It’s been 8 months since SARS-CoV-2 came into this world and there is much news out there about it. Many are accurate, but many are not. The public has a lot of questions about COVID19, the disease that results from an infection of the novel virus, SARS-CoV-2. The voices of the scientists and healthcare practitioners in the front lines are getting drowned by the hyper fast media cycle, so I decided to reach out to a local pediatric infectious diseases doctor and epidemiologist doing his residency at UCLA, Dr. Sean Fitzwater, to answer some of the most common and pressing questions that are being asked right now.
Read along to find out what he says about COVID19 and children, asymptomatics, masks, testing, reopening of schools, vaccines, and so much more!
This Question and Answer session occurred on July 30th, 2020.
CHILDREN
Question: Are children spreading it?
Answer by Dr. Fitzwater: Children can spread it, but to a much lower rate than adults. In families, generally the spread is between adults to children.
Q. Are you seeing any lingering effects in children who have recovered?
A. No. Kids are generally mildly symptomatic or asymptomatic. Adults do have some lingering effects, but they are not really seen in kids.
Q. My kids were COVID19 positive and didn’t have any symptoms. Is there anything that I need to worry about in the future?
A. Rarely, kids can develop MIS-C* (Multisystem Inflammatory Syndrome in Children, formerly known as PIMS, Pediatric Inflammatory Multisystem Syndrome) after COVID19. It can occur 2 to 4 weeks after infection with SARS-CoV-2. It is characterized by severe fever, abdominal pain, vomiting, diarrhea. Like Kawasaki disease, it is very rare. Very few kids will get it. The treatment is similar to what we do for Kawasaki disease and the kids seem to do well. We are still studying it though.
Q. What are your thoughts on preschoolers returning to school now that we know a bit more about the virus? Would you recommend keeping them home if we are able to?
A. There is, of course, no prefect answer. My son (3 y/o) is starting day care next week, so this question is close to my heart. The main things to consider are…
– Can you keep them at home?
– Is the staff / school taking this seriously? Do they have a plan? Is it reasonable?
– How big are the class sizes?
– Are the adults wearing masks? (little kids won’t be able to)
– Are there elderly at home that they may put at risk if they pick up the infection?
Q. At what age do children respond to the SARS-CoV-2 virus as a child vs responding as an adult?
A. Here is how I look at it:
– 0-12 month: minimal symptoms
– 1-12 years: minimal or no symptoms
– 12-18: minimal symptoms
– 18-65: Mild symptoms (generally not hospitalized)
– >65 or with medical problems: Moderate to severe symptoms. Higher rate of hospitalization and death.
Q. Is it necessary for kids to get tested for COVID19 if someone in the household tests positive for COVID19? I was told by my kid’s pediatrician it was not necessary unless they show symptoms.
A. I would assume they are infected. Keep them under close watch until the adults have gotten better. If they develop any symptoms, get them checked. Most kids with the infection will have no or minimal symptoms that resolve in a few days.
Q. What is the rate of transmission from kids to adults? And if a child gets it, how likely are they to show symptoms?
A. Most kids will have symptoms so minor you will not be concerned (and may not even notice). Many will have no symptoms. A very small minority will have symptoms that require medical attention. Most kids get it from their family members. In a Korean article comparing secondary attack rates in close contacts, it showed no case spread by kids <10 years old.
Q. Is there a concern about breast feeding if the mother is potentially exposed to COVID19 and waiting for test results?
A. Yes, because breast feeding puts your baby at close contact with your respiratory droplets. Keep breastfeeding, but to protect your baby, wear a mask.
Q. Do autoimmune conditions make children more likely to suffer from MIS-C or other severe forms of COVID19?
A. We do not know. I have seen kids with autoimmune disorders who had almost no symptoms. However, autoimmune disorders are very broad, and it really depends on the type of autoimmune disorder.
