Covid19 is changing the way we interact with each other (from 6 feet away or via Zoom) the way we care for out patients (increasingly by video or telephone) and for some unfortunate few, the way we die (alone, in a hospital for days, isolated from family and friends).
This is the first podcast in a series of podcasts about Covid 19. In this first podcast we talk with Lona Mody, Professor of Medicine at Michigan Medicine and John Mills, Associate Epidemiologist with Michigan Medicine. We cover terminology, epidemiology of the disease, and what we can do to protect our older and vulnerable patients.
We also provide a new suggestion for a 22 second song you can sing while washing your hands in lieu of happy birthday (some of us are sick of singing happy birthday so many times a day).
Our next podcast, to be released tomorrow, will be with Doug White and James Frank on the ethics of rationing ventilators.
In both podcasts, we refer to this New York Times Daily podcast with Dr. Marco in Milan Italy titled, “It’s Like a War.” Every day they admit 50-70 patients with severe pneumonia due to Coronavirus infection to their 1000 bed hospital. More than half of the hospital is filled with Coronavirus infections. 460 nurses are home sick or in home quarantine due to contact with infected patients. They’re admitting their colleagues. 20 patients died from Coronavirus in one day. He talks about rationing ICU beds by age. He says, “My colleagues, both physicians and nurses, they cry everyday.”
Important take away from both podcasts: Flatten. The. Curve. Now.
Eric: Welcome to the GeriPal Podcast. This is Eric Widera.
Alex: This is Alex Smith.
Eric: And Alex, this is not our normal podcast. This is our first in a series of podcasts about COVID-19, the coronavirus pandemic that we’re dealing with. And we have two special guests who are going to be joining us about this topic.
Alex: Yes. And first I’d like to welcome to our podcast Lona Mody, who is professor of internal medicine at Michigan Medicine. Welcome to the GeriPal podcast.
Lona: Hello. Thank you for having us.
Alex: And we also have John Mills whose associate hospital epidemiologist at Michigan Medicine. Welcome to the GeriPal podcast.
John: Great to be here.
Eric: So we’re going to be talking about a lot of different issues from the epidemiology of this disease to even how it affects older adults in nursing homes. But before we do, we always start off with song crest. And this is going to be a not your typical song crest because I got to say I’m getting really sick of singing happy birthday every time I have to wash my hands. Do you have another song that I could potentially sing instead of happy birthday?
Lona: Yeah. How about we try Hit the Road Jack or turn it to hit the road germs.
Eric: All right. Hit the road terms. I like that.
Eric: That was great.
Lona: Awesome. Great job Alex. Wonderful.
Eric: So real quickly, but before we go into COVID, let’s talk about washing hands real quick. How long are we supposed to do it? And do you have any other good discussion points about technique?
Lona: Well it is very important to wash your hands for at least 20 seconds either when you use soap and water or a hand sanitizer. Make sure you wash between your fingers around your thumb and take your time. Use it as a mindfulness moment.
Alex: So I actually timed that chorus yesterday and you have to sing it just like I did four times through hit the road germs and don’t return no more, no more, no more, no more. Hit the road germs and don’t you return no more. Hit the road germs and don’t you return no more, no more, no more. Hit the road germs and don’t you return no more. So I consider that, maybe it’s twice through but you’re saying hit the road germs four times.
Eric: So going to be my new song.
Alex: That’s 22 seconds.
Eric: And in our show notes we’re going to actually have a video that you can link to that shows proper technique for washing your hands, which is fascinating. I’ve been a physician for a very long time and I’ve never been taught proper techniques. So if it’s getting your fingernails into your palms, making sure you’re getting your thumbs, inner digital spaces. So I really encourage people to watch that video.
Lona: Yeah, no, thank you for putting the plug. I think it is a public health messaging that we have not emphasized enough despite knowing the hand hygiene importance and message over long time. Thank you for doing that.
Eric: Okay. Before we start into this, can we talk a little bit about terminology? COVID-19, SARS-CoV-2. What am I supposed to be saying?
Alex: Wuhan virus?
Lona: Yeah. I know so many different names to it. So COVID-19 is a disease caused by the novel coronavirus and SARS-CoV is the name of the virus causing the disease, it was previously known as Wuhan coronavirus, but now we have a name for it. It is genetically related to the strain of SARS, but it is different.
