Dr. Angela Rasmussen is an associate research scientist in the Center for Infection and Immunity at Columbia University Mailman School of Public Health. Her research focuses on how hosts respond to infection by viruses in order to determine the severity of the infection and outcomes of the disease, as well as to look for new pathways to treat the disease and how to design vaccines. She is especially interested in newly emerging viruses, such as COVID-19.
Listen to the podcast to hear her explain:
- where COVID-19 testing stands right now and what needs to happen to improve testing
- some measures that people who are undergoing chemotherapy or other immunosuppressing treatments might take to protect themselves
- how handwashing removes the COVID-19 virus membrane
- some of the myths surrounding COVID-19 and why they’re untrue
Running time: 30:34
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Show Full Transcript
Jamie DePolo: Hello. Thanks for listening. Dr. Angela Rasmussen is an associate research scientist in the Center for Infection and Immunity at Columbia University Mailman School of Public Health. Her research focuses on how hosts respond to infection by viruses in order to determine the severity of the infection and outcomes of the disease, as well as to look for new pathways to treat the disease and how to design vaccines. She is especially interested in newly emerging viruses, such as the one that causes COVID-19. Today she joins us to talk about what everyone’s talking about and thinking about, COVID-19 and what it means for people touched by breast cancer.
Dr. Rasmussen, welcome to the podcast. Thank you, so much, for being here during this very difficult and confusing time.
Angela Rasmussen: Thanks for having me, Jamie. I’m glad to help.
Jamie DePolo: So, before we start, I do want to point out two things for everyone who’s listening. The first is that we’re recording this podcast on March 18, 2020, so the information that we’re going to talk about is current as of that day. I know things are changing very rapidly, so I just want to tell you that. And two, Breastcancer.org is located in the United States, so the information we’re discussing is going to focus on what is happening in that country, just so everybody knows.
Now, I think most people have read about how COVID-19 spreads, but there’s been some new information coming out in the last few days about fecal spread and also about people who have no symptoms being able to spread the virus, which is kind of frightening. So could you talk a little bit about both of those things?
Angela Rasmussen: Of course. So, some COVID-19 patients have infectious virus in their stool. That does leave the possibility that the virus could be transmitted by the oral-fecal route, but there’s no evidence that that’s actually occurring. We still believe that the vast majority of transmission outside of hospital settings is fomites, or contaminated surfaces, as well as respiratory droplet transmission.
In terms of asymptomatic patients, there is an increasing body of literature that talks about people with either no disease or very, very mild disease being able to spread the virus, and that probably does occur. Whether it’s truly asymptomatic or just very mild disease is a point of contention. The point is that it can be difficult to identify those cases, especially considering the fact that we have a shortage of testing capacity in this country right now. That is definitely a matter of great concern.
A recent paper came out this week that used mathematical modeling to suggest that undocumented cases in China, early in the outbreak, were driving much of the transmission that was then later incorporated into documented cases. We need to be careful about interpreting that data because it is based on a model making a projection rather than data, but unfortunately, it’s very difficult to determine how many of these undocumented cases there are because they’re undocumented. If people are not very sick, they’re not going to necessarily go to the hospital or the doctor, they’re not going to be identified as a person who needs to be tested to determine if they have SARS-CoV-2, or COVID-19. So it’s definitely a risk, especially in communities that have been heavily affected, such as Seattle, where I am right now. And that is why these large scale social distancing measures have been recommended.
It’s incredibly important, especially for people who are immunosuppressed or have other preexisting risk factors or are older people, to stay away physically from other people, because we just don't know what the prevalence is and there may be a number of people who don't even know that they’re sick that are capable of transmitting the virus.
Jamie DePolo: Okay. Thank you. Now, most of our audience are people who either have been diagnosed with breast cancer or are caring for somebody who’s been diagnosed with breast cancer, and I know some hospitals have announced they’re delaying what they’re calling nonurgent and elective surgery. Others, there have been rumors that some hospitals are delaying all surgeries, which is particularly confusing and frightening for, say, somebody who’s got a lumpectomy scheduled. You know, what have you heard about this? What have you seen? What are people being told, because as you said, you're in Seattle which is a little bit ahead of the curve as far as the rest of the United States goes?
