March 12, 2020

Peter Attia, M.D. Answers COVID-19 (Coronavirus) Questions

Key Takeaways

• COVID-19 attacks a type of cell called the type II pneumocyte whose primary responsibility is to make surfactin, a detergent-like substance that allows the lung’s air sacs to overcome the surface tension that would otherwise prevent them from not opening
  • The inability to make surfactin can result in respiratory collapse—this occurs much more readily in older individuals (>75)
• “The virus is unpredictable enough in its presentation that it becomes very hard to walk through the world and know who’s potentially sick, and who’s not” – Peter Attia
• “There’s one thing that remains unambiguously clear: if you’re symptomatic, the first thing you want to do is self-isolate” – Peter Attia
  • BUT, the moment you have difficulty breathing, seek medical attention ASAP (no matter your age)
• The more people who are in a position to self-isolate that choose to do so, the better off we’ll be
• A recent paper suggests COVID-19/SARS-CoV-2 survives for:
  • Up to 3 hours in the air
  • Up to 4 hours on copper
  • Up to 24 hours on cardboard
  • Up to 2-3 days on plastic and stainless steel

Intro

• Below you’ll find a series of four videos from Peter Attia, MD (@peterattiamd) in which he answers common questions related to COVID-19

Part I

Does Peter have any virology and infectious disease expertise?

• No, but he has some training in immunology and access to many smart doctors
• During late December to late January, Peter didn’t pay much attention to the coronavirus outbreak. But, once the middle of February rolled around, he began to realize its severity.
• A week ago, Peter mobilized his team of medical analysts to begin speaking with virologists, physicians on the front line, and biotech executives working on a vaccine to put together an accurate information source for his patients

What’s the difference between coronavirus and influenza (the flu)?

• We understand influenza and what it does—it causes a hyperactive immune response (which is why, when you catch the flu, you’re sick as a dog) followed by an “immune crippling” (this is what leads to the flu’s devastating consequences in older individuals—often, “a super-bacterial infection”)
• COVID-19 acts much differently: it attacks a type of cell called the type II pneumocyte whose primary responsibility is to make surfactin, a detergent-like substance that allows the lung’s air sacs to overcome the surface tension that would otherwise prevent them from not opening. Low surfactin levels can cause respiratory demise.
  • The virus gains access to the type II pneumocytes through ACE2 receptors in the lungs & other tissue
  • This point is essential: the loss of surfactin doesn’t produce a linear adverse response—a slight decrease in its production and BOOM
    • The respiratory collapse occurs much more readily in older individuals ( >75) who have co-morbid diseases (but you can be totally healthy and still succumb to the virus’ effects)

Part II

Why is Peter so worried about COVID-19?

• 1) COVID-19’s lethality and rate of spread (r0) presents a bad combination—Peter drew up the graph below:
  • 
  • The larger a virus’ r0, the more people a carrier infects—if a virus’ r0 is 1, each infected individual will, on average, infect one additional person
    • Estimates indicate COVID-19’s r0 is 2.25-3.35 (for comparison, influenza’s r0 is ~1.3), but Peter’s team has interviewed doctors claiming it to be >5
  • COVID-19 is 10x more lethal than the flu
• 2) COVID-19’s rate of growth seems to be increasing in the U.S.
  • (A virus’ growth rate = the number of new cases on a given day / the previous day’s new cases)
  • The same thing happened in China until ~ February 12th
  • “Frankly, it’s going to be hard for me to sleep and think COVID-19 has come and gone until its rate of change has gone negative” – Peter Attia
• 3) COVID-19’s mechanism of action is hard to predict
  • Two otherwise healthy 40-year-olds can experience utterly different disease courses
• 4) COVID-19 has the potential to overwhelm the United States healthcare system (especially if we don’t slow its spread)

Part III

Why is social isolation such an essential line of defense?

