Seroprevalence and Black voices in healthcare

How many people have COVID-19 antibodies? What does having antibodies mean? Rosanna Peeling explains the latest, and we're joined by Ashley McMullen from the Nocturnists podcast to chat about her experiences and her new series, Black Voices in Healthcare.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello, welcome to Lancet Voice,

thanks so much for joining us again. I'm Gavin Cleaver 

Jessamy: and I'm Jessamy Baganal. And coming up on this episode, we've got a couple of really great interviews. First of all, I speak with Professor Rosanna Peeling from the London School of Hygiene and Tropical Medicine. And we talk about seroprevalence, what, what the presence of antibodies are in people who have had COVID 19 and on a national scale.

Gavin: And then I sat down to have a chat with Ashley McWillan, MD, who is Assistant Professor of Medicine at the University of California, San Francisco. And she's also the host of a new podcast series from The Nocturnists, which showcases black voices in healthcare. And we talked about her new show and the current moment as well for black people in healthcare.

First, on COVID 19 seroprevalence, here's Jess and me talking to Rosanna Peeling. 

Jessamy: Hi Rosanna. Thanks so much for joining us today. Perhaps you might be able to tell us a little bit about where you're working at the moment and what your kind of role has been in the COVID 19 effort. 

Rosanna: Hello. I work at the London School of Hygiene and Tropical Medicine, where I have a chair in Diagnostics Research.

I'm also the director of the International Diagnostic Center, which is headquartered in London at the London School, but we have members of the center around the world in the U. S., in Africa Latin America, et cetera. I'm also on the U. K. Public Health Rapid Support Team Steering Committee, and with that, we do a lot of work looking at support to not only in the UK, but for WHO and other countries that request support.

I also for COVID work as a member of the Africa CDC lab working group to help with the capacity building for lab based testing in Africa way back in February. 

Jessamy: Yeah, that's an incredible list of activities that you were involved in and you've kindly agreed to talk to us today a little bit about seroprevalence studies.

Perhaps you could just start by telling us what a seroprevalence study is. 

Rosanna: A sero prevalence study sometimes also called a sero survey, is a study where you use an antibody test to try to determine exposure to a pathogen. And usually the choice of what antibody you use and the purpose of the sero prevalence study are the most important factors that you need to consider.

In doing so. because those two aspects of it determines how accurate the serosurvey is. 

Jessamy: We've published one study and we're publishing another study from Spain and Geneva and they're looking at antibodies which they, believe are specific for SARS CoV 2. But how much can be gained from these studies?

What are the sort of major strengths and weaknesses of this kind of way of looking at mass infection? 

Rosanna: Usually we use antibodies to look for exposure. Antibodies are the most sensitive way to be able to document exposure of a person to an infection. And so if we do a seroprevalence, say, in the general population, you will be able to know how many people have had How many people in the community has been infected currently or in the past?

And based on that, you could develop public health measures as well as disease control programs. And so they, they are very important. And these types of antibody assays could also allow us to look at where are the hotspots if we do them in different geographic locations and the higher the prevalence.

The hot spot means that there's been more exposure. So a hot spot means maybe there's something going on there that you need to investigate why there's so much transmission of infection. It could also allow you to identify who are the people most at risk if you're collecting demographic information along with the survey.

And in this case for COVID, it's the elderly, it's those people with underlying conditions. And also we also determined, unlike Zika, we also determined that children are not specially affected, although now new data is coming out that children are affected in a different way with inflammatory diseases.

And so I think that in general, these are very useful studies to do to try to add to our understanding of what a pathogen can do in a population. 

Jessamy: And specifically related to COVID 19 and some of the uncertainties that we have around it with regard to, whether we even get have immunity after you've contracted the virus.

What is some of the sort of major weaknesses or flaws in serous surveys and this way of trying to look at things? 

Rosanna: If we read a a paper on a serosurvey, the first thing we need to do is to see what the purpose of the survey is and whether they've chosen the right antibody assay to do the survey.

As the accuracy of antibody assay, the sensitivity and specificity are really related. In a antibody survey, you really need to look at the prevalence estimated prevalence of the population ahead of choosing your antibody assays in terms of accuracy, because if you choose an assay that has It's low specificity.