Eric: And when did this first pop up? What are we dealing with as far as the timeline? What’s been happening?
Lona: So the official time line that when we were made aware, of when the WHO was made aware of this virus and John can jump in, was in December. The last week of December where a strange respiratory illness, a strange pneumonia was reported to from China, from the Wuhan province in China to the WHO. And then from then on, things evolved where China started reporting their first death was January 11th. Moving on to a strict lockdown in Wuhan, January 23rd. We reported our first case on February 26th and today we are on March 17, more than 5,000 cases and 85 deaths.
Eric: And worldwide. I think a lot of people have been talking about how are we are compared to Italy because things sound like they’re at surge capacity in Italy or beyond that. Where are we as far as on that epidemiological curve compared to let’s say someplace like Italy.
Alex: Let’s ask the epidemiologists.
Lona: Yeah, there you go.
John: So as of today, we have about 5,700 cases in the United States versus almost 28,000 cases in Italy. The thought is we’re probably one to two weeks behind them on the epidemiological curve. That being said, this is an important time and I think that’s why there’s been such a robust public health response to really promote social distancing so that we could flatten the curve.
Eric: Can you actually describe what we mean by an epidemiological curve?
John: Yeah, I think it’s the concept of, I think you have to first understand that the reproductive rate of a virus or the R9 that’s often used. So that’s essentially, for each infected person, how many other people they will infect. That is susceptible people. And for this virus, because there is no preexisting immunity and no active vaccine, essentially everyone is susceptible. So the R9 is roughly 2.2 to 2.8 it’s thought. So for each person they’re infecting 2.2 to 2.8 other people. So you could think about how that just increases exponentially in regards to the number of infections that causes without intervening..
Alex: Yeah. And then without intervening is a key point here. And this is where people are talking about flattening the curve. I wonder if you could say something about what that expression means.
John: Sure. So I think this is a concept. If you look at what’s going on in Italy right now, this is the effect of a peak to your curve. And if you think about it, if that spread of disease, if that chain is not disrupted then you have rapid spread and then a large influx of ill people into a healthcare system which may not have a surge capacity. So if you get a large number of sick people at the same time and you may overwhelm the resources of the local healthcare system. So the concept of flattening the curve is really trying to promote social distancing to slow down the spread of the virus and allow the healthcare system to better care for the folks that do get ill.
Alex: And what are some of the key measures that we can be taking or currently taking and maybe should be taking. Are there other steps we should be taking in order to flatten this curve so that the number of cases reduced to a more manageable rate over time?
John: Sure. So I think first you have to think about education in the population and letting folks know what can they do to avoid getting infected. And that that goes back to the hand hygiene we just talked about and avoiding other sick people and then avoiding large crowds and trying to promote that social distancing again. So if you think about a virus that’s spread through droplet manner, coughing and sneezing. Staying out of that six foot range of other people is going to protect you and therefore things that the local state and federal government can do to discourage these large events that are at risk of causing widespread chain transmission are going to slow down that spread.
Alex: We should talk more about happens to people. How serious is this? What is this? Do we have a good sense of what the fatality rate is?
Eric: Is it just a bad flu?
Lona: Well, no John can chime in, but again, it is really much higher than a bad flu. The mortality rate for flu is about 0.1%, 0.2% of the max and here we are talking about 2% of fatality rate and so that’s monumentally higher in terms of vital conditions.
John: Yeah, I’d say it’s an order of magnitude higher than the flu and that also gets back to this whole flattening the curve concept in that your mortality rates going to be dependent on your resources in your local health care system. And we know, what does this virus do? It generally causes a lower respiratory tract infection. So it’s causing an interstitial viral pneumonia and that’s causing people to go into respiratory failure, need ventilatory support, often go into an ARDS type picture. And that really, a modern healthcare system in the United States, ICUs can manage patients like that well. But when you’ve got dozens and dozens of them in an ICU, you could easily overwhelm that capacity. And I think that mortality rate is really dependent on where you are on that curve and what healthcare system you’re talking about.