• “We don’t yet fully have an understanding of how this disease spreads mechanistically” – Peter Attia
  • We know COVID-19 causes respiratory illness, and therefore, people can spread it through respiratory droplets, but it remains unclear as to what distance—do you have to be within a meter of someone to get it? 5 meters? We don’t know.
  • We also have no idea how long COVID-19 survives outside of the body; some doctors Peter has spoken to think it’s DAYS
• “The virus is unpredictable enough in its presentation that it becomes very hard to walk through the world and know who’s potentially sick, and who’s not” – Peter Attia

What are the reasons to self-quarantine?

• Start by asking yourself two questions:
  • Am I at risk, or do I live with someone at risk?
    • “If you’re answering yes to that question, I think you really have to scrutinize the idea of needing to be in isolation” – Peter Attia
  • Are you in an area where outbreaks are being reported?
    • If not, you’re afforded more liberty (but given the long period of time the virus can sit inside an individual without presenting symptoms, you’re not 100% safe)
• “There’s one thing that remains unambiguously clear: if you’re symptomatic, the first thing you want to do is self-isolate” – Peter Attia
  • BUT, the moment you have difficulty breathing, seek medical attention ASAP (no matter your age)

Part IV

Which biohacks help reduce the risk of COVID-19 infection?

• “Let me be really clear: I don’t care how much vitamin C you’re rubbing on your testicles, your nipples, or whatever; it’s total NONSENSE” – Peter Attia 
• “To think for one moment that going all-out on the do-it-yourself biohacker protocol is going to somehow offer you immunity is not only idiotic, it’s actually dangerous—you’re putting yourself and others at risk” – Peter Attia
• So, use the sauna, take vitamin C + D, but don’t think for a second that it’s reducing your risk of infection by any significant means

Why does Peter think COVID-19’s case fatality rate varies so much between different countries?

• First, know that the case fatality rate (CFR) = number of mortalities / the number of known cases
  • By definition, the mortality rate is an over-estimate—it doesn’t account for the number of people who have the disease but haven’t gotten tested
• Compare COVID-19’s CFR in China (2-3%) and Italy (7-8%):
  • In Italy, the patient population is much older; they also have a higher prevalence of smokers
  • Italy’s healthcare system was closer to capacity when COVID-19 hit

Who’s at the most risk?

• People who smoke or have smoked
• Those with type 1 or type 2 diabetes
• People >70 (at this age, COVID-19’s fatality rate doubles)
• Those who have high blood pressure or heart disease

What’s the status of COVID-19 testing in the U.S.?

• The CDC just distributed 75k COVID-19 tests to local and state authorities around the U.S.

Part V

The U.S. Has Done a Lousy Job of COVID-19 Testing

• “If I’m going to be critical of one thing that we’ve [the U.S.] done a lousy job of, it’s testing. We should have been far more prepared.” – Peter Attia
• “I’m struggling to understand why the CDC decided to create their own test in-house. Their own test was a disaster—it had a very low sensitivity and a very low specificity.”
  • Peter adds that, if you’re going to do this type of testing, high sensitivity and specificity are a MUST
  • (As it turns out, the CDC test was soon ditched)
• Here’s why Peter is frustrated:
  • One company (BGI) has done millions of these coronavirus tests worldwide (mostly in China)—they’re low-cost and have a high specificity/sensitivity
    • “For reasons I don’t understand, we’ve elected not to go with that company in the United States, and instead, go with another company called Roche … We’ve selected a company that’s very far behind in terms of their ability to do this … Time is of the essence, and personally, I believe that if we stay the course of relying on the Roche test … I think we’re going to lose a lot of critical time.”
      • And the quicker we identify positive cases/quarantine people, the faster we slow the rate of transmission, and the more likely we are to “flatten the curve”  

