Our weekly question and answer session with Fred Goldstein, Dr. Luis Saldana, and Nick van Terheyden, MD on our COVID Insights to Action Discussion webinar that takes place live every Wednesday at 4 pm ET
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Transcript
Fred Goldstein 01:56
Hey, hey, we’re all set. We’re actually got some folks on. So welcome, Bob and January, I see have joined us and what I think we’ll probably do to start off is just a quick introduction, you folks are welcome to open your cameras up if you’d like and join us in the conversation and your mics. It’s really your call. And why don’t we start Luis want to do a quick introduction. And then we’ll go to Nick and myself. And then we’ll get into get going.
Luis Saldana 02:26
Yeah, I’m Dr. Luis Saldana, emergency physician by background and, and training and also been involved in digital health and Healthcare Informatics and been working with Nick and Fred on doing covid work with businesses and college universities.
Nick van Terheyden 02:43
I and I’m Nick van Terheyden. I’m also an emergency room physician, spending a lot of time focused at the intersection between healthcare technology and behavioral modification, working with a range of businesses and educational institutions on how to open safely.
Fred Goldstein 03:03
Yeah, fantastic. And let me quickly promote these others as well. And see, we’ve got a few more that have joined us. And I’m Fred Goldstein with also working with Nick and Luis and Doug. And we’ve been, as you said, working with the university. So we decided to start this as a way to discuss things going on with COVID and get ideas and and discussion going with others that we we haven’t necessarily worked with or know and see if we can share ideas and develop things that that make some sense. So we had a couple of topics we were going to pick today. And those included. The first one was why don’t we start with that, which is the the topic was in essence.
03:47
Now I’m on it, then Oh, the the issue with what wasn’t matched when we start with masks first, which was the new CDC guidance on masks and go with that, and then we’ll go into the other topic on the second topic we had. Okay.
Fred Goldstein 04:04
So Nick, do you want to open that up? Talk about the new CDC? Well,
Nick van Terheyden 04:07
I was gonna let Louise thoughts on that. Sure.
Luis Saldana 04:10
Sure. Yeah, I can, you know, start on that. And I think, I think, to us, probably physicians, we always kind of figured that this was the case. But you know, there was concern about the size of the droplets and things about whether masking would would work both ways, in terms of protecting others and protecting you from either just reducing the dose you may have have of the virus. But I think the CDC guidance really lends credence to this, you know, clearly the CDC has had some, you know, some trouble with, you know, in terms of their credibility, I would say, and, but but I think in general, this is, I think data we feel pretty comfortable running with, in that this is a mask any good mask that really has been pretty well described in a lot of different articles layers and, and things will protect you from getting from other people that are, you know, around you that may have the virus and transmission of the virus, certainly the best scenario is both people wearing masks, that even reduces more in terms of the exchange of droplets and, and, and the aerosols and things. So, so I think, you know, as we kind of look at Thanksgiving, you know, while you know, your your household, and people that are within your circle, you know, you you probably don’t need to wear masks. But if you’re outside of that circle you I think it’s really a good idea as politically charged as it is to wear masks to protect yourself and protect the people you love.
Fred Goldstein 06:01
And what about from that perspective, just the whole issue? I mean, there was a early on arguments about whether or not gators were okay or not. Okay, any change to that.
Nick van Terheyden 06:11
Um, so let’s talk about some of those studies. I think, you know, this was an awful lot of clickbait news, in my view, picking specific elements from some studies, there was a study carried out, it was a perfectly good scientific study, but it only used very thin layer of Gator cloth in that particular instance. And I think you’ve got to be thoughtful. One of the things that I personally do whenever I’m reading anything online, is I look to the source below, whatever the headline is, and that informs the way that I think about it. And in the case of those headlines, gators can still be effective. What I see a lot of people doing is essentially a double gauge, right? I gotta be honest, I didn’t know that was a gauge, I have one. And I didn’t know what it was called, I thought it was a tube sock, obviously wasn’t one of those people wear them as a double layer. And that’s actually a great thing. So the more layers improves things, we know that the surgical masks that are made of artificial plastic material, there’s some additional capabilities built into that because of the electrostatic charge that has generated that attracts molecules and improves the overall filtration and to Louise’s point, it’s both outbound and inbound. So this is not just about being a good citizen, it’s also about protecting yourself. And those are important points. So, you know, mosques across the board. And the other thing I would say is, any mosque is better than no mosque. But let’s just briefly mention face shields, they really don’t fulfill any great purpose, because all of the flow of air flows out and around unless they’re completely sealed around. So they’re really an additional thing that we use in house cat. With a masa with a face covering, we put a face shield on as well to give expert predominately eye protection, because you can get viral particles coming in through the cornea, because that’s a an open exposed surface for the virus to enter in.