Alex: Now we’re learning other things about fatality rate. We’re also learning about the importance of age and comorbidity, how they play in mortality rates. Can you describe a little bit more about what we know about that?
Lona: So we know from Chinese, from data, from China experience that older adults over the age of 60 are at increased risk of both developing ARDS and second of increased mortality. So that’s really important if you go by the data, zero to nine years, young kids, surprisingly no fatalities whatsoever. A traditional flu we know has this spectrum. The young kids and older adults. This one is different and I’m sure we’ll learn more as we go along. But over the age of 60 the risk of fatality rate increases dramatically, I would say. If you have more comorbidities such as diabetes, heart conditions, respiratory conditions, the mortality goes higher as well.
Alex: So the old face sort of a double whammy here because A they’re old and we know that age is a risk factor and B, older people are more likely to have comorbid conditions or chronic conditions that place them at increase risk of poor outcomes including death such as heart failure, diabetes, respiratory disease.
Lona: Absolutely. That’s absolutely correct. And as a researcher, I would like to understand this even further. As we know, an older adult over the age of 65 is different if you have certain frailty or functional decline versus an older adult who is going on a golf course at the age of 70. So I’m curious to understand these data in more granular form but I’m sure that the outcomes for older adult with comorbid frailty is going to be even worse.
Alex: In the early days, I remember there’s a New York times story that talked about different outcomes for men and women and that outcomes were worse for men and they were speculating about the reasons why. Some having to do with immune factors in men versus women and some having to do with social factors like smoking. But I haven’t seen anything since and I don’t know whether you two have a sense of where things stand on, if there’s a gender issue in terms of how this or a sex issue in terms of how this virus causes illness in men versus women.
Lona: Yeah, I would like to see more data from Italy and America as well, but overall it’s believed that men in general have worse outcomes in recovering from infectious diseases. I haven’t seen much data after that as well, but John can chime in.
John: Yeah, I would say that also in China the rates of smoking are much higher in men, so it’s hard to know is that true causation or correlation. I think the problem with a new global pandemic moving this fast is that the data comes out fast. It’s mainly descriptive at this point. So we’re learning more on a daily basis.
Eric: And what is the typical presentation and does it look different by age or communities or we just don’t know that that data yet?
John: Yeah. I don’t know if we know that the presentation is any different other than we know that in general, about 80% of people have more mild disease, 20% more severe disease. We know the likelihood of severe disease is much higher with older age, over 60 70 to 80 again, the mortality rate increases. As far as the symptoms, it’s really again, because this is a more of a lower respiratory tract infection, really a cough, shortness of breath and fever are the cardinal signs and symptoms and it’s quite a bit less of the upper respiratory rhinorrhea pharyngitis symptoms are described, but much less common.
Alex: So less of the runny nose and sore throat, more of the cough, shortness of breath, fever.
Eric: I’ve been hearing that the incubation period is looking like around five days, but the range is long up to about two weeks. Does that sound about right?
Lona: Yeah, that’s about correct. 2 to 14 days is what we are hearing and seeing.
Alex: You know, I want to come back to that mortality rate. Eric posted a tweet that went viral within geriatric standards. Geriatrics and palliative care viral, and he said, “You know who’s at increased risk? It’s the elderly”, and this was a graph of the fatality rate in Italy and it showed a dramatic, it’s like a hockey stick, dramatic increase in fatality according to age. And somebody responded and said, “Well careful here because in Italy they may be rationing resources” and we’ll get into that in another podcast about rationing of ICU beds. But is it possible that our statistics may be conflated by decisions that people are making about whether to provide ventilatory support for older adults or older adults with chronic conditions who may have less opportunity to survive and less lifespan left to live?
Lona: No, I think that is possible, but I have heard conflicting messaging about whether they truly rationed resources in Italy or not. But if that is the case, certainly that could increase the mortality or skew the data that we are seeing right now. But that’s very important question about rationing in this era of scarcity. If the pandemic truly becomes very severe and Italy like in the United States.
Eric: Yeah, we’ll have a link to a really good podcast that came out today from the New York Times, which is an interview with a Italian ICU doctor. It sounds as I’m putting it together a week ago, it was not an issue. There was a lot of clamor on the newspapers about it, but now they’re admitting 60 to 80 people a day with severe pneumonia, as due to coronavirus. So they’re just being overwhelmed. So it does sound like there’s some resource allocation right now that’s happening. Although again, we don’t have any clear data.
