shedding and viability. The virus has to be replication competent. Just because it's sitting somewhere, if you touch it, the virus doesn't have the ability to invade cells in your body, to hijack the cells, which is basically its pathogenicity. These are the things that we don't know, like why do some people shed virus so profoundly whereas others don't? That story that was published in The Lancet is amazing. There was a couple hospitalized with severe infections. They had 372 contacts. Not a single one of them ever converted positive.

Whyte: What's the reason? What do you think?

Topol: It may be that they didn't shed. They were infected, but they're nonshedders. And then there are these other asymptomatic people who are shedding. So that's a lot of unknowns. That's why we all learn as much of the science as it comes on board, and that means not just the medical community—everybody tunes in. That kind of awareness will be helpful.

Testing Outside of Hospitals

Whyte: What about testing at home? There's been some discussion that people could swab themselves and then set it outside our door. Is that a safe mechanism of testing, or are we perhaps putting delivery and other folks at risk?

Topol: I think it's safe. This next week there are going to be two companies releasing an at-home kit you can buy for approximately $150. And then once you get it, it takes another few days to get results. You have to put this swab pretty far up your nose and then in the back of your throat, to the point where you gag. Otherwise you might get a false negative. At any rate, it is a way to get some information in a pathetic situation where testing is still not widely available. But that's a significant cost. Also, we shouldn't have gotten into this situation in the first place, right?

Whyte: Yeah.

Topol: In some cities there is also the emergence of drive-through stations.

Whyte: Yes.

Topol: I actually think that's a better potential solution, because then you save 2 days. You're basically driving through, so you don't have to wait for the kit to come to your house and then for it to go back to the central lab. And we should be doing those for free.

Whyte: Except right now they're only in certain locations.

Topol: I think we should have that in every city, all over the place. That's still a low cost. Here we are, sinking trillions of dollars in sending out checks to every American citizen. And these are relatively inexpensive strategies that we were talking about.

Whyte: The other question I wanted to ask, knowing your knowledge of drug development, is that people have been talking about the ARBs, the ACE inhibitors, and the NSAIDs, and we're starting to see some questions about statins—perhaps they have a role. Any rationale you see in terms of how statins might impact ability to fight the virus?

Topol: There are data on statins in non-COVID, in pneumonia and respiratory distress. And there was a lot of interest in that for a while, that it could decrease inflammation just like it decreases inflammation for cardiovascular disease. Then they did randomized studies and it was a bust.

So I think that the chances that statins are going to help here—because we haven't ever seen data, really positive data, for statins—are pretty low. They don't seem to harm. So we don't have that out there, about the use of statins. But its protective or beneficial effect has to be considered suspect at this point.

The number-one priority has to be the healthcare workforce. Eric Topol

Whyte: Other than increased testing, if you could wave your magic wand and make some fundamental change to address COVID-19 and this evolving pandemic, what would you do? Not what should we have done, but what can we do today?

Topol: I think the number-one priority has to be the healthcare workforce. We're not giving them the priority that is vital. It's not just that they're important to the care of the patients, but if we lose them along the way—not just their lives, but also if they're sick or have to be quarantined—we're not going to ever keep up. We may have a problem keeping up anyway, but we don't have the protective gear. It's just remarkable that this is supposed to be a first-world country, and we don't even have gear. I mean, the fact that that is occurring, the fact that not all healthcare workers have been tested yet, these are systematic evidence that we're not—that's priority number one. So it's not magical. It's sensible. But if there was a wand, we should have done that. It's never too late.

Whyte: And we've been putting online where people can help donate equipment. You've been tweeting about it as well. And I encourage folks to follow you on Twitter. I want to thank you for taking time on what I know is a very busy day, and thank you for really helping us think through some of this emerging data that we need to look at carefully to best figure out how to address this growing pandemic. Thank you, Dr Topol.

Topol: Thank you, John. And thanks to you and your team for all that you're doing to help our readership and all the people who are on the site. Thank you.

Eric J. Topol, MD, editor-in-chief of Medscape, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book,  Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.

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