That means this assay could have cross reactive antibodies could detect cross reactive antibodies against other causes of respiratory infections, or for COVID, it could be that it cross reacts with the seasonal or common. coronaviruses instead of specifically COVID 19 and or other I think there, there's been some instance of cross reaction for example with other causes of fever and and so if you choose a test that has low specificity, you're going to get more false positives than real false positives.

positives in a low prevalence situation. And so if you choose a test that has low sensitivity, then you're not detecting the people who indeed have antibodies to the assay. And so you will actually have a set of very misleading data on which you would try to determine public health measures. Or if you think that this essay is for to indicate that people already have immunity and can return to work or to be able to freely go around without observing any public health measure, those could be very dangerous in terms of Prolonging the pandemic, 

Jessamy: Both the studies that we are have published and are publishing show a kind of serial prevalence of around 5%.

Relatively low. What are the implications of that on, potential future outbreaks, waves of COVID 19? 

Rosanna: With low prevalence, what what it means is that in that first wave, the pathogen has not reached a lot of people, so 5 percent would be just infecting 5 out of 100 people. And so you could expect that if there's still reservoirs, of the virus in the community because in the first wave, contact tracing hasn't been done very well.

Then you could expect if you lift any of the public health measures, such as social distancing, you will expect a big second wave because there are more, still more susceptibles in the population. And if there are still reservoirs of the virus in the population, as soon as you lift those public health measures, then the virus will start to be transmitted and then you will get a second wave.

Jessamy: And obviously we've seen a, second outbreak in Beijing recently for, for the rest of the world, here in the UK where we are loosening restrictions fairly rapidly, relatively. What's the current thinking on a second wave or outbreak in, the UK and Europe?

Where do you stand on that? 

Rosanna: It's Very difficult to say at the moment. I think that in Asia, countries reacted very quickly to the coronavirus outbreak because they had a memory of SARS, where lots of people died. And they started Lockdowns very quickly, et cetera. And if there are still viruses in their population, I'm sure that's why we've seen these peaks come up again in Asian cities as soon as they lift the restrictions.

In the UK, I think we were slower to put in these lockdowns, and so maybe if we monitor the situation very closely, we may be able to continue not to have a big second wave, but to monitor the situation very closely. Be able to have a more flattened, even if we have a second wave to have a more flattened curve rather than a big spike, because we want to avoid the big spike at all costs because of the We don't want the healthcare system to be overwhelmed and we wouldn't have enough personnel to be able to do contact tracing thoroughly to be able to contain the spike of infections.

Jessamy: And if I might just ask a question that we were talking about before you said you were heavily involved in looking at tests and things like that, and I was just wondering whether you might be able to give us some kind of an update on where we are with tests. 

Rosanna: Yeah. Okay. So from very early days of the epidemic, when the virus sequence was first known, lots of companies and research institutions developed molecular testing and those were all available in the public domain and companies then made molecular testing kits so that you could buy them without having to make them yourself.

And so molecular testing, it would be the most sensitive and specific way to confirm that somebody who's ill has infection. And in fact, now we use molecular testing even on asymptomatic contacts of cases in order to see whether they also infected. So molecular testing is fine. There are now point of care molecular testing, where it's you just have to take the sample put it into a tube to process and then put it into the machine.

to read and it's all automated is what we call sample in answer out type of test. So these usually require a small instrument but it's very easy to use and can be used in community settings rather than big expensive labs where not molecular testing is usually done. But still molecular testing is very hard to scale to a community level and to be for nationwide testing.

And so we really need a fairly easy test. that would detect viral proteins, what we call an antigen test that would detect viral proteins, and would, you would take the same swab as you do for a molecular test, and this test could be done, a rapid one could be done in about 30 minutes. And a lab based one can be done in a couple of hours.

And those would be easier to use in a community setting, or even in, in a clinic. But so far, we don't have from all the evaluations so far, we don't have a sensitive enough antigen test yet for us to be able to use. The last type of tests that we could use in a pandemic are the antibody tests.

And as we mentioned, antibody tests are great for serial preference studies or zero surveys, but because of in a lot of countries they don't have access to molecular testing and we don't yet have antibody antigen tests that are good enough yet some countries are in fact using antibody tests.