Angela Rasmussen: So, I’d like to start by saying that I’m not a physician, so I don't treat patients at all, nor am I an epidemiologist, nor am I a hospital administrator or professional who knows the ins and outs of how healthcare resources are distributed and how these decisions are made. But that said, I’d be very surprised if all non-COVID-related procedures were going to be banned. If there were going to be no surgeries at all. Because even though this is a pretty frightening epidemic, and there’s probably many more cases than we’ve been able to identify, and yes, some of those cases, the more severe ones, will require ICU care, including some potentially invasive procedures that may or may not be surgical, there are still surgical procedures happening.
People are still getting into car accidents where they need trauma surgery. People are still having heart attacks where they might need bypass surgery. People are still having the type of cancer where they need to have surgery and it’s time-dependent. So I would imagine, without knowing from hospital to hospital or what physician to physician is going to recommend, that patients who are scheduled for surgery will have these consultations with their physicians and providers, and they will be able to make a recommendation as to whether a surgery or a surgical procedure should be delayed or not.
Unfortunately, I can't give a better answer than that, again, because I’m not a medical provider, and these decisions are also being made very quickly, and often there is a lot of mixed messaging surrounding them, too, which has been a problem for all of medicine, I think, during this pandemic now.
But I think that if people have a very time-sensitive procedure scheduled where if they did not have it, it would inextricably cause them harm, I imagine that physicians will do everything in their power to make sure that those patients still have access to the care that they need, including surgical care.
Jamie DePolo: Okay. Okay, thank you. Now, I know you said you're not a physician, but I’m wondering from your viewpoint as a virologist, somebody who’s undergoing chemotherapy, obviously, they’re immunosuppressed. If their doctor says, “Yes, you need to still go and get your treatment,” is wearing a mask and gloves to a treatment center... is that helpful? Is that enough? Are there other measures that they might take? I’m assuming the centers are getting people further apart than they normally do to receive the chemotherapy, but from your viewpoint as a virologist, what would you say?
Angela Rasmussen: So, in that case, they should definitely speak with their provider for advice.
In general, surgical masks do not protect you from exposure, but it may be that to be on the safe side, a provider will recommend that a patient wear masks just to be safe. With gloves, the same thing. The problem with, a lot of times, people wearing masks and gloves is that they don't really wear them right. The reason why you wear a mask or gloves is to prevent yourself from being exposed to pathogens that may be around you. When you're wearing a glove… I can use an example. I was at the airport a couple of weeks ago and I saw a woman wearing a mask and gloves, nitrile gloves, sat down, ordered a salad, pulled her mask aside by touching the front of the mask and proceeded to wear gloves while she ate. That completely defeats the purpose of both wearing the mask and the gloves.
So if you're wearing a mask and gloves, you don't want to touch the outside of the mask. You don't want to act as though gloves are invincible shields or barrier. You have to understand that the outside of the gloves are going to be contaminated, so you don't want to touch them to your face, you don't want to touch the outside of the mask and then touch your face after that. You certainly don't want to pull a mask down to eat or drink while wearing gloves. So again, I would encourage patients to reach out to their providers about what their guidance is specifically in their case and in their clinical center.
Jamie DePolo: Okay. Okay. Now, I want to talk a little bit about testing, you brought that up earlier. Everybody seems to agree that we have a shortage of tests in this country. I know that things are happening that we could potentially have more. But from your viewpoint, how important is it that somebody who is more susceptible, say somebody who is immunosuppressed, but they’re not sure if they’re having symptoms… maybe they also have asthma so they’re having trouble breathing, I’m not sure. How important is it for those people to get tested?
Angela Rasmussen: This is one of those areas that’s really a moving target. We’ve been getting really mixed messages, first of all, from leadership. I think over a week and a half ago, we were told by the vice president that that test would be available to anybody who wanted one, and that clearly is not the case because we don't have enough tests.
So initially, during the early stages of having an available test, only the most severe patients were being tested, and only after other things had been completely ruled out. Now, my understanding is that in order to be tested, at least here in Washington — and this could've changed today, so I want to make it clear that by the time your listeners are hearing this there might be completely different guidelines. But most recently I had heard that in many places people were still not able to get tests unless they knew they had direct contact with a confirmed case. So you had to physically be in contact with somebody who tested positive.