Alex: And another way that the statistics… There’s uncertainty. As you said Lona, we need more data about this. Another area I think we don’t have great data is that, for example, in the United States we’ve been testing so few people that it’s hard to say what the fatality rate is unless you know how many people actually have the disease. We don’t really have a good sense of what that denominator is.
Eric: Because we’re just testing right now people who are very sick or very sick. We’re not testing those people who are asymptomatic or even I have mild symptoms. Should we expect those case fatality numbers to actually decrease once we start testing a lot more people?
Lona: Right. So a couple of different ways that people are looking at this. On Twitter some of the newer epidemiologist as so-called newer Twitter epidemiologist, they feel that the mortality rate could go up because we can now attribute a particular death to a condition. To me, my reaction is similar to yours Eric, that if we do more testing then I think we should be able to see the true mortality rate. I won’t say lower, but the true one. But again, that will pan out in the next few days because I feel that we’ll pick up with the testing quite a bit more of less severe cases.
Eric: Yeah. And I also feel like a big question that’s coming to my mind that it seems like a lot of people are talking about is how is this transmitted? Are there a lot of asymptomatic transmitters? Do you need those respiratory symptoms to transmit? Do we have just a large pool of people just walking around and then transmitting it? How should we be thinking about COVID-19 transmission?
John: I think in regards to asymptomatic transmission, it’s really unclear at this point. There had been a couple of case reports out suggesting that it’s possible, but from the data coming out of China, at least the thought is that the vast majority of spread is caused by symptomatic patients. And we know that the levels of virus in the nasal pharynx, early in illness are quite high. So I think what’s more likely to be happening is folks when they’re just a little bit sick on the first couple of days are highly transmissible at that point because the disease chorus is actually… If you read through some of these cases, it can move fairly slowly and patients can look okay for the first five to six days and can then de-compensate after that.
Alex: Yeah. I wonder if we could talk more about our people we care for and so many of our listeners care for older adults or older adults with serious illness including disability. Do you have any particular recommendations for those persons?
Lona: Yeah, I mean I think that my first reaction and my first recommendation would be that narrative is important. We have to be very mindful when we talk about this condition and say that this impacts older adults and those with comorbidities because they are one of us. We should be a bit careful of how things are portrayed to that population. Remember these are the older adults who may not be able to get their essentials by themselves. These are the older adults who may not be able to wash their hands by themselves.
Lona: So that would be my first reaction is that be mindful. From our clinic and what we are doing is we are reaching out to our older adults with disabilities. We have our senior centers and senior programs where we are organizing Skype calls and video calls and phone calls to make sure that these patients are reached and are okay. So I think that’s where we have to step up our game as healthcare providers and probably the social work community as well as just community at large.
Alex: Yeah, it sounds absolutely right. Particularly in California here, we’re in shelter in place mode, which means that our older adult patients are increasingly socially isolated and we need to find ways of reaching out to them to check in on them for many reasons. For the practical reasons, as you said, making sure they have basic necessities like food, clothing, shelter, can wash their hands, et cetera. And also because for social reasons, because there is increased risk of them feeling lonely or having depressive symptoms if they’re so isolated.
Lona: Absolutely. The third reason I think we have to be mindful and careful is because we are canceling several of our non essential outpatient visits. These are the individuals who do have comorbidities and do they have enough communication lines open with their formal caregivers, their informal caregivers to ensure that the underlying condition is not getting worse in the face of this unprecedented era .
Alex: Mm-hmm (affirmative) and John anything you want to say about how your health system is preparing particularly in regards to care of older adults?
John: Yeah, I’d say that. Number one, we’re trying to improve lines of communication with the local nursing facilities between the hospital, the nursing facilities and the public health departments and have a plan in place for folks that do get ill or have signs or symptoms that are potentially consistent with COVID and to make sure that the local facilities have resources and a plan in place on what to do and that we really have good lines of communication, again with the public health department because they can really get early involvement, can help with getting a testing prioritized and giving guidance on facilities that may not have the same level of resources as the hospital.