To try to identify people who have been infected and this has the use of that is a little bit controversial, but when you have no access to testing at all, having an antibody test. that you could use to identify if somebody's been recently infected is also useful. I think that what we ideally like at this stage of the pandemic is an antibody assay that could tell us whether we have neutralizing antibodies that could be protective, that this type of antibody response would offer us What we call immunity to the virus that we're protected from being infected again Or that we are no longer shedding Infective virus and therefore not at risk of spreading our infection to anyone that we do not have yet What we've seen in a lot of studies is that you could have antibodies to what we know now in the lab as neutralizing antibodies in the lab.

They don't seem to, patients with those antibodies still seem to have a lot of virus that we could detect. So we still don't really know what neutralizing antibodies mean, and I don't think we've identified adequately. A neutralizing response or protective antibody response that we could use to decide who is it safe to return to work if after you've been infected.

And this is especially critical for healthcare workers or essential workers that are in touch that are in contact with the public. And we want to know whether truck drivers who are. Who we need to transport food and others everywhere, they should be tested. But is that test good enough to know whether if they've been infected that return to work?

And also, as schools reopen, do we know that we have a safe environment in the schools? And how should we conduct testing among school teachers and school children to know that we're spread of virus in the second wave in schools. So those are still what's difficult. We have quite really accurate antibody assays that we could do in the lab but unfortunately right now, Those assays require that we take venous blood.

And so it means that if you do want to take a large scale survey you will have to have teams of people who could, who knows how to take venous blood, which is a quite a big drawback as to how you design or carry out zero surveys. 

Jessamy: Thank you, Ana. That's a great way to end, I think, a lot to a long way to go.

It seems. 

Rosanna: Yes, I 

Jessamy: am 

Rosanna: afraid 

Jessamy: yes. That's really brilliant. Thanks so much for taking the time to talk to us. 

Gavin: So lots to think about there and thanks so much to Rosanna for chatting with us. So Jess, what are some of your takeaways of these sero prevalence studies that have come out recently?

Jessamy: We've published two sero prevalence studies. One of them is from Spain. It's a sort of the largest, so far of 60,000 different nationals that were randomly selected. And it shows a really interesting sort of nationwide picture. So there's a great divide between the sort of rural areas and the urban areas from a nationwide specific.

sort of point of view, the seroprevalence is 5%. But in areas around Madrid or particular sort of urban hotspots, that can exceed 10%. That's a sort of really interesting picture that's reflected elsewhere. We also published a paper from Geneva, which was of 2, 766 participants. And there the seroprevalence was about 10.

8 percent in early May. Obviously that is a sort of more urban area, but Switzerland is a country in Europe that's had a very high number of cases. So I suppose what both of these demonstrate is that there's, single digits basically of people who are showing antibodies to COVID 19. And that's in agreement with other published studies from China and from the USA.

So in terms of people who have been exposed to the virus so far, it's pretty low. And that means that the majority of the population are still very much susceptible to the SARS CoV 2 virus. 

Gavin: And it ties in as well, doesn't it, with the UK government results recently which they got from analysing blood donations, which suggested that in London, obviously the major urban centre.

17 percent of people had antibodies, but outside London it was more like 5%. So it looks like we're seeing like a relatively consistent picture across all these seroprevalence studies. 

Jessamy: Exactly, and we have to then bring in the fact that we know very little still about the correlates of protection with regard to immunity.

We don't know whether these antibodies are in fact going to be providing any form of immunity and for how long that might be. It's still a very uncertain picture, but I think what is clear is that there's just a really long way to go before we get anything like a level where, you know, the most of the population were not susceptible to the virus.

And, outside of a vaccine, that means we're falling back on the public health measures, the sort of package of measures that the WHO has been touting for the last couple of months. 

Gavin: Yes, if you consider the number of deaths so far around the world compared with these studies of how many people have actually had COVID 19, the idea of herd immunity seems a little bit fanciful, if you think that the UK has had at time of recording around 43, 000, 44, 000 deaths officially in the official toll.

And if you think that's then still in single percentages across the country for actually contracting COVID 19 according to their estimates, then the idea of us suffering from multiples of that is, is a difficult one to to square away with any ideas that herd immunity might be a solution to this.

Nocturnus

is a really great podcast series which hosts real life anecdotes and stories from clinicians all around the U. S. I sat down with the hosts of The Nocturnist's new series, which is called Black Voices in Healthcare. Her name is Ashley McMullen, and we talked about how the series came together and about some of her experiences working in healthcare.

