
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)
- Am I at risk, or do I live with someone at risk?
- “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”
- “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.”
- One company (BGI) has done millions of these coronavirus tests worldwide (mostly in China)—they’re low-cost and have a high specificity/sensitivity
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
- Peter’s view has shifted:
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.
- There are ~1.5-2k ICU beds in NY