Listen: Plasma and Immunity

The writer F. T. Kola had COVID-19 in March, and she’s still dealing with the aftermath. She returns to the podcast Social Distance to ask about whether she should donate plasma, and if she should worry about “reinfection.”

Also on this episode: Atlantic senior editor John Hendrickson talks about disability at the Democratic National Convention. Read his definitive story on Joe Biden and stuttering.

Listen to their conversation here:

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Here’s part of the conversation with F. T. Kola, edited for length and clarity.

James Hamblin: Are you still doing well?

F. T. Kola: I’m doing so much better. I’ve been very lucky, but I’m still recovering, slowly getting back to normal strength. I went for a 25-minute walk with a slight hill two days ago, and I’m still recovering from that. I’m dealing with the damage that the virus did and the trauma it inflicted on my body, but the virus is gone.

Hamblin: Remind me, this was March when you were diagnosed?

Kola: Yes, my viral course was March 6, when I developed symptoms, to March 23, when I left hospital. And then I came home, began the recovery period, and have tested positive for antibodies, which leads me to my question. One of my dearest wishes has been to donate plasma, ever since I found out I have this antibody-rich blood. And now I’m not sure what I am doing when I hopefully donate plasma. What does it look like they can do with it?

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Hamblin: Well, this idea of testing convalescent plasma, or plasma from people who have recently had the disease, goes back a long time. Even in the [1918 flu] pandemic, we attempted to use plasma that you just—sort of distilling out the antibodies in the blood of people who’d been sick—

Katherine Wells: Can I ask what plasma is?

Hamblin: It’s once you take the red and white blood cells out of blood … and you’ve just got this yellowish protein-filled plasma that … should just have proteins in it, including these antibodies …  And in theory, they should be antibodies that would work similar to if your own body had made those antibodies and protected you from the disease, or at least help to stop the virus.

It’s a nice idea that has been tried in other respiratory viruses to mixed effect. There’s even a lot of debate about whether it helped during the 1918–19 influenza, but it was definitely tried. And the debate continues now for what we’re seeing as to whether it actually helps with coronavirus.

The Mayo Clinic has done a big study, and it seems like there could be some benefit, depending on the case, depending on when it’s given, depending on an individual’s physiology and how they respond to it. But the reason it was just in the news is because the FDA on Sunday gave plasma an emergency use authorization, allowing doctors to use it to treat COVID-19.

Wells: Yeah. I saw this headline ... “FDA Issues Emergency Use Authorization for Convalescent Plasma as Potential Promising COVID-19 Treatment, Another Achievement in Administration’s Fight Against Pandemic.” That’s a news release from the Food and Drug Administration, a nonpartisan scientific organization designed to protect our health.

Hamblin: Yeah, that alone is really concerning and unprecedented, as well as the language from the commissioner thereafter in a press conference kind of misstating how effective plasma is, exaggerating these effects in a way that seems to be in line with the need for the administration to have some success in fighting the pandemic right now, politically.

Kola: So my kind of vision of what this would look like was probably always a little bit wrong, in that … they weren’t going to take the plasma from me, immediately give it to another patient, and that patient was going to the next day be, like, sitting up rosy-cheeked ...

Hamblin: Well, until now, they would have done it in a research setting. And it still could be used in a study that could help us identify [if] plasma is useful if given during days four and six to patients between ages 20 and 40 who have respiratory symptoms. And I’m optimistic there will be use cases like that. The work just remains to be done to identify them, exactly how. But when you lump it all together, too broadly, we’re not seeing a big effect. But now that there is this emergency authorization, people might just request that their doctor prescribe it.

Wells: Is there any … downside of giving people plasma, even if you don’t know if it’s going to be specifically helpful to them?  

Hamblin: There theoretically shouldn’t be, but there could, and that is the reason that you don’t just authorize these things, that you have an FDA to make sure that something is safe and effective ...

Kola: It seems like people have antibodies within three months of them having COVID-19. And I definitely had antibodies back in May when I was given an antibody test, but then, given the news out of Hong Kong, it looks like those antibodies might wane over time? When I imagine the plasma, am I imagining blood that has actual antibodies in it, or does it have the memory of how to make antibodies? What’s actually in the plasma?

