- The US may not see the health benefits of social distancing and lockdowns for 3 to 4 weeks.
- A vaccine and herd immunity are the long-term goals and are key to defeating the virus.
- There are 4 types of drugs being researched right now: Antiviral medications, drugs for antibody development, anti-inflammatory drugs, and vaccines.
We're living through a public health crisis that is literally something that we have not seen in over 100 years. This is impacting the daily life of people everywhere around the world.
When I think about the health care crisis that we're going through, there's a short-term, medium-term, and long-term impact that we're going to feel as a sector, as a society, and as an economy.
If you look at what's happening in Italy now you can see the progression of new daily infections. You're starting to see curves in Italy, which is a good thing. It means that the rate of increase in new daily infections is slowing. This is by far the most important metric that matters to really understanding if we are getting this outbreak under control.
The way that this virus manifests itself in the population is that if you're infected on day zero, you start showing symptoms around day 2 or day 3. And if you end up being hospitalized, you're hospitalized about 7 to 10 days after that.
So new daily infections are a lagging indicator, hospitalizations are a lagging indicator, ICU stays are a lagging indicator. And mortality is also a lagging indicator.
Because we are chasing this epidemic curve higher, we are not going to see the benefits of social distancing and the impact of these lockdowns on hospitalizations and mortality for at least another 3 to 4 weeks. What we're seeing in Italy now will hopefully start to show up in the US curve toward the end of April into the early part of May.
One thing to remember is that the United States is 50 different states—all 50 states are going to go through their own epidemic curve. The epidemic curves will start at different time points, and they should peak at a lower rate, if the US follows the same pattern that was seen in China.
Social distancing with testing and treatments will be key
The whole point of social distancing and lockdown is to break the chain of transmission and to really understand who's been sick and get them into the hospital if they need it. The next step is surveillance screening if it's available in the market. Can we do point-of-care testing? Can we identify the clusters before they become an outbreak?
That's when we go back to containment and mitigation in a way that is much more locally driven. It's obvious we cannot live in a world where our economies are locked down forever. So we need to go back to being able to manage this at the community level, at the regional level, at the state level. And then in the longer run, we are going to need a health care breakthrough to get to herd immunity—and that's going to be a vaccine.
Testing infrastructure that will be needed through the intermediate term
Right now, what we really need to do is start testing at a massive scale—including antibody testing. This could help identify those who have the virus, help quarantine those who have been exposed, and identify people who have recovered and have antibodies. As of the end of March, the US has done about 1.2 million tests. A little bit more than 100,000 tests per day are being done. Of the tests that are done on a per day basis, about 18% of them tested positive. So if 100 people were tested, 18 people have, on average, tested positive at the national level.
This is another very important leading indicator to know where we are in this crisis. Social distancing measures have shown progress as more people are being tested, so I expect this number to start to roll over in the next couple of weeks and hopefully get to low single digits. Then we can start thinking about restarting our economy.
In order to really have a very good public health understanding of where we are in managing this pandemic, we need to know how much population exposure there has been. So we have to go to antibody testing to understand exactly how many people in the world have been exposed to the virus, have antibodies to the virus, but didn't necessarily test positive for the virus.
And that antibody screening or serology screening, it's going to become available at scale. As we go into the later parts of the second quarter, that's going to be a very important tool that epidemiologists use to understand where we are and how to manage the reopening of our economy. This will give us some insight into the development of herd immunity.
Herd immunity means that the population has built enough immunity to slow infection naturally. In order to get herd immunity for an infection that is as contagious as COVID-19 you need to achieve a population in which 60% to 70% of people have antibodies to this particular virus.
Then, the other thing that we need to do in the long run is point-of-care testing. We need testing that can be done at high-risk locations—at homes, at schools, places of work, where you can actually get a result back in 15 minutes. Or somebody can walk into a hospital, be tested, or take a nasal swab, and have a result back in 15 minutes. That testing infrastructure needs to be built out.
Obviously from an investment perspective, the companies that are going to help deliver that testing infrastructure are going to see high positive demand dynamics.