Q. What is your take on schools re-opening/closure?
A. It is a bad idea to open schools widely now given the outbreak. To re-open schools we need:
1. To control the current outbreak
2. Have testing plans for school
3. Have clear guidelines when to shut down a school if tests are positive
Q. Would a child that has epilepsy, lung and airway issues be at high risk for more severe symptoms?
A. This child would be at a higher risk than other children. But still lower than an adult.
Q. My child has missed her last 2 pediatrician appointments due to Stay At Home orders. She’s 18 months. We are scheduled for wellness and vaccine catch-up later this month. Should I take her?
A. Pediatric clinics are safe to go to. Especially since not many kids are getting ill enough with COVID19. Get her shots updated and take precautions while you are there.
Q. Curious about mask-wearing for kids in a summer camp (cloth facemask). Is the length of day wearing a mask a concern? Additionally, if in a sports camp, safer to wear all the time or better to not wear while exercising/engaging in sports?
A. Wearing masks all day is not unhealthy. It is very uncomfortable though. Sports camps worry me. There is lots of close contact, lots of heaver breathing and sweating… I don’t see how they can be safely done.
Q. Kids and COVID19: What have been the treatments and results?
A. I only work with kids. Most had very mild symptoms, and the kid’s parents just needed reassurance. A few were hospitalized. They had moderate disease, but did well. One had a very rare disorder and did not do well. Most kids do not need treatment. The few hospitalized patients got convalescent plasma, Remdesivir, and respiratory support. Also, steroids in the severe cases.
Q. Orthodontia appointments – do you feel it’s safe to start orthodontic treatment right now? My child requires monthly visits to the orthodontist office…
A. It depends on the precautions the orthodontist is taking. If they have good precautions it should be safe, if the procedure is needed.
Q. What are your thoughts about sending children off to college and living in a dorm?
A. College kids have been the root of many outbreaks because of how little they control their social activities.
Q. What is your take on the recent pediatric JAMA article?
A. This study is legit. It simply states that there is more viral RNA in children’s nasal secretions… it doesn’t speak to how often they transmit infection. Epidemiological studies are the way to demonstrate transmission, and they show that kids can transmit to adults, but that adults are the major drivers of transmission.
Q. We have a 4-month old who no one outside of the nuclear family has held or been close to. We told grandparents they needed to quarantine for 2 weeks in order to see the baby. They don’t want to do that. I just want to make sure that is still what is recommended?
A. It comes down to how risky the activities your grandparents are taking:
– Going to the store with a mask on? Walks around the neighborhood? Low risk.
– Visiting friends? Not wearing masks? Going out to eat a lot? High risk.
So if they are only doing low-risk activities, have them come over, wash their hands, wear a mask, and see the kiddo.
Q. Do you have any information about the impact of the virus on kids with type 1 diabetes? Diabetes is a stated risk factor, but I assume they mean type 2 in adults. I can’t find any info on if this risk exists in children with type 1? We are trying to determine if we need to be extra careful with our type 1, or if her risk is about the same as her siblings.
A. People with type 2 diabetes are at high risk because of the long-term cardiovascular damage they have. If you have type 1, are young, and have well controlled sugars, that extra risk should be minimal.
TESTING
Q. Are there enough COVID19 tests in Los Angeles? And is getting tested even worth it, given the long delay in getting results? And how come antibody tests seem to be so inconsistent?
A. LA is doing OK with testing, but many places in the country have shortages. If you have concerning symptoms, please get checked… It is the only way Public Health knows how bad the outbreak is now and the only way you can know if you are putting your family at risk.
Q. There are multiple tests out there for the public to use, both free and paid. Deep nasal, mid nasal, oral, etc. Can you tell us the pros and cons of these tests, and which particular lab or testing you recommend?
A. There are too many to comment on, and you’d really need a laboratory microbiologist to summarize all of them, since the market is so flushed right now with test. General rules are what I can offer:
– Tests done outside of major labs, hospitals, or public health programs are more likely to be of poor quality.
