Coronavirus in Context: Exploring COVID-19’s Impact With Cardiologist Eric Topol

Hello, I'm Dr. John White, Chief Medical Officer at WebMD. And welcome to coronavirus in context. My guest today is Dr. Eric Topol, a renowned cardiologist, geneticists, researcher, founder of a research institute at Scripps, and Medscape's editor-in-chief. Thanks for joining me Dr. Topol.

Oh, of course, John. Great to be with you.

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 over 99% of deaths, the person had some co-morbidity. 75% percent of them had hypertension. 35% had diabetes. A third had heart disease. Are you surprised that number is so high, 99% of deaths.

Well, I don't know that it really is. First of all, anybody, once you get past age 50, you see a lot of co-morbidities But we also know that there have been some young people who have succumbed in Italy. And 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. The other thing, of course, that comes a week after the memorable Oval Office presentation where young people have full recovery, no problem. So I know you're queuing into the people who are vulnerable, that is the aged, and because they have co-morbidities, but you know, some of these co-morbidities don't make much sense, like hypertension.

And there's no good explanation to link high blood pressure. That could be a proxy for just age. The ones that, that do have some reasonable connection would be things that would impair the immune system-- so 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, of course, in Italy now are the number one in the world above China. And we don't have a good explanation for that. The fact that we just tossed it on to, oh, we'll they're older in Italy and they had co-morbidities. It doesn't make much sense really. There's something else that we don't know yet.

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?

Yeah, 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 that one, I don't, I don't know that really it is important. But as you allude to, heart failure, diminished heart function, is certainly one that you would connect the dots, because, you know, you just are 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, to me that's not a clear comorbid condition that would set up for this.

Now you've been very involved in your career in post-market surveillance. I interacted with you during my time at the Food and Drug Administration. What about this preliminary data, much of it un-reviewed, 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?

Well, you know it's really interesting, John, there's been these two drug classes that have been put into confusion mode. One is, of course, ACE inhibitors and [AUDIO OUT] and receptor blockers. And the other are the non-steroidal anti-inflammatories. And what's amazing about both is that it's just chaos, because there's no data to support either harm or potential benefit in either. Now there was--

And on the ARBs they've been saying both. For they ARBs they've been saying it could actually could be protective.

This is a false alarm. You know there have been people that say stop taking ACE inhibitors. And now a group in France, and backed up to some degree by the WHO, that say, oh, don't use non-steroidal anti-inflammatory drugs. You know there are no data that I have seen, and I try to get my arms around this, that would support that. There's theoretical things, just like, you know, today we heard that the chloroquine story. It's theoretical. There's no data to show that chloroquine compared to control truly has a, is treatment, effective treatment. So we have lots of-- you know, we're in a panic state. It's a crisis. It's just-- and you're getting a lot of things that don't have data or even a basis for making this proclamations.

Well, there's another study out there from China that says if you have blood type A, that you're more at risk of dying if you develop coronavirus. And if your blood type O, that you're doing 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?

Good point.

Is it needless worry?

At this point, I think so. First of all, you know, there's been all sorts of studies over the years, decades, where this blood group associates with that blood group. And associations are not cause and effect. And they're frequently spurious. So we just don't know yet. I mean, first of all that data has not been peer reviewed. Secondly, many of these turn out to be assertions about connect, a link between a blood type and a outcome, didn't hold up. It didn't get replicated. So these are, I think, are suspect, because the blood surface antigens, you know, are just not that big of a determinant, typically, for outcomes, particularly here 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.

Now 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. And you tweeted a little earlier today about 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 about on social media, 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 you know, some people are, especially younger people, are doubting the seriousness of this epidemic, this pandemic?

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

Right.

Well, 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.

Sure.

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, you know, except in specific hot zones, Seattle and New York City, that most everything looks kind of business as normal, if you will, that is you don't see. We're at the earliest point of this country's growth curve, this serious hit that we're going to see. And doubling is every couple of few days. So just roll this out for another 10 days, which is how long it will take to be like Italy. So 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 an emergency rooms, a real problem keeping up. I mean, in Spain yesterday I communicated with a physician there 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 [AUDIO OUT], where they're seeing that in select hospitals. You know, it's not, sort of, even distribution. It's a problem where each of the outbreak regions, that's the real challenge.

Now 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?

Well, there's two parts to that one. One is--

I like multi-part.