Now, hopefully that will change as testing capacity becomes more widespread and more available, and we’re increasing our throughput, or the number of tests that we can do in a given day. But for now, we’re still not able to test people unless they meet sets of strict criteria, just because there are not enough tests.
Jamie DePolo: Okay, and testing right now, too, to me — I’ve not experienced it — but it does sound slightly cumbersome in that you have to get swabbed and then it takes like 5 hours for the test results to come back, which I guess is down from the day, but still a while.
Angela Rasmussen: Yeah, so it really depends on the system that a clinical lab has up and running. And I will say that I don't work in a clinical diagnostics lab, so the specifics of the automation process will probably vary from lab to lab, and system to system, the different instruments that they’re using, because multiple types of instruments can be used to do this test.
That testing time can be decreased both by increasing the number of available instruments to run the test as well as developing ways to get the tests to the lab where they’re going to be run in a faster manner. Because right now, my understanding is that in a lot of places they’re relying on existing shipping infrastructure to ship them to a central location. What we need is to have local communities, local hospitals equipped to do the testing, and that should reduce some of the testing time.
Jamie DePolo: Okay, and is this something — this is kind of farfetched, but it’s something I was thinking — is this something that we could potentially ever have a test for that is like a home pregnancy test, where somebody could just do it in their home and read it there?
Angela Rasmussen: People are trying to develop a rapid test. I doubt that it would be… I mean, it’s possible. The Gates Foundation, I know, has funded efforts to develop a home test for this. I don't know if it would be so much something that it occurs in your home, because often when somebody gets the flu, for example, or strep, you do still go into your doctor to do the rapid strep test, or the rapid flu test, which work on sort of the same timeframe. It’s not as much like a pregnancy test.
In this situation, it’s hard to say if a test works, if it would be rolled out for home testing. That might well be useful, in terms of testing people by the PCR test that we’re currently using, at the very least it could screen people who might be positive to go get that other test to confirm that. But I’m not sure at what point those rapid tests are… I’m not sure where they are in the regulatory process in terms of their availability to be manufactured and distributed widely at this point.
Jamie DePolo: Okay. Okay. Thank you.
Sort of jumping to another topic. I’m not sure if you've heard about anything like this in Washington, so I’ll ask. Some people on our Discussion Boards have said they’re having problems getting their palliative prescriptions filled. Is that something that’s happening out there that could be rolling across the country?
Angela Rasmussen: So, I can't speak to specific medications, but one big problem with the supply chain disruptions — because this outbreak has severely affected supply chain, also due to the shutdown of many businesses in China specifically — many of the raw ingredients, the vast majority of them for all of our medications, come from China. And with the factories that produce those chemicals nonoperational with travel restrictions limiting shipping to the rest of the world, there are major supply chain problems that are related to our drug supplies. So if there is a problem getting prescriptions filled, it may be because we are going to be dealing with the effects of medication shortages because of this supply chain issue. I hope that it’s not as bad as people are predicting that it could be, but right now we don't know, and I’m not sure that there is a plan B to sort of address this, at least not in the short term.
Jamie DePolo: Okay. Now, I’m also hoping you can debunk some potential myths that I’ve heard about COVID-19 that also people on our Discussion Boards are talking about. Is there a toothpaste that can cure this disease?
Angela Rasmussen: No, there is no toothpaste that can cure this disease, or as far as I know any other household product. Household disinfectants and soap and water will remove it from your hands and are good for cleaning and disinfecting household surfaces, but there is no special silver solution, or toothpaste, or herbs that are effective for treating COVID-19.
Jamie DePolo: Okay. Thank you, and also, I should point out, too, this is on the World Health Organization website. People should not put disinfectant all over their entire body. Do not spray yourself with disinfectant spray. That’s not really going to do anything and could probably hurt you.
Angela Rasmussen: Yes, that’s a great point. In fact, people should know that the reason why good hand hygiene is being so encouraged is that the coronavirus particles themselves are covered with a membrane. And that membrane can be completely disrupted with soap, or any detergent. So washing your hands, 20 seconds with soap and water, just good old-fashioned soap, will remove that membrane from any infectious virus particles and render the virus noninfectious.