– Routine PCRs – very sensitive. But there are questions about if they are too sensitive, since a PCR that is barely positive test may not correlate with how infectious a person is. The free test (via public health departments) generally fall under this category.
– Rapid PCR tests: Less sensitive, and some have issues with false positives. More variable than the slower PCR.
– Serology: only useful to look for prior infection. We do not know how any tests predict protection, or how long they stay positive for.
– Samples site: Deep nasal samples are known to be a good source. Mid nasal looks good as well. There is ongoing debate about if oral or anterior nasal samples are as good — studies disagree. Many labs / health programs are doing oral swabs now, since they are much more comfortable than nasal swabs.
Q. Has the accuracy of the tests changed? Or what is the accuracy of the tests?
A. The accuracy of the test is dependent on the exact test the lab running them. Most commercial labs (Quest, ARUP) are 99% accurate. Rapid tests (e.g. results given in 15min) are much less so.
Q. I know someone that’s positive. They’ve been sick for about 1 month; last fever was 2 weeks ago. They tested positive again 3 days ago but have no other symptoms. Are they still contagious?
A. They are unlikely to be infectious. The tests are very sensitive, and look for viral RNA, but this does not say if the virus is active or not. In situations like this, the best way to tell if they are infectious is to check the threshold cycle on the RT-PCR. If the threshold is nearing the limit of detection, they are unlikely to be infectious.
Q. I’d really like to know if you think you can get this twice. I was extremely ill from March 8th. May 5th is when I finally started feeling better. Last week, I started feeling all the same symptoms as March (only much milder) and was then told two days after my symptoms began that someone I had been in contact with had tested positive.
A. Please get tested. We don’t know if re-infections can happen. If you are re-infected it will be important information for the scientific community.
Q. Is the Sofia antigen 15-minute-result test accurate?
A. The Sofia antigen tests claims to be very sensitive, but I have not used it myself. In general, the rapid antigen tests are best used for screening tools… the PCR are much more sensitive.
Q. If someone takes a COVID19 test and it is negative at the time, could they still expose others if they test positive a week or two later? I understand there is 30% false negative rate but let’s say this person has no symptoms and they go test and receive a result as negative. They then visit grandparents. However, a week or two later they develop symptoms and retest again as positive? What are the risks?
A. About 50% of cases are spread by persons who have no symptoms. Most will develop symptoms at a late date, but some will never develop symptoms. So yes, if you had an infection but were initially negative, you could still spread it.
Q. What do antibodies mean?
A. Generally, antibodies correlate with protection against an infection. Sometimes the protection is permanent, often it protects for months to years, often they reduce symptoms if you do happen to get the same disease again. However, there are some infections that antibodies do not protect you against. Our hope is that a person with antibodies will be fully or partially protected against future infection with SARS-CoV-2. However, we don’t have enough information to know if this is the case right now. There are several studies looking at re-infections, so hopefully we will know soon. In the meantime, keep social distancing until we know for sure.
COVID19 VACCINE, CURE & TREATMENT
Q. Will you & your family be getting the vaccine (when it comes out)?
A. Assuming the vaccine is studied correctly and there is enough available, yes – I and my family will get it. I will be reading the scientific papers on the phase 3 trials to make sure they were properly studied, because I am always worried about corners that may be cut during vaccine development.
Realistically there will be shortages of the vaccines. I will not get it until the elderly have had it, since they are at a much higher risk than I am.
Q. What company is closest to developing a vaccine?
A. Several companies in China. They… cut corners. The US does not have any candidates that are close to being completed.
No Chinese vaccines are available in the US. To be available in the US, they would need to be approved by the FDA. Chinese companies will not go through the hassle of getting it approved in the US, and certainly not under the current political climate.