We should have tested, you know, 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 patient came to the US, that can count was diagnosed in the US January 21, which was two months ago. We haven't done really any testing until just in recent days to any degree. If we are tested at scale, random, and broad based, you know, not cause you're very sick, we could have gotten on top of a lot of this.

Would you have tested non-symptomatic people? Would you have tested community testing?

Absolutely. No, it's--

If we had the ability to do it, right.

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. You know, that's not the-- we were not prepared. So now the other path, which by the way, we should be testing every health care worker, because that's part of the protection for them, as well as all the patients that they touch and see.

Now the second part of the story is there is a great tool that we can use, which is digital mass surveillance. So most of us have a smart watch of some kind, and there's tens of millions of Americans. That date-- we've already shown the heart rate from that data can be exquisitely helpful for picking up a flu outbreak before it actually happened. We published on that. So things like that-- yesterday we saw a big report on just using body temperature with a smart thermometer. So 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.

Should we be using location services? Should we be tracking people? Absolutely.

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

This would not be the time for privacy concerns. I mean, normally, that's a biggie for me.

Well, that's why I asked you that.

But right now we're, 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 it's going to-- people that 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--

Mass testing-- 20,000 tests a day.

Good isolation, quarantine lock down, if you will, or shutting the free movement of people. So they have contained this, but now 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.

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?

I can't imagine it's anything beyond that this is an eventuality, that is, as you say, it's delayed. But you know, this is, we started the same day that South Korea did, here in the US, within 24 hours, our first case. So we'll have to see. You know, there's a, kind of, incubation phase, whereas enough people that are infected, that are transmitting. 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 you know, these are the, sort of, unknowns. And the Japan story is part of that conservation of unknowns, wait to see what happens.

How concerned are you about, you know, we want to get information out there, but it's not necessarily peer reviewed. So 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 so much different sources. I've joked everyone's an armchair infectious disease doctor, an epidemiologist with no training.

[INAUDIBLE]

Does it help or hurt?

It's kind of good. If everyone did convert to become a citizen scientist, that would help, because that means they're tuning into 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, or steel, or copper, there was a nice new one in the Journal paper 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.

But the other part of that is, what we don't know is about the shedding story and viability. So the virus has to be replication competent. So just because it's sitting somewhere, if you touch it, and you don't, the virus doesn't have the ability to invade cells in your body, to hijack the cells, which is basically its pathogenicity. So these are the things that we don't know, like why would people shed virus so profoundly, whereas others, they can be infected-- you know that story that was published in The Lancet is amazing. You have a couple, severe infection, hospitalized. They had 372 contacts. Not a single one of them ever converted positive. So we got a lot--

So what's the reason? But what do you think?

It may be that they didn't shed. They were infected, but they're non-shedders. And then they've got these other asymptomatic people who are shedding. So this is 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, that kind of awareness will be helpful.

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

Well, no, I think it's safe. There's going to be-- there's. This next week there's going to be two companies releasing a at home kit you can buy for approximate $150. And then once you get it, then it takes another few days by sending it back in 48 hours. You know 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. And also, you know, it's something that we shouldn't have gotten in this situation in the first place, right.

Yeah.

So yeah, the home kits-- you know, there's also in some cities the emergence of these drive through stations.

Yes.

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

Except right now they're only in certain locations, right now.

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

The other question I wanted to ask, knowing your knowledge of drug development, people I've been talking about the ARBs, the ACE inhibitors, and NSAIDs, we're starting to see some questions about statins and perhaps they're role in if you become infected with coronavirus. Any rationale you see in terms of how statins might impact your ability to fight the virus?

Well, there's data on statins in non-COVID, in pneumonia and respiratory distress. And there was a lot of interest in that for a while, because, oh, that will 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 is pretty a low likelihood. It doesn't seem to harm. So we don't have that out there, that use of statins. But it's protective or beneficial effect has to be considered suspect at this point.

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

Yeah, well, I think the number one priority has to be the health care workforce. We're not giving them [AUDIO OUT] the priority that is vital. The reason being is not just a fact that they're important to care for the patients, but if we lose them along the way, not just their life, but also they're sick or they have to be quarantined, we're not going to ever keep up. We're not-- we may have a problem keeping up anyway, but we, 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. And I mean, the fact that that is occurring, the fact that all health care workers have not been tested yet, these are systematic evidence that we're not-- That's priority one. So it's not magical. It's sensible. But if there was a wand, we should be, we should have done that. It's never, it's never too late.

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 do we address this growing pandemic. Thank you, Dr. 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 that are on the site. Thank you.

Thank you.