RSU Professor and Infectologist Baiba Rozentāle: We Have to Be Able to Predict the Development of the Virus
The Latvian Centre of Infectious Diseases is currently the largest hospital in Latvia treating patients with moderate to severe COVID-19 infections. However, with the rapid increase in the number of cases, patients are also being admitted to in-patient care units at the Riga East University Hospital. Baiba Rozentāle, the Chief Physician of the Latvian Centre of Infectious Diseases and a Professor at Rīga Stradiņš University (RSU), is participating in a national research project aiming to study the development of COVID-19 and develop the best treatment options.
We invited the Professor to a conversation to find out what a doctor treating patients suffering from this serious, insidious and mysterious virus on a daily basis thinks about the spread and treatment of COVID-19.
What are coronaviruses exactly? Do they have a long history?
Coronaviruses have been known to be an upper respiratory tract viruses since the 1950s. There are currently four known subtypes of this virus that transmit to humans, with three other subtypes observed in animals. The coronaviruses that are known so far cause quite a mild disease, but this new, fifth virus is different and probably much more dangerous.
How does this virus spread in the body?
The first organs at risk are the lungs, because the virus mainly spreads through exposure to virus-containing respiratory droplets. After inhalation you might initially experience mild inflammation of the pharynx, the larynx or the trachea, a slight hoarseness, and a dry, hoarse cough, but the virus continues to travel through the body and causes severe lung damage, resulting in a lack of oxygen. The lungs are like bellows that supply oxygen to all organs through the bloodstream. If a patient additionally develops clots in the blood vessels, a serious lack of oxygen can start to develop in other organs as well, often resulting not only in lung damage, but also in significant dysfunction in other organs.
I can remember that at the end of spring and in early summer there were hopes that the virus would become milder, but as autumn began, it’s been confirmed that the virus is actually gaining in strength.
Photo from personal archive
SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2) is one of the upper respiratory tract viruses characterised by an autumn and winter seasonality. In countries that have temperate climate zones with four seasons, a virus' circulation seasonality is one epidemiological characteristic. Currently, the Latvian Centre of Infectious Diseases has been transformed into a COVID-19 hospital, and the number of patients is constantly growing.
Please tell us about the study that you are involved in.
Broad and intensive research into COVID-19 is currently under way in Latvia and all around the world. The virus is being studied from both a medical and social sciences perspective. The studies are multidisciplinary and involve a wide range of specialists. Our section of the project is led by Prof. Ludmila Vīksna who is the Head of the RSU Department of Infectology. My job as the Chief Physician of the Latvian Centre of Infectious Diseases is to examine and treat inpatients, as well as to conduct dynamic monitoring after they are discharged from the hospital. Our main task is to develop the most optimal examination plan possible so that we as doctors would be able to predict the course of the disease as quickly as possible.
Why is this important?
Because it is necessary to be able to determine as soon as possible whether a patient with a moderate form of the disease might develop a severe form later on, or whether they will remain in the same moderately severe condition. This is crucial because different treatment algorithms have to be applied in both cases. Thus, being able to predict the course of the disease allows us to develop a more precise treatment plan.
Will you also follow up with patients after they are discharged from the hospital?
Definitely! It is necessary to follow up whether patients who have been cured of an acute infection is actually completely healthy. Their lungs may have been damaged during the acute illness, and possibly also the brain or the liver. We have to know whether the virus is gone completely or whether it still present and maybe even developing somewhere in the body. Dynamic observation is necessary in order to answer these questions. There are currently plans to observe patients until the project ends in December. But I believe it is essential to continue observation even longer - for six to twelve months. In addition, as a specialist I would say that research should carry on for even longer.
It would be extremely beneficial to have the opportunity to continue the national research project, as the most unexpected things can be discovered.
We study everything starting from the brain to peripheral blood vessels, as this is definitely not a simple upper respiratory tract virus and a great deal of unknowns remain.
How is the dynamic examination of the patients integrated into the study?
A specific algorithm has been developed that determines which tests need to be performed. We make an assessment using radiation diagnostic methods – X-ray imaging of the lungs, computed tomography, magnetic resonance imaging, as well as liver ultrasonography and other examinations according to the study protocol. This national research programme project is complex and involves doctors from a variety of specialities, not just infectologists, but laboratory specialists, immunologists, geneticists, radiation diagnostics experts and others. We have a multidisciplinary team.
We can already see that some patients have recovered fully, while others have retained pathological changes, for example in their lung tissue.
In these cases, we set a period of time during which the patient has to be re-examined.
Can you say that one of the study's goals is to predict the course of COVID-19?
