#99 – Peter Hotez, M.D., Ph.D.: Continuing the conversation on COVID-19

KEYPOINTS

• 01

  A snapshot from March 19, 2020

  This follow-up with vaccine scientist Peter Hotez was recorded when the US had a little over 13,000 confirmed cases, up from just under 10,000 that morning. Both warn that pandemic podcasts become 'obsolete pretty quickly'. Hotez says what they say 'may look totally ridiculous in a few days or a week'. Treat the specifics as a record of what was believed at the time.

• 02

  Confirmed cases badly undercount real infections

  With so little testing, the US was 'just picking it up'. Models suggested 20 to 50 true infections for every confirmed case. Attia's team built its own model, based on the time from infection to death and an assumed infection fatality rate. Their conservative multiplier was about 25, while others argued for no less than 45–50. Attia notes the result is highly sensitive to both assumptions.

• 03

  Think in local waves, not national averages

  Even 125,000–200,000 real cases wouldn't be spread evenly. New York might have 30,000–40,000 of them, with Seattle and other hot spots also emerging. National averages mislead. The fear was 'a New York situation' appearing in city after city, with hospital capacity the limiting factor.

• 04

  Protect frontline health workers first

  Hotez says the US was 'not doing all we can, even close' to protect healthcare professionals. Hospitals in Philadelphia, Baltimore and New York already felt overwhelmed. Weeks earlier he had warned Congress about nursing homes after about 25 deaths at the Kirkland, Washington facility, calling it 'the angel of death' to get attention. He wanted a White House task force focused on frontline protection.

• 05

  Ideas for surge staffing

  Moving rural doctors is unrealistic, since areas like western Nebraska are already underserved, and young physicians are already stretched. Hotez floated a large expansion of the commissioned corps of the US Public Health Service, or using the military, to train medic-level helpers to manage ventilators. He acknowledged Congress would be hard to persuade.

• 06

  Young adults were landing in hospital

  US data suggested roughly a quarter to a third of hospitalised patients were 20–44, and about half were under 54, which differed from China. Possible explanations, such as smoking (which can upregulate the ACE2 receptor), vaping or genetics, were unknown. Attia read out the ages of one London hospital's ICU admissions that day, many in their 20s and 30s, including a 34-year-old whose chest X-ray was 'a complete whiteout'.

• 07

  Long-term damage is a concern even among survivors

  Attia cited a 10-year follow-up of SARS-1 survivors showing non-trivial heart and lung disease. Hotez noted early Chinese reports of 'acute heart injury' whose cause wasn't clear.

• 08

  Immunity probably follows infection, but an 18-month vaccine is unrealistic

  Hotez pointed to a non-human primate preprint showing that infected animals resisted reinfection. He would work on the premise that infection confers immunity, unlike flu with its antigenic drift. He suspected the federal 18-month projection came from Imperial College models, with the virus dipping in summer and returning in the fall. He repeatedly lowered expectations of a safe, rapidly deployable vaccine within 18 months.

• 09

  Repurposed drugs: interesting, not proven

  Hydroxychloroquine inhibits the virus in vitro and has anti-inflammatory effects. Hotez knows Didier Raoult and calls him an excellent microbiologist, but says his small study was over-hyped and much larger trials were needed. Evidence on ACE inhibitors and ARBs was mixed. Some argued they might block viral attachment, others that they upregulate the receptor.