Ashley McMillan, MD. Welcome to the Lancet Voice, your host of the Nocturnist's podcast, Black Voices in Healthcare. So perhaps we could start off by you telling us a little bit about your background. 

Ashley: So I am an assistant professor of medicine. So I'm on faculty here at University of California in San Francisco.

My clinical appointment is with the San Francisco VA. So I'm a primary care clinician. I work in our main VA hospital and also a downtown satellite clinic. My role is primarily a direct patient care, and I also do a lot of teaching for trainees, our residents and medical students who rotate through internal medicine.

I have a lot of interest in medical humanities and narrative medicine, particularly as it pertains to primary care education and how to equip our trainees to be prepared to take care of patients across differences. 

Gavin: The Nocturnists is this great series that showcases voices in in medicine and health care over in the U.

S. So tell us a little bit about how your part in it came about. 

Ashley: Yeah, so I am a big fan of The Nocturnists. Emily Silverman was maybe two years ahead of me in residency, and she develop this storytelling series like during residency, which is incredible. I could barely get through and she came up with this whole program.

This past January, I actually took took the leap and was a one of the featured storytellers. So I was on stage at the Yerba Buena Theater, and I actually told a story about my hair. And just as that being a lens into what it's been like growing up as a Black queer woman and what that has meant for me in medicine.

And so we became friends after that, and we actually had some of these same conversations around race and identity. And so when the events surrounding George Floyd happened, it was a big reckoning across the country. Again, for, of course for those in our country who identify as Black, it's these are things that You know, we know happen often and we deal with and we grapple with and I can't, quite put my finger on exactly what it is about this particular incident.

There are a lot of things, but to have this happen, in the context of, two or three other like very proximal unjust deaths of black individuals in the middle of a pandemic that is also very much disproportionately impacting black Americans. It was just, it's too much to look away from.

And so I think for many folks in our country, maybe have not thought about this as much before really. Thought about it and we're on a more personal level. It was a challenge to decide whether or not you're going to take an active role and being a voice or a part of change that really needs to happen.

And Emily had reached out maybe a couple days after after the incidents and I brought up this idea of collaborating on the nocturnist and she really just put the idea out there, left it open ended to see where I was at. And I, it was actually exactly what I needed to hear.

It was just like people who were ready to like. Do the work of change. And so we talked about, a number of different ideas of how to use the nocturnist platform. And this is what we landed on modeling a series, what they did previously with the COVID pandemic series. And from there, the ball just got rolling.

The nocturnist has a great production team, and I was just floored by how quickly and efficiently they worked with us to put the series together. 

Gavin: Yeah, the first episode is sounding really great. It's got some really emotional, raw, moving stories in there. What are some of your aims with the series going forwards?

Ashley: Yeah, so I think that the first episode, certainly we wanted to be grounded in the moment. I know that When there's a lot of media uproar, things trend, and then they die off, and then we move on to something else in our consciousness but we really wanted to bring it back to the visceral level of what that incident meant particularly from, through the lens of Black Americans.

So it was a little heavier but I also, one of the aims was recognize that we are not a homogenous group. Everybody among us, um, interprets and experiences. Racism according to their own lived experience, people who are older, who've been through this in multiple ways, are going to experience this moment differently.

People who immigrated here from other countries or their parents immigrated from other countries and they experienced racism in America, however, they are not necessarily descendants of slavery. And so while we are all have these common threads among the black community we each, and handle and manage these events differently.

So I wanted to showcase all of that. Along with that we also wanted to add more context to like the black experience, because we hear a lot about, Some of the, a lot of the difficulties and tragedies, but also being black is quite a, I would say a magical experience. I personally wouldn't trade it for anything.

I love I love my culture. I love my family. I love the legacy of being a part of a people who've come up from, nothing and still manage to do just incredible things. We are across the spectrum, amazing scientists and inventors and artists and athletes and so much more. And we give all of that to the world.

And I wanted to make sure that is a story that gets told as well. 

Gavin: Moving on to, generally like working in the health care profession. What do you think health care clinicians can take from this current moment going forward? 

Ashley: Yeah, I think that being in healthcare is unique in the sense that particularly being black identified healthcare worker, you bring that into the room.

And it's interesting to have that lens of your own lived experience and be taking care of someone who's also bringing their experience into the room and you. can I don't know, I think it's privileged to be able to take care of someone who, who looks like me, or at least can, I can empathize with, having an identity that is traditionally marginalized or having a story that, that doesn't necessarily get told or gets told for you.