I would say the course of the disease must be predicted in two stages – when it is acute and in recovery. One prognosis would be about how the acute disease might develop in a particular case. Perhaps a patient whose condition is moderate shows some parameters that could indicate that the disease is progressing to a severe form, and it is crucial to be able to prescribe medications quickly according to the patient's prognosis. The second case would concern a patient in recovery to see whether the disease has progressed without consequences or whether there might still be residual symptoms.
Do patients willingly agree to participate in the dynamic observation?
We have to obtain patients’ consent in order to use their biological material. Our doctors examine patients wearing protective clothing and ask for their consent to take part in the study meaning that their biological material will be thoroughly studied. After being discharged from the hospital, the patient will also periodically have to visit the Latvian Centre of Infectious Diseases to undergo various examinations. Collecting patients’ biological material has been funded by the Boris and Ināra Teterev Foundation and the doctors' hard work is being paid for by donations from the Foundation. The material that is obtained is stored in a biobank at the RSU Institute of Microbiology and Virology.
Patients understand that both detailed in-patient examinations and all follow-up assessments help protect and improve their health.
In addition, participating in post-hospital dynamic examinations is free of charge. There are no co-payments for magnetic resonance imaging, for example, and patients do not need to get a referral from their GP. I have to say that patients are generally responsive, and we encourage them to use this opportunity in the future. Additionally, the doctors involved in the national research programme call patients at home and inquire about their health.
What are your thoughts on a vaccine? Will it be a panacea that will solve everything?
I don’t think it will be a panacea at all, because we can already see that half of all patients do not develop antibodies. Although I am a strong supporter of vaccines, I would like to remind people about the influenza. The goal of the influenza vaccine is not to eradicate the disease, like it was for example with smallpox.
Similarly, as with influenza, the COVID-19 vaccine, which we are still waiting for, would not give life-long immunity, but most likely protect recipients for one and a half to two years.
In addition, the virus is insidious and volatile, so the antibody response induced by the original vaccine might not be effective in all cases, i.e. if the virus mutates, the antibodies might not have an affect on it.
There is also a question regarding the range of people who should be vaccinated. In my opinion, at-risk patients should be vaccinated first, and it is only through research and practical experience that we will be able to see which patient groups are really at risk. We now say that these are the people over the age of 65 and those with chronic diseases, such as heart disease, diabetes mellitus, metabolic diseases, immunosuppression, which can be caused either by diseases or by certain medications, such as corticosteroid hormones, immunosuppressants, etc. Excess body weight is also a risk factor.
Patients with HIV have secondary immunodeficiency, but interestingly we have had only a few COVID-19 patients who were also infected with HIV. It might be that HIV patients rarely get COVID-19, but the reasons for this still need to be investigated.
Practice and studies show that, unlike influenza which is very dangerous for children under 2 years, COVID-19 is not particularly dangerous for children or for pregnant women.
There are currently more than a hundred candidates for developing the COVID-19 vaccine.
You should always remember that a vaccine is a medical preparation, and therefore a medicine. And any medicine must be first of all safe and second of all effective. It usually takes at least five years to develop a safe and effective vaccine.
One way forward is to develop a vaccine, and another is to develop therapeutic medicinal products to treat COVID-19. Again, compared to the influenza, we should keep in mind that there are now effective medications to treat influenza. There has been one COVID-19 antiviral drug developed that we use on patients being treated at the Latvian Centre of Infectious Diseases with promising results.
Is there hope that we will be able to treat COVID-19 patients effectively?
Effective treatment includes high oxygen flow, which is available in hospitals. But people are definitely interested if there is, or will be a medicinal treatment available as well. As I said, an antiviral medicine to treat COVID-19 has been developed recently and is registered in the US. The European Commission has procured this medicine and it is already being distributed to EU member states.
Infectologists, pneumologists, emergency care specialists and reanimatologists in Latvia will in the near future also have a sufficient quantity of this medicine, which is crucial for treating COVID-19 effectively. Patients recover faster and the progression of the disease’s acute phase symptoms is halted.
It is not necessary to prescribe this medicine to every patient with COVID-19, but at the same time it is a bad idea to wait until a patient needs mechanical ventilation, so it will be up to the medical council to decide.
How do you see the future of COVID-19?
I don’t think this virus will disappear. The best option would be to make SARS-Cov-2 induced disease COVID-19 a controllable and effectively treatable seasonal disease. In this case, it will be the fifth common coronavirus in humans. The previous four are quite harmless. It would take time to find out whether this virus could also become harmless after a vaccine and medicines are developed.