Q. How close are we to finding a cure?
A. Don’t expect a cure. The best we will get is a vaccine, and that is probably not until early next year.
Q. Hydroxychloroquine has been in the news. Can you tell me what is known about this drug?
A. An early (poorly designed) study suggested that Hydroxychloroquine may be helpful in treating COVID19. However, there have been many studies since that show it does not help and may be harmful. So it is no longer being used for COVID19. It can be very toxic, so we stay away from it.
LOS ANGELES (As of Q&A date July 30th 2020)
Q. Is Los Angeles trending forward or backward? I’m curious about if we are making progress or only heading towards disaster.
A. We are treading water right now. People need to social distance and wear masks.
Q. Do you think there will be a 2nd waive in the Fall?
A. We have been in wave one since March. How things are going now we may still be in this mess continuously now into fall. No second wave, because wave one never ended.
Q. Are death rates decreasing in Los Angeles?
A. Yes, somewhat. Our treatment of severely ill cases has improved as we figure out what medications and treatments work. Also, there have been a lot of young adult cases recently, which have lower mortality rates anyways.
Q. Data on current rate of infection in LA County? Perceived safe re-opening rates?
A. The LA county website is a good place to get this info… there is updated info on it: http://publichealth.lacounty.gov/media/coronavirus/
The Johns Hopkins website is the best place to look more widely: https://coronavirus.jhu.edu/map.html
ASYMPTOMATICS
Q. What is the percentage of people diagnosed with COVID19 but have no symptoms or minor flu-like symptoms?
A. Nearly all kids have minor or no symptoms.
Around 40% of adults will be asymptomatic. About 50% will have mild disease (which means they will not be sick enough to be hospitalized… they will feel terrible though and symptoms may last for weeks). Less than 10% will need medical care. These are all approximate numbers.
Q. Can you spread the virus as well when you do not show symptoms yet? When is the virus most easily spread?
A. About 50% of spread happens before symptoms occur. This is why social distancing and masks are so important … you can spread it before you know you have it.
COMORBIDITY, PREDISPOSITION, GENETICS
Q. Would you tell me your thoughts on genetic blood diseases like Factor V and COVID19 risks?
A. People have high risk of clotting after the disease and it can last for quite a while. This is now well recognized and is part of the treatment plan for adults, especially those who have severe COVID19. I don’t know of any information for Factor V itself, but any person with a clotting disorder who gets SARS-CoV-2 should be closely monitored for clotting events.
Q. To what extent does asthma affect an adult’s (in this case in their 30s) predisposition to COVID19 complications?
A. People with asthma are at a higher risk of COIVD19 complications than a person of the same age, but not as dramatically as we first thought. Best to keep your asthma under control if you have moderate or severe asthma.
Q. Is it fact or fiction that there is data to support that people with A and B blood types get hit harder with that illness than those with “O” blood types?
A. There is no huge difference between different blood types. If there is a difference, it is very minor, and not really important from a medical perspective.
Q. Does having active pneumonia put you at higher risk? My father is 75 and has pneumonia.
A. Yes, his age and pneumonia put him at high risk.
Q. I’ve read conflicting reports about obesity being high risk. Early on it was BMI over 40. Recently they moved it to 30. Is there high mortality rates for someone with BMI of 30 who is considered overweight, not obese?
A. Folks with high BMIs are at higher risk for bad respiratory infection due to decreased respiration (the extra weight makes breathing more difficult, and clearing respiratory secretions more difficult), co-existing cardiovascular issues, and diabetes. The absolute risk of an individual is going to be a spectrum based on all these factors. A BMI of 30 puts you at a 20-30% higher risk of severe disease, a BMI of 40 is more like 200-600% increased risk. Different studies have shown different number, but they are overall consistent.
TRAVEL
Q. How safe is it to get an Airbnb and go to a place like Sequoia?
A. Safe, if you wipe down the surfaces beforehand. If you go to a place for the weekend that had been vacated for a few days that is even better.