Widespread testing and continued containment is important because countries that have started to mobilize and try to reopen their economies have seen some regression. I'm going to use Singapore and Hong Kong as 2 examples. Both Hong Kong and Singapore told the population to go back out into the world about a week ago—now Hong Kong is back on lockdown. Singapore is also back on lockdown now.
Treatments being tested for COVID-19
So when you think about the current treatment paradigms that are available in the marketplace today, they fall into 4 buckets.
- Antivirals. Antiviral drugs could help a person's immune system fight off the virus if they are exposed. There is testing on traditional antiviral drugs that are approved for infections like hepatitis C, hepatitis B, and HIV to see if they will work on newly infected coronavirus patients. Researchers are also working to get real randomized data on the drugs chloroquine and hydroxychloroquine. I would say we really need to see randomized data on that front, because the data that's out there is very much anecdotal so it's suspect. And there are data integrity problems with some of the data that we've seen out there.
- Drugs for antibody development. A person who's been infected with coronavirus has neutralizing antibodies inside their system. Can we synthetically create neutralizing antibodies that we can give to people to create natural immunity? That's what these antibodies are supposed to do. These drugs are going to enter the clinical stage this month. And we'll start to get data on these drugs in probably 4 months' time as we exit the summer. The science around this is actually pretty promising. If this works, we'll be able to start giving these antibody therapies to high-risk individuals, to frontline responders, and health care workers. As manufacturing ramps up, we'll be able to give these drugs to more and more people.
- Anti-inflammatory drugs. Anti-inflammatory drugs have been approved and are on the market for other autoimmune conditions. These drugs can suppress the response of the immune system.
The reason people die of a coronavirus is because of the immune system's response. The virus is something that humanity has never seen before. Your immune system tries to attack the virus and in the process of attacking the virus, it actually doesn't know when to stop. So it ends up attacking itself. And that leads to this thing called ARDS, which is acute respiratory distress syndrome. ARDS can cause fluid to leak into the lungs or the air sacs in the lungs, and may cause them to collapse. That prevents oxygen from getting into the bloodstream and being circulated to vital organs and prevents the body from expelling carbon dioxide. And that's why mortality events happen.
Once a patient is in the hospital, doctors monitor the oxygen content in their blood. As oxygen content in the blood starts to go down, the patient may need to get on a ventilator and go to the ICU. That is when doctors may intervene with these anti-inflammatory drugs. Anti-inflammatory drugs actually tamp down the immune system and allow the immune system to recover to fight the virus instead of fighting itself. And the data on those drugs, I would say, is also encouraging. We're going to see randomized data for these trials in the next 3 to 4 months as well.
- Vaccines. The first vaccine candidate went into trials about 10 days ago as of April 3. The other manufacturers that are developing vaccines will start putting their vaccine candidates into clinical trials this month—some next week.
This virus is an RNA virus (ribonucleic acid) and as it has traveled around the world, it hasn't really mutated. The protein that this RNA expresses is a large protein and is actually very stable. It has a spike protein, a spike on its cell surface, which can be targeted by currently known and validated vaccine platforms so there's a lot of hope that we can use existing vaccine platforms to develop a vaccine for COVID-19.
Vaccines will hopefully be available for all by the second half of 2021
We will have much better answers to these questions as we go into the fall of 2020. Assuming that the data is good, the vaccines may start coming off manufacturing lines toward the early part of 2021. That is when we'll start seeing some really good data on these vaccine programs.
Ultimately, we need to inoculate the global population. We need billions of doses of this vaccine. So if we know it works—and we'll know the answer to that early next year—then the next challenge is how do we make this vaccine at massive scale.
The ability to produce hundreds and hundreds of millions of doses of the vaccine is most likely for the second half of 2021. So we're still pretty far away from that. But that's the healthier toolkit that the industry is working on. The toolkit is going to get better as time passes. So the reason we're trying to suppress and contain the virus now is because as time passes, we're going to have much better tools to deal with this virus.