Soap is very effective at inactivating this virus, and furthermore, when you wash your hands as opposed to using hand sanitizer, then the water actually washes, physically, any particles that might be on your hands off of them.
However, hand sanitizers that are based on at least 60% alcohol are also effective at inactivating a virus. So those can be used between handwashes. But for me, I wash my hands a lot, and then I use hand cream to keep my hands from getting too dry. But definitely don't bleach yourself. That can be harmful in other ways. Just take a shower as you normally would, use soap, wash your hands frequently, wash your clothes with laundry detergent, and you should be fine.
Jamie DePolo: Okay, thank you. Now, I will ask you this, too. The hand sanitizer — obviously, there have been shortages of that. Some people have been saying, “yes, you can make your own with alcohol and aloe,” and then other people are saying, “no, no, no, you can't do that.” Do you have an opinion on that? Can you weigh in on that? Is it possible to make your own hand sanitizer?
Angela Rasmussen: It depends on the kind of alcohol. So, vodka does not have enough alcohol in it to be an effective hand sanitizer. So as I said, they need to be at least 60% alcohol. And many people, if you have a bottle of Purell handy and if you flip it over, it says, I think, 60% ethyl alcohol, that we all know and some of us, myself included, like to drink. However, again, most types of liquor that people are going to have in their liquor cabinets don't have enough alcohol in them, so you can't just mix one part with aloe because then it won't be concentrated enough. You need 60%.
So unless people have a big stash of Everclear, which is 95% ethanol, and then you can bust out your high school chemistry skills to calculate how much of that would be needed to make a 60% solution. But that’s available in a pinch. There are, online, sort of how-to explainers to make your own hand sanitizer, and I advise going to those as long as they are emphasizing that you're making it with at least 60% alcohol.
Jamie DePolo: Okay. Can you use rubbing alcohol to do that?
Angela Rasmussen: Rubbing alcohol is a slightly different kind of alcohol, it’s isopropyl alcohol and not ethanol, which is another reason why you shouldn't drink rubbing alcohol. It’s not the same thing. Seventy percent isopropanol is usually the guidance that I see, so if you do have a 70% isopropanol solution in your medicine cabinet, as long as it’s not too old you could use that directly as a hand sanitizer in a pinch. Don't mix it with anything, because then you would dilute it below 70%. But you can use rubbing alcohol.
Jamie DePolo: Okay. Okay, thank you. Now, if you can hold your breath for 10 seconds does that mean you're not infected with the virus?
Angela Rasmussen: No. That’s completely incorrect. I have asthma. Other people with asthma and COPD, and other types of respiratory diseases, know that when they’re having an asthma attack, for example, or an asthma exacerbation, you probably can't hold your breath for 10 seconds. And that has nothing to do with you being infected with COVID-19 or any other virus. It’s part of the deal.
Many people have reduced lung capacity for various reasons. People who have had surgeries where they’ve had part of their lungs removed may not be able to hold their breath for 10 seconds. There’s a lot of reasons why somebody might not be able to hold their breath for 10 seconds, but it is absolutely not a diagnostic method for COVID-19, and I suspect that many of these asymptomatic or extremely mild cases of COVID-19 are people who can probably hold their breath for 10 seconds.
The only way that you can know if you are infected with SARS-CoV-2 or have COVID-19 is if you take a test that shows that you are infected with the virus.
Jamie DePolo: Okay, thank you. And then on a slightly more serious note, I know France has put out a notice saying that anti-inflammatory medicines, such as aspirin, ibuprofen can make COVID-19 worse. The World Health Organization and other experts don't necessarily agree with that. Can you shed any light on that sort of controversy?
Angela Rasmussen: Yes. So, the government of France made that recommendation based on the case of four patients who were young and had no preexisting medical conditions that were known, who developed severe COVID disease and had reported that they also took large doses of ibuprofen. Four cases is not a statistically significant number of patients.