Q. If one flies, how many days after flying should they get tested for COVID19 to make sure they are safe to be around other family members?
A. If you have the option, in 1 days and then in 5 days.
WHAT DOCTORS AND SCIENTISTS KNOW SO FAR
Q. What’s the most important thing you’ve learned the last 3 months? Can you share your experience as a doctor?
A. The most important thing that we have learned is that the virus is spread by close contact (within homes, at social events, offices, etc). Masks work to prevent it and so does social distancing.
Q. What are the most common lingering long-term effects so far among those who seem to have fully recovered?
A. These are seen in adults (and all improve over time):
– Increased risk of cardiovascular clotting events
– Slow recovery of lung function
– Poor cognition
– Increased risk of bacterial pneumonia
Q. Can you please talk about the effects of SARS-CoV-2 on pregnant women and the baby she’s carrying and on the impact on the eggs and sperm that make the embryo.
A. Women are at risk for COVID19, but the mortality rate is not as high as the elderly. All infections tend to be harder on pregnant women than non-pregnant women. COVID-19 is already linked to a higher rate of cesareans and preterm births. There are no birth defects associated with babies born to women who had COVID19 that I know of. There is no evidence that semen contains SARS-CoV-2.
Q. Are people really getting re-infected or is it more likely that they didn’t recover fully the first time and virus lay dormant for a while before attacking again?
A. There are case reports of re-infection, but there is not enough information yet if re-infections are common or have a modified course (either more severe or less severe). For the other human coronavirus (which do show some waning immunity), immunity wanes over several years… so we are too early to really know right now. There are several studies pending now in health care workers that will hopefully answer this question better.
Q. How likely is it that the disease lingers in the air (is “airborne”)?
A. The majority of spread is by droplets, which generally fall with 6 feet. These droplets are very infectious, which is why social distancing and masks are so important. They also settle on surfaces, which can potentially be touched or stirred up again. There is airborne transmission in some situations (intense close contact, medical procedures, etc.), that most people will not be exposed to. There are some cases of super-spreaders that may have been airborne transmission, but they are uncommon and have mostly occurred in dense social situations, which we should all stay away from anyways.
Q. How long can droplets remain active on surfaces indoors where they are able to be stirred up and still infectious?
A. It depends on the surface. Cloths, fabric, cardboard, and porous material deactivate the virus in a few hours. Hard non-porous materials can have viral RNA detected for 1-3 days (though there is debate if it is infectious after this long, so this is likely a high-end estimate).
Q. Is it accurate to say that COVID19 is “just a cold” for 90% of people? Also, what are your thoughts on the number of deaths? This may seem like a stupid question but I’m continually being told that the numbers are inflated and inaccurate. I believe this is simply a political talking point, but I’m wondering if you can kindly share your perspective.
A. Not exactly. Nearly all kids have minor or no symptoms.
Around 40% of adults will be asymptomatic or have minimum symptoms. About 50% will have mild to moderate disease (which means they will not be sick enough to be hospitalized… they will feel terrible like an awful flu, and symptoms may last for weeks). Less than 10% will need medical care. These are all approximate numbers.
The fatality rate may be as low as 0.5 % but is much higher in the elderly. Still, if everyone gets infected, that is 1.6 million deaths in the US.
The numbers are not inflated. Hospitals are full of sick and dying. Politics is what has kept this country from addressing the pandemic.
Q. How long does the virus stay in one area, i.e. a small room or elevator?
A. Most droplets will fall out of the air within a few minutes, but the inside surfaces may be contaminated for longer periods of time (especially on hard surfaces like steel or plastic)… potentially for hours or a day or 2. Wear a mask in the elevator. Wash your hands after you get out. Use the stairs if you can.
LIFESTYLE
Q. Our neighbor smokes cigarettes. As much as our windows are closed, some smoke trickles in our house. Can SARS-CoV-2 travel more easily in the smoke exhalation or should we assume droplets fall to the ground before coming in our windows? Our neighbor smokes 15-20 feet away probably.
