Rajeev Fernando, M.D., is no stranger to being on the frontlines for infectious disease outbreaks. The globally-recognized infectious disease specialist and chief of infectious disease at Stony Brook Southampton Hospital in New York, as well as an affiliated specialist to three other New York City hospitals during the COVID-19 pandemic, has previously provided medical services for the Ebola virus in Sierra Leone and the Zika virus in Brazil.
Dr. Fernando was also one of the only American doctors to go to Wuhan, China to investigate COVID-19 back in January when there were just 50 cases in the world. He is also leveraging his COVID-19 expertise to advise testing company Sensiva Health in helping to develop effective COVID-19 tests. Sensiva Health owns and operates its own high-volume Clinical Laboratory Improvement Amendments (CLIA) Certified medical lab, production lines, and IT platform through its affiliated family of companies.
Fernando recently spoke to Healthcare Innovation Managing Editor Rajiv Leventhal about several COVID-19-related issues, including his trip to Wuhan, the United States’ response to date, testing issues, how things could get better going forward, and more. Below are excerpts of that discussion.
Can you describe your experience in Wuhan in January? What did you learn there?
Every day I follow different outbreaks across the planet. It’s one of the things I do as an infectious disease doctor. So if there’s something going on—let’s say a plague in China or meningitis in Italy—it’s up to us to make an assessment on whether that [outbreak] will be endemic, if it will get bigger and be an epidemic, or if it will go global and be a pandemic. For SARS-CoV-2, when I started following it late in 2019, it was easy to think this would get worse for the simple reason that it was following the exact pattern of SARS-CoV-1, [which was] another coronavirus in a wet market. They were going down the same pathway. So I said I have to go to Wuhan to investigate this one. I set up a few meetings and got to Wuhan, trying to get the key information from the right people so I could come to my own conclusions.
About two days before I left, the World Health Organization (WHO) said there’s no evidence of human-to-human transmission of the novel coronavirus. When I went there to assess the situation, I did feel there would be human-to-human transmission, and I mentioned that at the time. At that time there were 50 cases in the world, and I didn’t feel that it would [grow[ to be a pandemic. I know it’s hard to imagine that now with 17 million cases [worldwide], but a lot of information was hidden at the time, so no one could have [predicted] this would happen.
Was it difficult to get trusted information from their leaders?
It was very evident from the minute I landed there that no one wanted to talk. You could feel a palpable tension. A lot of people were wearing masks, and people in Asia are very sensitive to masks, even when the CDC said they wasn’t necessary. But it was impossible to get any information. I sampled some areas and was able to draw some conclusions, but they were doing everything they could to hide information, even with doctors reaching out trying to understand more. Also at the time, they mysteriously stopped exporting PPE, which they have traditionally exported all over the world. But in January all those numbers stopped and they kept a lot of those [supplies].
The COVID-19 statistics in the U.S. are obviously not good and it’s frustrating to see most states stuck in neutral, if not going in reverse, especially considering the resources we have. If you could pinpoint one or two areas that help explain why the U.S. has responded poorly to the pandemic, what would they be?
This is a tricky pandemic. Even if you take one step forward, if that step is a misstep, you are really going five steps backwards. We haven’t learned from our lessons before, and [decisions] should be based on science and epidemiology. People are opening states all over the country, but without science and epidemiology, that continues to be a problem. I am currently in Mexico City for the day investigating on the ground, and a lot of the issues that exist in the U.S. exist here, too, such as the president not wearing a mask and people thinking that COVID is really only from China.
Early on, our government should have played a more active role in channeling the information and working with the states, rather than giving the states their own independent situations to make decisions. As an infectious disease physician, it’s difficult for me to say this, but I think lockdowns would be the only way to save certain states right now. Wearing masks and social distancing are great, but we might be a little bit past just doing those things.
To that end, if you were asked to formulate a COVID response plan for the U.S. today, what would be the core elements of that approach?
One of the things I would be doing is moving towards expediting testing. This is a real problem front-line healthcare workers face, and it’s one of the reasons I joined Sensiva Health. I have investigated Ebola in Sierra Leone, Zika in Brazil, and have been all over the planet, and what I have learned is that once you make a clinical assessment, it’s really important to have laboratory tests to confirm it. For example, Ebola and malaria can present in a very similar fashion, and the tiebreaker would be the blood test. So it’s really important to identify exactly what is going on. Testing in the U.S. has been a problem, even though we now do the most testing in the world today—about 800,000 tests a day. But my target would be 8 to 10 million. That’s what we really need to get on top of this epidemic.
A few months ago, some experts were suggesting that 800,000 tests a day would be suffice. Why do you contend that we need 10x that number of tests today?
We do know that about 80 to 85 percent of people [who are positive] have very mild symptoms. Most youngsters brush that off; that’s the vast portion of people who have COVID-19. But more than 50 percent of people who get COVID-19 don’t even know where they got it from. That is a big problem, accompanied by the fact that many people in the states don’t believe in wearing masks. So we need to test, diagnose, and contact trace. It’s at the core of what we need to be doing.
Have cases skyrocketed to a point where contact tracing is just far too difficult?
We will see the true numbers of this pandemic sometime next year. We’re doing the best we can to get the most accurate numbers possible, but contact tracing would apply to states that have stabilized their infections. If you bring the infection rate down significantly, contact tracing could really help out. Also, when you talk to someone who [tested positive], oftentimes they don’t want to give out information. So there are a lot of flaws with contact tracing, and when you have 40 states increasing in their case counts, contact tracing won’t fly in those situations.
It also seems like we have gone backwards in getting rapid test results. Are you seeing this too, and if so, why?
I think we have gone in reverse a bit. When the pandemic started all over the world, it was a two-test approach, where someone would conduct the test, identify the viral DNA, and confirm it. That was the first approach used all over the world. But you do need a skilled technician for that, and it’s labor-intensive. The other strategy is a pooled approach where you gather X number of people, put them in different groups, and test them. That would work in some of the Northeast states where the numbers are much lower, because if you have very few infections, if one comes back positive, you retest it. Pooled samples are really big in different parts of the world, but in our situation here, it’s not the best approach.
Another test is the rapid antigen test, but this isn’t a good idea for the entire country. The problem is that it lacks sensitivity; it’s only about 80 percent sensitive. To put that in perspective, Sensiva’s PCR test is 100 percent sensitive and specific. But the antigen tests are not ready for primetime. They can be used in a nursing home, perhaps, where you are repeatedly testing people a few times a week, or for when people are coming to visit their loved ones.
There is some growing speculation that pre-existing immunity to the virus could be more prevalent than once thought, and also that this coronavirus possibly weakens or burns out after infecting a certain number of people. How does this hypothesis land for you?
With regards to immunity, we haven’t heard much about reinfection. China had their worst month in January and pretty much kept things at bay by March. It’s now four months later; where are these reinfections? There is science saying that antibody levels may not last, but with the term reinfection, infectious disease doctors are looking for it, but we haven’t seen much of it. The jury is still out on how long that immune response is, though.
Right now, since we don’t have a solid explanation, a lockdown is the safest and most proven method to keep people safe. If you are getting worse—like the U.S. is—we should use the lockdown as a measure, because that is the only [strategy] that we know has worked in places like New York City and Wuhan.
Another thing to keep in mind with reinfections is that the PCR is such a fine test that can pick up any dead [virus] fragments, and that is probably what’s happening [if someone has a positive test, a negative one, and then another positive one]. It’s such a specific test that picks up these nucleic acid fragments, so that is another reason the result could come up positive.