Eric: Yeah. Speaking of facilities that don’t usually have the same level of resource. Before COVID-19, nursing homes are usually on that fine line between under-resourced and just minimally resourced to meet good standards. Knocking off a lot of potential people who are going to be sick, LVNs, nurses in nursing homes, it really feels like this is going to be an area of struggle. Any thought about the impact in nursing homes and nursing home populations?
Lona: Yeah, I think that that’s a worry that we all have every day because of the research that and the area that I’ve focused in for last several years. It does take care of a very vulnerable population. The staff turnover is very high. As you mentioned, the resources or infection control resources are not not optimal, but the communication is much improved than in the past 10 years and one agency that has made some difference really very well… Well two agencies that have made a difference very quickly. One of them is CMS that have very promptly rolled out a couple of guidances, a couple of directives. One of them being that their inspections will roll for the next few weeks solely comprise of infection control. They will be checking up on nursing homes, especially those who have had citations in the past to ensure that they have all ducks in the row in terms of infection control side and stop everything else.
Lona: The focus of inspections are going to be on infection control. I thought there was a really nice move by CMS and then they rolled out policies on visitation. CDC has also done a good job in updating their checklist for nursing homes, which I feel that they are a bit more prepared than what they were 10, 15 years ago. Certainly my heart goes out to the Seattle nursing home and what’s going on there, so I’m keeping my fingers crossed.
Eric: Any other things that nursing homes can do right now to prepare?
John: Yeah, I think having a robust policy on visitors, restricting visitors. Obviously that’s going to be hard in the longterm as far as talking about mental health. But in the short term I think it’s necessary. And then having a clear policy in place with the staff as you mentioned to avoid sick members coming to work.
Lona: Yeah, and to add to that, to staff education on appropriate hand hygiene and glove use as well as PPE use is going to be extremely important. John did a really nice study and he can talk just a couple of seconds about it, but hand hygiene among our frontline providers could be much better.
Eric: Tell us more.
John: So we’ve found in the past that doing observations in local nursing homes is that hand hygiene rates were pretty low in general. I’d say 27% to 30% on entry to the room and then around 50% on exit. So obviously much room for improvement and it’s hard to know exactly why it’s particularly bad before room entry and the thought by some is that maybe the exit is driven by a healthcare workers desire for self protection but not necessarily thinking about the transmission aspects of not washing your hands before you go in. So I think, the silver lining of a global pandemic is it may give us the motivation to really improve hand hygiene rates.
Alex: Yeah, I think there are so many right unintended consequences, positive and negative of this epidemic. And one may be that we may be become more germaphobic as a society and that may be positive in a number of ways that extend beyond COVID-19 to reducing rates of influenza for example.
Eric: Well I think that’s the challenge. I think that’s part of also hopefully trying to prevent a peak. So flatten that curve is that there’re no masks in the community, there’s no hand sanitizer and know the importance about washing your hands over hand sanitize, but some people if you’re not near a sink. And it gives us the opportunity actually to make those products that are important for helping disease spread or decreasing the spread.
Lona: Yeah, good points.
Eric: I got one more question. Can we go to testing real quick, we skipped over testing. There’s been a huge issue in the US with actually getting the number of tests out there. Do we have any idea, and I know there’s a number of tests out there, what is the sensitivity and specificity are these tests? How good are they? If somebody tests negative, are they negative negative or what do we know about them?
John: Yeah, those are great questions and I think we’re still figuring out the answers to that. As far as sensitivity, I think it really depends on where someone is in their state of disease. So, when you think about obtaining samples you need to make sure the collection is correctly done. In general though, PCRS or respiratory viruses are quite sensitive. But I don’t know the data specifically on this. I think as far as whether one is sufficient to determine that in effect a patient is no longer transmissible or if you need multiple, I think we’re still working that out and hopefully you can get guidance from the CDC in the near future.
Eric: That was my last question. My other question is around personal protective equipment. I brought up the lack of masks in the community. I think there’s issues around, especially in small practices, access to a N95 masks and just masks in general. Where are we right now with guidance of what we should be doing with suspected COVID-19 patients as far as personal protective equipment? PPE is what people say.