A. Smoke particles are much smaller than the particles SARS-CoV-2 is thought to be transmitted in. SARS-CoV-2 does not travel in smoke. So I’m sorry you have to deal with the smoke, but there is no SARS-CoV-2 in it.
Q. Should I continue to wipe down groceries?
A. I have never wiped down groceries, unless it was something I thought was heavily handled. The most important thing about groceries is to wear a mask when you go to the store and wash your hands. Unless someone sneezes directly on your food, you should be OK.
Q. Should I be worried about having my windows open? I worry the breeze will bring germs along.
A. Don’t worry about keeping your windows open. Long distance outdoors transmission does not happen.
Q. Given you don’t stand within 6 feet of each other for a long period of time, would you say that the virus spreads much outdoors?
A. It does not spread well outside. Sunlight kills it pretty well. If you are outside and not around people, you will not get it. Crowds and close distances are really the biggest things to be concerned about.
Q. Can you please advise on the efficacy of fabric face masks (Non PPE/N95)? I’ve seen a ton of commentary and possible misinformation regarding the matter and wanted to hear an infectious disease/epidemiologist’s take on this.
A. The purpose of these cloth masks is to catch small respiratory droplets. They do this fine. Since they are cheap and reusable, they are a very good alternative to no mask. My extended family uses them, and I fully support their use. N95 masks are overkill outside of specific situation in the hospital.
Q. Can the virus spread from person to person by swimming at a pool?
A. In the pool itself? No. The risk of transmission at pools is close contact with other people, enclosed areas (inside pools), and contaminated surfaces. An outside pool, in the sun, with no other persons around is pretty safe.
Q. We have been doing socializing outside with masks on. Kids keep masks on 65-90% of the time while adults keep masks on most of the time and distance. Have you seen any infections from outdoor interactions with masks on most of the time? What are your thoughts on this?
A. This social scenario depends on how many people are there, if people are going to other social events, and how closely the kids are playing. It just takes one asymptomatic person without a mask to get everyone sick, so you have to trust that they are all being carful all of the time. There was a huge spike in cases after Memorial Day, and that is when people really relaxed using the masks.
MORE GOOD QUESTIONS TO PONDER…
Q. What’s the real truth?!
A. The next 6 months are going to be rough.
Q. How much influence do you think the current administration has over the FDA? I am losing trust in federal agencies these days.
A. Dr Anthony Fauci is well respected by doctors and scientists and has an excellent track record. As long as he is heavily involved, I am hopefully. My biggest concern is that corners will be cut due to political pressure, leading to a non-effective vaccine that will undercut folks trust of vaccines. However, there are many being developed, so the chances of having several options in vaccines is possible.
Q. If you were to gauge how long it’d be that we have to keep up mask wearing and social distancing, what would be your prediction?
A. We will probably be social distancing, no restaurant-dining nor large gatherings until we have a vaccine (early next year if we are lucky). It may take months after that until there are enough doses to allow widespread protection.
If the US as a whole gets the outbreak under control, we may be able to see family and friends. Most other countries in Europe and East Asia have controlled their outbreaks, so it is possible. But right now, the US’s response is so fragmented and confused from the top, that I don’t see this happening anytime soon.
Q. I have heard people saying that everyone will eventually get COVID19. Do you think this to be true?
A. There is no need for everyone to get this virus. We know how to prevent its spread and most European and East Asian countries have it under control. We need to follow their examples.
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Thank you very much for reading! I’d also like to give a big round of applause to Dr. Fitzwater for answering so many questions. Thank you Dr. Fitzwater!
*If anyone would like to learn about MIS-C from an Eastern Medicine point of view, please read my blog entry on MIS-C: https://www.iyashiwellness.com/pims-misc-pediatriccovid19disease