Fred Goldstein 08:18
And just briefly, obviously, it’s been pretty clear now and CDC has come up pretty strongly Don’t be wearing your masks that have an exhalation valve on them.
Nick van Terheyden 08:26
Oh, thank you. Right?
08:27
Yes, walk around.
Fred Goldstein 08:30
So, you know, it was interesting to see them finally come back and say, Hey, this thing works. You know, just from my, my mind thinking, Well, some of those viral particles, or some of those droplets have to stick to that fiber as it’s coming through as you’re breathing it in. So it’s got to reduce it to some extent to begin with. So the secondary really wanted to discuss quickly was and are there any, anyone have any comments or questions or thoughts from themselves? They like to bring in?
Nick van Terheyden 08:57
Yeah, so there’s a couple of questions I, I asked in the chat. So that’s one of the ways and you know, we’ve made this relatively open, understand that people don’t want to come on video, that’s fine as well. But you know, we’ll monitor the chance. If someone’s infected but asymptomatic and spreading the virus, what happens when they get the COVID-19 vaccine? Luis,
Luis Saldana 09:25
someone is infected but asymptomatic when they get a covid vaccine? Well, as a matter of fact, you know, that scenario has not been fully tested yet, but based on prior experience with vaccines, there there will be any harm or risk in terms of them receiving the vaccine. And I think as what I know now is they will encourage everybody to have the back the vaccination, you know, parody, but he potentially even if they’ve already had COVID and things, I think I think there will be a lot of research and looking at better at the immunity question, the immunity question has not been totally clear. Now, well, you know, we looked at antibody tests, which are becoming less and less useful, I think, we always thought they weren’t totally useful. But now we’re seeing this T cell antibody test. And, and so there’s, I think there’s be better measures of the immunity piece. But I think everybody should count on getting the vaccination.
Fred Goldstein 10:31
Let me ask you what I think that may be driving into Louise and Nick, and from my thinking is, I’m infected, I’m going to go get in and get the vaccine. And now I’m not. But in effect, it’s probably going to there’s a period of time it takes for that immunity to build up. And so you’re not going to suddenly, at that point, be clear to go because you’re infected, and you just got the shot.
Nick van Terheyden 10:55
Yeah, I and, I mean, there’s also, what actually occurred to me as part of that is, if you’re infected, you really shouldn’t be going in to a vaccination center to try because you’re potentially spreading to people because A, at least with, you know, certainly some of the pre eminent arrivals on the vaccine scene, we’re looking for two doses for effectiveness that are at least two weeks apart. And I’m pretty sure that after the first dose, you’re not delivering immunity, and certainly not the instant that you inject somebody. So we would want to preclude that. And that sort of leads into the other question there, which is, how do we identify? So if you’re asymptomatic? You know, how are we precluding that. And that’s one of the key facets that I think we continue to push with all of our clients. This is a group activity or response. It’s not just vaccination, it’s also testing. And we need to test those individuals, we should be testing them on a regular basis, I’ve seen some great words and great insights in terms of regular testing, we would test people before they show up at the vaccination center to make sure that they don’t show up. Yeah, and spread the virus to people that haven’t been vaccinated. So I think we would try and prevent that with a good solid testing strategy that is highly frequent, daily, for instance, very brief.
Fred Goldstein 12:24
Pay to watch, welcome. You can unmute yourself you’d like.
12:30
Thanks. Um, I thought you only had camera here on people who were on the panel. But um, we’re allowing
Fred Goldstein 12:36
him to come on who’d like to join us?
12:39
It’s a small group. I’m shy asked my question that I put in the thing yesterday, when I registered,
Fred Goldstein 12:45
that he actually wrote it down. But please, go ahead.
12:47
I think what I asked was, how do you convince people that think, you know, their small bubble is okay, or that it was something about that? You know, it’s it’s, it’s, it’s people have a small bubble, but like Thanksgiving coming, they think their bubble can be a little bigger. How do you convince people, you know, not okay, and that the bigger bubble is at risk? Was that my question?