John: Yeah, that’s a really complicated answer.
Lona: We were just discussing that.
John: Let me start with what the CDC says right now, which is evolving as the pandemic evolves. Essentially for patients under investigation, which are folks are that you are concerned enough for COVID that you’re testing them for it or those with confirmed infection. It’s recommended that you wear an N95 or PAPR with eye protection, gowns and gloves. And when resources dictate, to use negative pressure rooms. And I think this was probably driven by an over abundance of caution early on with the virus that… It’s a coronavirus like other coronaviruses and most respiratory virus sources are generally found to be droplets spreads. So not airborne like measles which has an RO of 12 to 18 compared to again the RO of COVID is 19 is similar to that of influenza.
John: So now we’re finding that due to supply constraints throughout the country that the N95s are in shortage and we’re seeing facilities, if you look at for example in Seattle out of necessity when you have multiple infected patients, you run through supplies quickly and convert it to a model of purely droplet precautions, which would be a regular face mask plus eye protection, gown and gloves in all non critically ill patients. And that’s more consistent with what the World Health Organization recommends right now. So I think the difficulty is there is a discordance between the CDC and the WHO and again, things are changing based on the more we learn about the virus and the supply constraints that we’re facing.
Alex: Mm-hmm (affirmative) thank you. Last question from me. How are things in Michigan with COVID-19 right now?
John: We went from, I would say we had our first two cases last Wednesday and we are up to the mid 50s now.
Lona: 54 as of yesterday.
John: The vast majority of those cases are still travel associated, but we do have a handful of cases with no travel suspected local community transmission. So again, I think we’re in that crucial phase where this social distancing really has the potential to make a big impact in flattening that curve.
Eric: I tell everybody I am an optimist so we know we can control this virus. We can flatten this curve because we see it in other countries. We see it in countries like Taiwan. The flatten the curve very, I don’t think they’re having new cases right now. China’s done an amazing job to get through the peak and flatten that curve.
Alex: South Korea.
Eric: South Korea.
Alex: Actually through testing.
Eric: So there’s a way we know we can do this because other people have. So I’m an optimist. I’d love to hear from your kind of last point is where’s your thinking? Am I just diluting myself?
Lona: You can go first.
John: Yeah, I would say as more of a natural pessimist. I agree that it can be done and you’re seeing the strengths and weaknesses of different healthcare systems around the world and I think the United States leads as far as technology. I think there are facilities that can do amazing things. I think where a weakness is, is the nature of our healthcare system, more siloed nature of our healthcare system. It makes it a little more challenging to broadly communicate recommendations and make sure that supplies are available at all facilities.
John: So I think we are going to not witness something to the extent of Italy. I think we are catching it a bit earlier and intervening earlier but I don’t think we have the level of nationwide coordination amongst healthcare systems to do something similar to Taiwan for example. So I think we may fall somewhere in the middle. I think really building testing capacity is going to help us a lot. And again, the States that have really implemented strong language around closure of whether it’s schools or large public events. I think those are going to help.
Lona: I think I feel somewhere in between. I know as an optimist that we will get through this and there will be other side. I do know that in the process we will test out our system in various areas of our system as well as leadership within our institutions that we have never been known or we have never tested out before. But there will be an end to this and there will be the other side. I want all of us to remember that.
Eric: Great. I want to thank both of you for joining us today.
Alex: Thank you Lona. Thank you John.
Eric: I Learned a lot. And then one more thing before we leave, we’re just going to, again, the importance of hand hygiene washing. I want everybody who’s listening to this podcast, pretend you’re washing your hands right now. Just so we get used to what 20 to 30 seconds actually sounds like while we’re singing this song.
Eric: And with that, I want to thank both of you for joining us today and to all of our listeners, stay safe out there. Remember, older adults are both vulnerable from a social distancing standpoint, from a coronavirus distance issue, and also just social isolation, not being able to get the things that they need. So if you have neighbors who are older check on them. If you have patients who are older, and you do. Check on them. By telephone or telemedicine. And with that, thank you everyone.
Alex: Thank you. Thank you Archstone Foundation. Thank you Lona. Thank you John.
Lona: Thank you, bye. Stay safe.