José María Peña Sánchez de Rivera, Professor of Medicine at the Autonomous University and Clinical Chief of Internal Medicine at the La Paz University Hospital in Madrid, sees a promising future in new treatments against Covid-19 disease, while defining the current situation as a “nightmare” from his hospital, where he has kept the HIV patient unit for 30 years, fighting “bugs”, as he defines them, like this coronavirus, “a simple microorganism” but that is “a historical challenge”.
Will the pills or the vaccine save us from the pandemic?
The vaccine will not be there for a year. We are all in a hurry and when reality does not match our desire, frustration and anger arise. But that’s what there is. For example: AIDS virus, 1983, and here we are, without a vaccine. The good news is that this virus mutates little and the feeling is that you are going to get a great vaccine. Meanwhile, treatment, and there are several possibilities.
Is injecting plasma obtained from the blood of infected patients one of them?
Exact. It is going back to history: we know that the organism, if you give it time and the bug does not kill you, manufactures molecules called antibodies, which are super neutralizing, but you have to give the body about three weeks, and of course there are microorganisms that will they kill before. What was done before antibiotics existed was to inject microorganisms into animals, horses for example. The animal made antibodies, you extracted this serum and gave it to the sick and cured them. That is older than cough. It was also made in Ebola. We also learned long ago that it is better to use plasma from our own species. But for that you have to be sure that these antibodies are neutralizing, because not all antibodies eliminate bugs, and the prototype again is AIDS, where we saw that the antibody did not block. This bug is simple and there is a very reasonable hope. The issue is how much can be achieved, logistics, although for now there are thousands of donors.
They are testing other pills, for example those used for arthritis …
It is that there are different approaches. You can attack a virus when it is circulating before entering the cell, when it enters the cell and when it leaves. Before it enters, the drugs are useless because what they do is block replication and when the virus is out it is quiet. In this phase the antibodies neutralize, they are great at that moment because this way the virus will not harm me. Direct drugs are useful as hydroxychloroquine was found to change things within the cell that make it difficult for the virus to replicate. It is a classic of malaria, also lupus and rheumatoid arthritis, because it regulates the immune response. Many drugs are being tested, it will have to be seen, because the risk of error is high in the few cases, although there are very well-planned clinical trials, also in Spain. Trials should be double blind, neither the patient nor the doctor administering it knows what is giving, to avoid interpretation biases. We will have answers in a couple of months.
Are there more options for the sick?
Yes. The bug itself does not give a lot, it does not give a lot of fever, it is our immune system that recognizes that something strange has entered and puts in place connected mechanisms to eliminate it, which are what cause the effects of fever, discomfort … In exchange for that they kill the bug, but in a small percentage of patients and without us knowing exactly why, the immune system gets excited and produces a cytokine storm, and it kills the bug and kills the host. So people suddenly get worse, not because the virus is more harmful or aggressive, but because of the hyperresponsiveness of some patients. That is why monoclonal drugs are used for the most serious people, you block that response and the patient comes out ahead, because too much immune response kills.
Is it known in which patient profiles there is too much response?
Not yet. We are now working in ICU and hospitals early in identifying severity criteria.
Is it possible that young people are infected less, as the figures provided by the Government say?
It is not like this. We will know for sure in a couple of months, because when you pass the disease there are some proteins in the blood and later, when population studies are done, we will have a great map that will confirm that a very high percentage of the youth population has passed Covid-19 without find out. It is like hepatitis A, which in 95% of cases passes asymptomatically. This will also change the mortality rate, because there are now a minimum of 250,000 people infected in Spain, for sure.
Does incubation be so long, up to 14 days, complicate the treatment and the clinical fight against the virus?
I am not clear about that. From what we are seeing, the incubation is 5 days, add more minus 2, and if we get very good we are between 2 and 12 days.
Why are we talking about such long terms, then?
Because it is politics for millions of people and not all are equally aware or responsible. The WHO publishes for 7,000 million people in the world, and they put a lot of safety margin. Clinically, this 14-day margin has not been demonstrated.
Is there a risk of reinfection of patients who have been cured?
No. The magazine ‘Science’ started an article saying “don’t talk nonsense.” There is definitely no chance of reinfection in cures.
So why will Minister Irene Montero quarantine after the illness has passed?
If you test positive again after the disease has passed, there are several options, including that you are producing residual intermittent elimination of the virus’ genetic elements, not viruses with full infectivity. This phenomenon is very common in many other infections and is solved by explaining and reassuring the patient. Not isolating it.
Is contagion on surfaces where the virus remains, such as metal or cardboard, a risk? Should we disinfect?
On surfaces it is an absolute reality that the virus remains, it should be reasonably disinfected. But in sprays [de menor tamaño a las expulsadas al toser o estornudar] no. Well, in this case there is a risk if I am a doctor and I am intubating a patient. The doctor should wear a mask with a good filter. But in normal life, on the street, with the subway distance to spare.
So, so many masks that you see on the street, are they really of no use?
It is difficult to get the idea that they are not necessary because almost everyone has them. Nor do I know who advised Felipe VI to go to Ifema the other day with a mask, because he abounds in this idea and that image hides any reasoning. If I am a toilet or caregiver and I am going to approach a person, then yes, mask and glasses.
What incidence can Covid-19 have in pregnant women and neonates?
There was a lot of fear with this, because immunologically the pregnancy situation is special. A woman has something inside her that is only genetically hers in the middle, so she must have an immunosuppression system so as not to kill what is inside. Fortunately this virus does not affect pregnant women especially, the flu virus, however, was horrible. This remains in the respiratory tree and does not reach the blood and neonates do not seem to affect them either, although there are few studied experiences. And no malformations have been reported either, that this is a nightmare and that is what happened with Zika.
What is a day at the Hospital of La Paz like now?
A nightmare. 95% of the beds are for patients with coronavirus, we have residents dedicated to this. I’ve been in college for sixth and a list of volunteers to help has been made, people are giving their all. Of course, the rest of the diseases have not been taken on vacation, and with the bloody cuts that we dragged we were already at 98% occupancy. Although people go little to the ER now, there are still heart attacks, digestive hemorrhages … And you find yourself with 200 daily admissions, and that’s a nightmare. It is especially hard because the sick are alone because of the risk of contagion.
How do you imagine life after confinement and when the crisis is overcome?
Trying to see something positive, next year’s flu is going to seem silly to us, because people are going to wash their hands and be careful. There is a reflection on public health and the cuts that have been made. Let’s see if they learn. This is something historical, because never in human history has a civilized society tried to block an infectious disease, it reminds me of the fourteenth century black plague, when they failed, of course. It is a collective challenge.
Doesn’t the so-called Spanish flu even overcome this challenge?
Also, there was not enough technology and it was another society. Epidemiologically they did very well because of the isolation, but it was not as focused on time as now. In this case it has been historical. Can you imagine that in a free and democratic society they won’t let you out? It was inconceivable, but people have assumed it with an extraordinary sense of responsibility, with a high level of solidarity, but also fear.