Part VI

The Status of COVID-19 Testing in the United States

• As of 8 PM on March 15, we’ve done less than 50k tests in the U.S. (we should be doing 50k tests/day!)
  • Currently, we’re only testing people according to CDC guidelines (if they show symptoms); we should be testing ANYONE who’s come in contact with someone showing symptoms
• “There’s plenty of literature talking about what a symptomatic person can do in regards to shedding the virus, and those numbers look quite frightening .. We’re talking about viral shedding that can lost up to 24-30 days in someone infected.” – Peter Attia
  • Also, you can be 100% asymptomatic and still spread the virus
• On testing:
  • A test’s sensitivity (AKA true positive rate) is the probability that the test will be positive if the person does, in fact, have the virus
  • A test’s specificity (AKA true negative rate) is the probability that someone who doesn’t have the virus tests negative
  • Ideally, you want both the sensitivity and specificity to be as high as possible
  • According to Peter, the most important thing: you don’t want someone with the virus to test negative
• Many people are saying 50%+ of Americans will be infected with COVID-19 within the next year—Peter isn’t buying it
  • “We still probably have a chance to slow the rate of growth. We’re still in the exponential phase of growth, but there’s a chance it doesn’t have to continue unabated for another two weeks. And the difference of growing between 13 and 14 days exponentially is ENORMOUS.” – Peter Attia

Part VII

Should we all be self-isolating?

• Simply put, the more people who are in a position to self-isolate that choose to do so, the better off we’ll be

SARS-CoV-2 Transmissibility

• In these Podcast Notes, Peter discussed how the virus survives for:
  • Up to 3 hours in the air
  • Up to 4 hours on copper
  • Up to 24 hours on cardboard
  • Up to 2-3 days on plastic and stainless steel
• Realize though, that these numbers are the result of experiments done in ideal laboratory conditions, not the real world
• Given the above, here’s what Peter’s doing:
  • Because of this, Peter started opening his Amazon packages outside, wiping the contents of the package down with Windex/Lysol, and then, washing his hands (very carefully)

Part VIII

Current Thinking on ACE-Inhibitors and ARBs (Angiotensin II Receptor Blockers)

• Both are classes of drugs used to treat high blood pressure
• Coronaviruses gain access to cells using ACE2 receptors, which raises the question, should people be taking ACE inhibitors and ARBs?
  • Peter’s view has shifted:
    • A week ago: ACE inhibitors and ARBs might down-regulate ACE2 receptors, and thus, they could serve as preventative drugs—or drugs you could take once infected to reduce the rate of spread
    • Now: He doesn’t think this is the case. In fact, they might even pose a risk.
      • Peter’s advice to his patients: “If there’s an alternative to an ACE inhibitor or ARB that can allow equal blood pressure control without an interruption, it might be worth considering. But, this a big, ‘What if?'”
  • The European consensus guidelines recommend that patients on an ACE-inhibitor or ARB keep taking them

Part IX

An Update as of 3/23/20

• Think of each city in the U.S. fighting COVID-19 as a car driving towards the edge of a cliff
  • Take the analogy further: each car is different, driving at different speeds applied the breaks at different times, etc.
  • The point: we need to stop comparing COVID-19 country by country and, instead, compare city by city
• Let’s examine Italy:
  • Milan: 2200 deaths out of a population of 10 MM
  • Rome: 31 deaths out of a population of 6 MM
  • Sicily: 3 deaths out of a population of 5 MM 
• Out of all the “cars” in the U.S., NY is the one to be worried about
  • There are ~1.5-2k ICU beds in NY 
    • “The question then becomes, will the rate of people who are infected that will require ICU care over the coming weeks overwhelm that number? Unfortunately, ever way I look at this, the answer is yes.” – Peter Attia
  • The ICU case count in NY:
    • March 20th: 150
    • March 22nd (morning): 300-330
    • March 22nd (night): 450
    • March 23rd (morning) 621
  • In Italy, the ICU rate of infected people was 4.7-4.8%; in NY, so far, we’re at 4.9-5%
  • Peter’s advice: if you live in NYC, and can get somewhere else quickly/easily, leave. You do NOT want to get infected 2 weeks from now and need an ICU bed.

Drive with Dr. Peter Attia : coronavirus, covid-19, pandemic, peter attia, virus
Notes By MMiller