peter attia covid-19

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.
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