Hamblin: That’s a great question … You’re just getting the antibodies themselves. The act of producing them will involve the white blood cells that should be taken out of plasma …

Wells: They’re the things that make the antibodies ... and that do have the memory of how to make them?

Hamblin: Right … When you transmit plasma, you’re not teaching someone to make antibodies. That’s what happens by exposing them to the virus. That’s vaccination. It’s called “passive immunization,” where you temporarily have these antibodies until your blood clears them out. They’re gone, and you’d theoretically have to get another transfusion.

Kola: So there would be the possibility that, having had COVID-19 in March, and maybe being called upon to donate plasma in October, my blood might not have the antibodies anymore that it had in May.

Hamblin: Yeah, that remains possible.

Kola: Wow.

Wells: Is that upsetting?

Kola: I think it’s like much to do with COVID: Just one of the sort of confusing complexities of it is that I know that I had the antibodies at one point. I can’t know for sure that I have them now without another antibody test. And … being someone who had it relatively early, my experience of the virus is myself and everyone around me learning about it almost in real time ...

Hamblin: Well, if it helps reassure—I guess Katherine can explain the immunology here, because we had a whole episode on this—but there is more to your body’s memory than just the presence of antibodies themselves. There are immune-messaging pathways such that even if you lost your antibodies, it’s possible that your body might be able to kind of quickly make new ones and call them back and have other ways of fighting off this virus so that, if you are reinfected, it is not so bad, even if you don’t actively have the antibodies.

Kola: Can you explain how people like me who had COVID-19 and are hopeful about immunity … should interpret the information from Hong Kong, because that was obviously, on the face of it, quite scary for people who’ve had an experience of COVID that they wouldn’t wish to go through again.

Wells: Can you explain the Hong Kong news, Jim? … Doctors out of Hong Kong reported the first case of confirmed reinfection … which is obviously … terrifying … but what does it really mean?

Hamblin: Well, I respect that both of you saw it as terrifying. I didn’t. Because you had a person who was infected but did not get sick. His body cleared out the virus in a way that is what you would expect. I’m not even certain how you define infection other than a positive test. And I would expect that people will have the capacity to test positive again. What we don’t want to see is people having a second bout of severe disease. And we have not seen that.

If you got vaccinated, you still could be expected to test positive. There could be times when your body’s been exposed to the virus and has some in your nose ... and the test comes out positive. But it doesn’t mean you’re sick. It doesn’t mean you have COVID. I think the same thing can happen with any respiratory virus.

Wells: What do we know about the person in Hong Kong? Just that the person had it, tested positive, cleared the virus, and then tested positive again?

Hamblin: Yeah, and the second infection, it’s reported, was asymptomatic. And that’s exactly how you want it to work. Just because you’ve had the virus, when you come into contact with it again, it doesn’t mean it won’t populate your nasopharynx: that you won’t have virus with you for a little bit and that a swab couldn’t test positive. But it does mean that your body will get it out before it causes illness. Either zero symptoms or mild symptoms should be what you hope for. Your immune system doesn’t make it so that the virus just can’t enter your nose.

Kola: That’s really reassuring. I mean, I have assumed this whole time, in the absence of any other information, that I should behave as if I can get the virus again. I guess my last question is: Even if I could be reassured that if I were to get it a second time, and it wouldn’t be like the very traumatic first experience, what does that mean in terms of my ability to spread it to other people?

Hamblin: That is likely going to vary depending on a person’s own immune response. We have different degrees to which our bodies eradicate a virus when we see it again. For some people, it will barely be with us at all. For others, we will not so efficiently clear it out. It’s very unlikely that we’ll have disease as severe the second time. But depending how long it’s been, the shape of our immune system, the infectious dose, how much virus you were exposed to ... it’s impossible to know right now, because this is our first documented case of reinfection at all.

We’re going to need to have thousands of people who’ve tested positive after having it to get a sense of how many of them seem to be able to spread it before we know for sure. But I hope this is reassuring. This is what you expect, and I am reassured that we have not seen, so far, people who’ve had two bouts of serious illness. Or even a bout of very serious illness and then a bout like a bad cold. We haven’t even seen that.