Luis Saldana 13:16
Yeah. You know, Fred, I don’t know. I think that was a question because like, we were talking about the questions before and and i think that that leads to the actually the paper we were going to talk about or the article, which was, how are people getting COVID now, and it is the smaller gatherings early on, we were seen almost all this spread been through these super spreader events. But now we’re seeing it happening in these kind of more intimate gatherings. And I think that’s why you’ve seen so much guidance from physicians around Thanksgiving, be very careful, I think we saw spike from the colleges around Halloween. And I think not only to colleges, I think even in, in, in the communities as well. And so I think those were small, you know, they could have been even small gathering. And so I think each person needs to, to really think through their own personal risk, but then also the risk that they that they present to the folks that are that they’re going to be gathering with. And certainly by making the circle as small as you can, as local as you can, and and being sure that their circles that they have are as small as possible. I think we’re the message has really been pretty strong. I don’t know if Nick has an ad about really, especially protecting those that are the most vulnerable. I mean, that’s that that’s our biggest fear. And the worst thing we would ever want to see is that our Thanksgiving led to somebody that’s at potentially high risk from from getting that disease. Especially now, with the, you know, light at the end of the tunnel with the vaccine, we, you know, we should be seeing the light at the end of the tunnel. Right?
Nick van Terheyden 15:08
Yeah, I would say the other I mean, most of this is pressing on behavioral modification and using the right drivers. And I’ll give you an example of that around flu vaccines that, you know, variable uptake. And one of the most effective communication measures in increasing uptake in the elderly population, believe it or not, was to communicate with them that they weren’t protecting themselves, because they said, well, it doesn’t matter about me, but they were protecting their grandchildren. And I would say that the same messaging around Thanksgiving, Louise, sort of intimated, which is, you know, this is not just protecting you. And by the way, if you’re young, fit and healthy, there’s some troubling data that suggests that long COVID is impacting those individuals in some substantial way. So don’t diminish that, right. But you, you want to be a participant in an activity that doesn’t cause severe harm to your family, especially your wrist family members. And I think that’s the predominant message that I’ve focused on making the right choices for the people around you.
Fred Goldstein 16:22
We are seeing, you know, some places are doing using some sort of incentives to try to move behavior, particularly some of the colleges we’ve seen where they’re now talking about in the spring semester, if we hit certain targets, we’ll have days off. So it’s kind of that whole behavioral economics approach and trying to figure out how to throw that in on a national level is something we probably should look at to get people to begin to recognize it. Obviously, messaging is critically important. But if there are ways we could incentive individuals to do it, I think that would help. And whether that’s a family incentive, or a large scale kind of thing, I think, is something we should be considering.
Luis Saldana 17:01
Yeah, and I think one more thing, because it relates to the work we’re doing with the colleges, the colleges and universities really are thinking about this a lot and really communicating with the students in advance of being prepared for this. How can you reduce your own circle if you’re going home, and also up in the testing before that kind of exit testing as well? I think the problem is few folks fear that they’d have to go into a quarantine, you know, or isolate me to isolate themselves and so and and with Dr. Fred, as he you know, he should you Eisley said you should your college kids isolate when they get home? and and you know, so I mean a quarantine so should they you know, they should they quarantine when they get home and everything he can do every little bit helps. And you know, I think every situation is very specific. But I think it’s really more naked. You just have to think through the situations individually and make this a much smaller Thanksgiving.
Nick van Terheyden 18:02
Yep, treachery. Let me just grab
Fred Goldstein 18:05
that. Grab that. See ya.
Nick van Terheyden 18:06
Yeah, the question around rapid tests are not as accurate false negatives. But the PCR can give false positives with lingering virus. Very true. That’s one of the reasons why we don’t test people that we know are positive. Subsequently, there was that terrible story of the pregnant mom who was kept away from her child for 54 days as a result of continuing to test positive, but a false positive because she was shedding virus, but that virus was not effective. So those are the challenges. So how do we recommend or what do we recommend from a testing procedure? Well, all testing is done based on what’s the question that you’re trying to answer? And what decision do you make based on that? testing procedures. So rapid tests do have variability. But to be clear, even a test that is 100% accurate, can still be inaccurate, depending on the timing, that you take that test relative to whether somebody when somebody was infected. So all of this is about reducing risk. And when we approach testing, we take the testing availability, so what’s available, and try and apply that with the best possible strategy with an understanding that certain tests in the case of PCR, for example, that has a very high level of accuracy, so when you get a positive, for the most part, it’s a positive unless you get this very long tail, and use that in conjunction with your clinician or your clinical team to make the decisions based on those tests. So there is no one single answer. And I think what you’ll see over the course of time is we’ll use a blend or a matrix of tests that say we’ll use this test and then if it’s an under to end, determine And then we might use another one to confirm. And we can get to a very high level of probability because they have different crossovers in terms of their sensitivity and specificity.