And I think that level of understanding and empathy actually helps us become better healthcare providers in whatever. Whatever sector of healthcare work we do. So I carry that with me with all of my patients and I love them all regardless of their backgrounds.

Gavin: What is it like more generally being Black, identifying and working in healthcare? 

Ashley: It has challenges and it has a lot of joys. Just starting with some of the challenges I, every time again, me as a physician and a primary care physician, which, my, my job really depends, my ability to do my job well, depends on me establishing a relationship with my patients, because we're gonna be seeing each other for ideally a pretty long time.

And I have to recognize that Every time I see a new patient and I work in the VA hospitals. I have a lot of veterans who are older Male and often white and I know that when I see someone for the first time I might be the first black physician they've ever seen and particularly a black woman, and a black woman who looks young and all of those things.

And it always reminds me like, I gotta sometimes have a little bit of a bigger psychological size. And hold that level of professionalism a little bit higher. I don't enjoy Having to keep a little bit of formality in terms of people wanting to call me by my first name but I recognize like I have to set that tone because the default is sometimes the assumption is that I'm not as Qualified regardless of my you know, my pedigree.

So But I will say that you know apart from a few Isolated incidents I've had good interactions with my patients even those Who maybe been a little bit more hesitant up front but that is the beauty of my job is that I do have, more times as a VA practitioner and in my clinic to spend with patients.

That part, again, has had its challenges and then, but as far as it's the joy, it's like I said before, in terms of having that lived experience and being able to. Empathize more with my patients. A lot of my patients, particularly my downtown location, are struggling with homelessness, mental illness, um, substance use disorders, and there's a lot of people, not just in terms of race, but a lot of people who have been felt put down or let down by the healthcare system.

And and I recognize that I am a part of that. We know that there are a lot of disparities when it comes to, to race in medicine and I know particularly for, from my own knowledge many Black Americans have been systemically harmed by the healthcare system and along with that, I recognize that there are other identities who have been put down or let down by healthcare providers as well, and many of those folks don't actually get recognized as much, and so I try to recognize that or at least bring that into the room when I see patients who are struggling with things that I might not be as familiar with but can empathize with the need to feel visible, to feel seen and not be judged.

Gavin: So again, finally, I wanted to just wrap up by talking a little bit about There's been lots of research obviously out in the last few months talking about the effect of COVID 19 on the black community, on minorities. What are some of your thoughts about this disproportionate effect that COVID 19 has been having on the black community?

Ashley: Yeah, it's it's devastating and heartbreaking to see that and it's not surprising. Because we've known for a long time that our health care system was not set up and it has not been maintained to take care of. Vulnerable patients. And that has consistently been the case for black Americans.

And I'm not I'm not one who's directly looking at some granularity in terms of the research of what are some of the specifics around why that is in terms of COVID. Can hypothesize in terms of access to care having stable insurance, a lot of these social determinants of health that disproportionately have impacted health outcomes for black people and brown people in our country for generations.

And so what else can you expect, when you have a pandemic like this? It only makes the disparity that much more worse. It's just like that. I don't know that inner conflict of yes, like we're seeing this, like maybe something will be done about it, but also this has been going on for years and now it's resulting In such disproportionate rates of death because we didn't take the time to deal with it before.

I can only be hopeful that this will pour more fervor and more energy into tackling disparities in the same way that we pour energy into tackling other things. 

Gavin: Ashley, it's been lovely talking to you. I really appreciate it and I'm really looking forward to the next few episodes as well. 

Ashley: Yeah, absolutely.

Thank you for sticking with us and hopefully we'll chat with you again sometime. 

Gavin: So it was a real pleasure to talk to Ashley, and it was super interesting to hear her different perspectives. And I've got to say people listening to this, if you haven't listened to this new series from the Nocturnists, Black Voices in Healthcare, Episode one's out and it's a really it's moving and very raw to listen to which makes it, I think, a proper representation of the current times that black people are going through across the world in the wake of the George Floyd killing.

Jessamy: Thanks so much for listening to this episode of The Lancet Voice. You can contact us on podcasts at lancet. com with any feedback at all, and you can subscribe to us wherever you usually get your podcasts. We'd like to thank you for listening to us, and we hope to see you again next 

time.