After Dogs Detecting COVID-19, What’s Next?

You may recall my recent post describing studies that demonstrate how accurately dogs can sniff out COVID-19. The answer to “What’s Next?” may be found on your wrist right now.

“Wearables” outfitted with artificial intelligence (AI) to report back health data may send a message to asymptomatic or presymptomatic people with the virus before they spread the disease. That means Fitbits, smartwatches, and heart rate monitors that cardiac patients strap to their wrists may help us fight against those dreaded spikes we’re seeing nationwide. The key is that these wristlets monitor heart rate.

In a fascinating discussion, Abraham Verghese, MD, Professor and Vice Chair in Theory and Practice of Medicine at Stanford in California, spoke with Eric J. Topol, MD, Professor of Genomics at The Scripps Research Institute in La Jolla, California. Topol is also the editor-in-chief of Medscape, which carried the video and transcript of their interview.

First, a couple of items that may seem surprising. You know how diligently everyone’s taking your temperature as a precaution? I’ve visited two doctors, my dentist, and my hairdresser over the past several weeks; each time, my temperature was dutifully taken before I’d stepped well into the reception area.

“But that’s so silly,” said Topol, “because…multiple prospective studies about fever and COVID-19 have found that large numbers of people don’t have a fever.”

Topol mentioned a large study published in Nature Medicine that found only 30% of COVID-19 patients had a fever. Another recent study, published by Color genomics, put that figure even lower: 12%.

So temperature taking may catch some potential COVID-19 infections, but not that many. However, it’s such a noninvasive and seemingly inexpensive method that it seemed to me worthwhile. Unless, of course, it’s causing a distraction, and that appears to be Topol’s objection.

Wth those study findings in mind,  consider that between 30% and 40% of COVID-19 patients are asymptomatic but are still shedding virus—and that presymptomatic people are also shedding virus and are as infectious, possibly even more infectious, than those with symptoms.

For these reasons, Topol calls temperature taking “a placebo.”

Verghese agrees.

“We learned too late that we didn’t emphasize masks enough and we overemphasized temperature measurements.”

Lest anyone be thinking, “Oh, these scientists; they don’t know what they’re doing,” I want to underscore here—because science and scientists are under such unjustifiable and dangerous fire now—that both men agreed the progress that’s been made with the coronavirus has been remarkable.

Said Topol:

“The science is moving at a pace that I’ve never seen—everything, from the structural biology of the virus and the antibodies to the virus from patient, to the design of drugs and vaccines and neutralizing antibodies. The sequence of tracing it temporally and spatially geographically through the world has been extraordinary.”

The point is that this is a very complex virus causing a worldwide pandemic. Equally important, scientific progress isn’t linear: there are bound to be erroneous assumptions, initial errors, blind alleys, and failed medication/vaccine clinical trials.

It’s always been that way. Many of us just haven’t followed the process so closely because we’ve never been in a pandemic before—in which there’s such pressure to move quickly and get things right (and in the US, I must add, ignorant political interference that has had lethal effect).

Topol did discuss testing problems, including the false negatives, the logistics of testing done appropriately to scale, and the expense and time limitation of all these one-time tests. He looks forward to home testing but believes that’s at least several months from now. (See also The New York Times for this article about better testing.)

The big question remains:

“How can we find people in a cluster or an emerging outbreak before it spreads more? Because we know, by the famous Pareto rule or principle, that 80% of transmission comes from 20% of the cases.”

Since we can’t test everyone constantly, the urgency is to locate and concentrate on those “early spreaders.” And that’s where the wearables show promise.

Apparently, such wearables had been generating great interest even before the pandemic, but are now attracting the attention of large research consortiums because of their potential to forewarn about infection with this tricky and highly contagious virus.

Acknowledging that the US is far behind most countries in controlling the spread, Topol said:

“Here is the opportunity to use sensors that get continuous data and would give us an edge.”

In a project named DETECT, begun in March, he and colleagues now have roughly 38,000 participants using a smartwatch or fitness band. Other studies are using rings.

In the first 30,000 people, they found changes in three indicators: increased resting heart rate, more sleep, and fewer steps. And all three indicators then correlated with symptoms and positive tests.

Topol’s group had previously used sensor technology in studying a flu-like illness. When their findings were published in January, a group in Germany developed a smartwatch app that’s being worn by more than 500,000 people; in China, 1.3 million are using such an app.

Verghese, impressed by the number of people involved in Topol’s study, asked two questions: have the results been rigorously tested?; and “do we get the signal early enough to make a difference in some way?”

Topol said they still have to validate the results, but in their Fitbit flu-like illness study, they saw the signal well before the CDC had even observed the presence of the illness. COVID-19 is even more suited to the technology, he believes, because of the large numbers of asymptomatic people.

Studies of asymptomatic people who were on the Diamond Princess cruise ship and in Korea found more than half of them showed the same lung abnormalities as people who’d had symptoms. The presumption is that their heart rates would have shown what they did not feel.

Amazingly, more than 100 million people in the US are currently wearing some kind of wrist sensor to monitor their heart rates. Twenty percent of Americans wear a fitness tracker, according to a Pew Research poll done in January.

I sense that if this approach is validated, it might escape the politicization we’re currently seeing over wearing masks!  Think that’s possible? Of course, it wouldn’t replace masks, but it might be acceptable to some of the diehard anti-maskers among us.

Topol points out that the measure isn’t as helpful on the individual level as it is in a neighborhood.

“If your heart rate goes up, you still don’t know why. But if COVID-19 is in your neighborhood, if there is a cluster, then that makes it more of a real signal.”

Then what? Suppose your Fitbit is yelling at you (digitally)—what do you do next? That’s when testing, tracing, isolation come in, says Topol—while we await more accurate home tests that could provide quick results.

As to the wearable alerts, he says:

“The issue is to get people to be citizen scientists….a lot of people like to get their data and like to get a notification that something in their neighborhood is showing a potential signal, without inducing anxiety. But I’d like to at least raise awareness. You don’t need everyone in the country to be a citizen scientist; you just need enough. We have every state covered but not densely enough yet, so that will be important.”

Verghese raised an important question about equity and access. Not everyone has a Fitbit, smartwatch, or heart rate monitor.

“How do we ensure that we truly are studying a representative cross-section of this country and that everyone has equal access to what is basically a public health issue?”

Acknowledging the gravity of the question, especially in terms of the statistics showing the far greater burden of the pandemic on minorities, Topol stressed that not everyone needs a device: if enough people in the area are alerted to a problem, “The people who don’t have this technology will still derive the benefit of knowing that there’s an outbreak potential in their area.”

I would hope that with this knowledge, there would be a concerted effort to ensure that sufficient numbers of wearables were available in areas most likely to see disease clusters.

But that’s not enough. Topol pointed out:

“The problem is that people in these underrepresented minorities and of lower socioeconomic status don’t have access to testing. They aren’t looked after. Many of them are afraid to come in because they could be deported, or who knows what could happen to them. We have a lot of collateral damage from the pandemic here because of our tenuous and, in many cases pathetic, framework of healthcare.”

It is deeply troubling that we continually confront the vast numbers of people, particularly poor and minorities, who are being deprived of decent health care in our still wealthy nation. But I was pleased to see that the question was at least asked and discussed in this conversation. I’ll be looking at additional ways healthcare has been inequitably skewed in the near future.

My questions for you: Do you currently wear a Fitbit, smartwatch, or heart rate monitor? If you do, would you like to have it inform you if you have possible COVID-19 symptoms? If you don’t wear one, would you be willing to for this purpose? And any other comments you’d care to add are, as always, most welcome!

Annie