Luis Saldana 20:09
Could you just add to that, I think the way we need to look at these rapid antigen tests is the fact that they are rapid, and the results are available much quicker to to make those decisions, they are a single point in time. But they may be better in general for identifying infectious individuals. And so as Nick said, we put we put that as part of a strategy, but that also probably recommends a successive testing or ongoing testing using that same modality. As America, I shared something today about the country of Slovakia, and they use the rapid cell tests to actually drive down the incidence they had a big spike and actually drove down there are not I think, as from 1.3. To below below one like point, David, just through the or point six, it was really low is really impressive, just by using these rapid tests. So so I think they have to be used, he always say it’s about the question, your your the clinical question you’re trying to answer and and so there’s definitely a role for these tests. And even what’s coming even more is the self test at home, the the self at home testing, is something and I think you’re going to see the incoming administration really push on, on the approach, like Slovakia have broad aggressive testing to drive down the incidence of COVID in our country.
Nick van Terheyden 21:44
So I’m gonna ask you, Luis, because I think you know, you’re closer to clinical practice. The question is, seems treatments are now pretty successful, have the characteristics of those being hospitalized change.
Luis Saldana 22:00
You know, I think, though, the web thing we’re seeing is certainly the system’s overloaded. So I think number, as cases increase, hospitalizations increase, you know, we have the capacity or our problem, we have, we do have the new drugs, but day in and of themselves are not yet that magic bullet, even the newer therapeutics, so with the monoclonal antibodies that we’ve seen used, we thought there are going to be for the sickest patients, but in fact, they’re going to be probably to reduce hospitalization and the highest risk patients and, and actually, the the elite, Eli Lilly drug, we’re still trying to figure out how to one get that out there and how to use that. In other words, I think hospitals are thinking through, we don’t want to be providing them and others we don’t want people come into the hospital, we have to give them this infusion. So they may want have separate areas. So let’s say you get tested, and you’re identified as high risk, you may move on to get an infusion of of the, of that monoclonal antibody to prevent you to hopefully reduce the risk for for hospitalization for you. Really, otherwise, the foundation is still the very things that were there the first time, which is advanced critical care, and I think we see is, as those resources get sprayed, the mortality rates continue, will, will rise as far as that goes. So so but the patients that are coming, they are coming from abroad, there’s they’re still largely going to be the elderly, but we still are seeing young patients succumb to this illness, we still have not identified all of the risk factors, I think that are out there with this, you know, with this illness that Who is the most susceptible and who is not?
Nick van Terheyden 23:54
Yeah, the only thing I would add to that is that, in fact, of of all of the treatments that we have some of the oldest, and the cases are right here, right. And interestingly, proning, so that means ventilating people face down, as opposed to lying on our backs, have been some of the most effective therapies in terms of reducing the severity of the illness and importantly keeping people away from ventilators which is typically on a precipice of some relatively poor outcomes.
Fred Goldstein 24:32
And we got this question coming in also it came in on the when people registered was, you know, as the vaccine goes out, through 2021, as people get vaccinate, vaccinated, do they still need to wear masks? And what about if only half the country is vaccinated? Now how might that impact it?
Nick van Terheyden 24:52
Like I think everybody wants to hear that. No, we’ve got a we can stop wearing masks. I would say caution that that’s not going to be something that’s in the near term. First of all, we have to reach some level of immunity. And I think, you know, one of the things that we learned through this, just look at the flu season in the southern hemisphere, it was a fraction of what typically took place. Why was that because everybody was behaving, very cautiously trying to prevent spread. I have the fortune of visiting Japan, which is one of the countries that has managed this disease pandemic better than others. They’d had prior experience with MERS and SARS, Coby one, and that informed much of the populations behavior. And one of the things that I noticed was people in general, not everybody, but people wearing masks, and then those instances, my understanding at that time was they were wearing it because they thought they might be effective, and we’re trying to protect those around them. So I think we might see a flex or a chain, so not constantly and not all the time. And it might also be informed by our ability to test to, you know, free people from the need, you know, so I know that you’re immune to the virus that might inform an opportunity to not wear a mask. But I would say that that’s further out in the future, in my experience or my expectation.