There are a number of things, when we think about ourselves and the various things that we do all day, there are so many variables that can go into that. So let’s say that you're not eating right, you’re malnourished. Let’s say that you are taking ibuprofen one day and not the next. What’s a high dose of ibuprofen? You could be not getting enough sleep. You could just be genetically more susceptible to severe disease with COVID. And I’m not saying that the ibuprofen thing isn’t true, it may be. But right now there is no evidence at all that suggests that ibuprofen makes severe COVID worse.
And one thing that I’ve been talking to people about is yes, we have these four patients where there is at least the appearance of a correlation between ibuprofen and severe disease, but there have been thousands… hundreds of thousands of patients worldwide. Ibuprofen is an extremely common available drug that many people use daily or frequently. How many of the other patients who recovered, who had mild symptoms and maybe treated them with Advil Cold and Flu, how many of those people developed severe disease? Can we link ibuprofen to any other cases where ibuprofen use notably made the disease worse or at least coincided with a patient taking a turn for the worse? So far that evidence may exist. It may not be published yet.
But the World Health Organization has said that they are withholding making an official recommendation until they can evaluate more of the data and until they see evidence that does suggest that ibuprofen is a problem. And some of that is doing a literature search. There’s nothing in the literature about this specifically for COVID. So the World Health Organization does have access to public health data from many, many different countries. They may be able to get that evidence first and foremost. So I trust them to do this investigation and to make the appropriate recommendation if it’s warranted.
That said, there are other indications that I’ve heard from some physicians that should be considered when deciding whether to prescribe ibuprofen or Tylenol to a patient. And there are also reasons why you might not want to take Tylenol, because long-term Tylenol use can cause liver toxicity and liver damage. Too much Tylenol use puts you at risk for acute serious liver injury. And in some cases, ibuprofen use, with certain infectious diseases, notably sepsis, has resulted in kidney problems.
So there are other reasons why a physician may or may not want to recommend either an NSAID versus an analgesic, like acetaminophen, to their patients, but those are not related to COVID. Those would be decisions that would be best made by physicians talking to their patients with regard to their medical history and their own level of risk.
Jamie DePolo: Okay, thank you. And I guess to wrap up, from your perspective, what is really the bottom line of COVID-19 for people who are being treated for breast cancer? To you, what are the three most important things they need to know or that they should do?
Angela Rasmussen: They should definitely practice physical distancing from other people, and their caregivers — if they’re very ill and need care from a family member, just their family members in general, if there’s somebody in your house who is being treated for breast cancer or any other cancer, people who are taking hormonal drugs, people who are on chemotherapy, who are getting radiation, all of those things can have an immunosuppressive effect or immunomodulating effect. So people need to be really careful to make sure that they are not being exposed to COVID themselves and giving it to the vulnerable people in their lives.
I think that until we have widespread testing and we can really accurately identify where community transmission is occurring, there’s a risk every time you interact with a stranger who’s been outside. So even though I’m still going outside, my husband and I are here, and neither of us are sick, neither of us are immunosuppressed, so we are able to live in our house together. We go out to the grocery store when we need to, but we’ve really minimized our interactions with the public, just because it’s good practice.
I mean, you don't want to infect anybody with this, whether they’re likely to have severe disease or not. We know from France, and there have been other reports, including in Seattle, that younger people do sometimes get severe disease if they have no prior medical conditions that would predispose them to it. So we are all at risk, and it’s really important for people to understand that until we can take more target measures, until there’s a vaccine, or until there’s an effective treatment for COVID-19, we unfortunately have to do this pretty severe, strict, physical distancing to make sure that we are stopping spread within the communities.
And people who are being treated for cancer, who would be, in my view, more vulnerable to potentially having severe disease or having complications resulting from an infection — so, I like to tell people that just because we’re physically distancing ourselves from each other, we should still look out for each other and care for each other. And that means that people like me, who are at probably a lower risk could go out to the grocery store for folks that really shouldn't go out at all.
So help out your friends, help out your family, help out your neighbors. We are all in this together, even though we can't be physically together for a lot of it. It’s really important to take care of each other, because that’s going to be a critical part of the public health efforts to join together and fight this pandemic.
Jamie DePolo: Dr. Rasmussen, thank you so much. This has been really informative. I really appreciate your time.
Angela Rasmussen: It’s my pleasure, Jamie.