Luis Saldana 26:27
Yeah, let’s just go ahead and add about 50% I think there’s two reasons why we worry about folks not not getting the vaccine. First is right now there’s maybe some distrust of the, of the process and the vaccine and, and getting an approval and things like that. I think that’ll go away, as you see people actually getting it out in the real field. So that will go down. Then the second is kind of the anti Vax kind of a movement that’s out there. That’s a very small percent of folks. I think we look at this as as kind of a small pox and, and and measles, mumps, rubella, we can do universal vaccination. I feel pretty comfortable. And I think if you talk to like Dr. pouchy, they feel pretty comfortable with that, that we can get well above the percent that we actually need for real herd immunity and not not the the you know, not not the foe herd immunity here or gain it in other ways. But I think we can we can get there.
Nick van Terheyden 27:26
vaccine induced herd immunity, I think is maybe the word you correct?
Fred Goldstein 27:31
Yeah. Good stuff. So the other day said a quick question in regards to smoking or vaping, a risk factor and young insight into the seemingly healthy young people getting sick? And what might be the cause for the long hollers? Bunch there.
Nick van Terheyden 27:46
Yeah, good. Good questions. I think the first ones the easiest, yes. vaping is a risk anything that impacts your respiratory system negatively, which is smoking and vaping. In particular, we saw prior to all this, I think we were very strong troubled by some of the indicators that we’ve seen in the youth that had sort of taken this up. So much so that I think there was some government movement against vaping as an available opportunity for our youth, when it comes to the young and these long haul is that the science is still not clear. I mean, there are some this this puzzle is is really challenging. I’ll give you some data points that just as an example, we see long haul as effective four to one more women than men, right? Which doesn’t make sense. When you look at some of the reasons why some people are getting the disease early. Some of the signals, for example, also immunity seems to be a factor in who gets severe disease. And we know that women have a preponderance, they tend to have more autoimmune disorders, yet we’re seeing this counter intuitive data point. I wish I could answer that. I know, I want to be able to I know people are looking at this intensely, but it’s a very complex problem. I think the overriding point is it this is real. This is not, you know, flu, and it doesn’t matter. We’ve seen it in, you know, fit and healthy athletes. We’ve seen it in people that have no symptoms. I don’t know if you’ve seen anything. luisi stay close to all of this. You know, the published research. Yeah.
Luis Saldana 29:31
Yeah, I think I think you described it perfectly. Nick, I think the the real key as to why the both you brought in that part about the young people and the long haulers, it’s that autoimmune kind of component. This looks more and more like a disease that we see autoimmune just kind of to a to a kind of an extreme level. That’s why you’re seeing like, things like blood clots. pomaria you know, young people succumb from a pulmonary embolus as a result of COVID vaccination, this is much more like an autoimmune type of disease. And so actually an active immune system may may actually be counterproductive. We, as Nick said, we don’t know the all of the Cascades involved here. But I think it’s more of that than a direct lung disease or direct, you know, it’s kind of a systemic, almost autoimmune type of thing. We know the interferons play play a role here, but we don’t know exactly, exactly where and I think there’s, that may be another promising therapeutic type of thing. Where were they addressed that I think probably explains why steroids probably helped a lot. And then many of these are getting anticoagulants now that could prevent the morbidity from from venous thromboembolism or, you know, that those type of episodes as well. So, so I think that’s the that’s the big part of it. And I think what makes this disease so fascinating, I think that’s why you see Dr. pouchy. And things being very kind of fascinated with this with this disease process.
Fred Goldstein 31:09
Yeah, and I know we’re coming up on the end here. But I just wanted to point out also, as part of this, that, you know, is we’ve been working with people, we’re seeing some alarming data for long haul stuff and younger kids who were asymptomatic, and then two or three months later, they’re experiencing stuff. So yeah, definitely difficult one.
Nick van Terheyden 31:28
And Sue asked, I answered in the chat, but just to be clear for everybody, in case you’re not seeing it. The metric on women is that four times as many women are suffering COVID long haul, so they’re having long haul symptoms post covid 19 infection than men. So four times more women than men suffer long term COVID.
Fred Goldstein 31:55
And also, we should point out, there’s that one group survivor corps that it writes like 100,000 people have now joined that group, are these longer hollers or
Nick van Terheyden 32:06
long I asked them that very question, in fact, and the response I got back was that more women have joined that group, but you can’t tease anything out of that necessarily. That just may be those are the ones that have signed up. You know, more work needs to be done. But we have seen certainly a preponderance on female impact with the long haul disease. Well, fantastic. And
Fred Goldstein 32:31
we wanted to keep this to 30 minutes. I see. There’s another question, then we probably should do is grab that one and take a look at and see if we want to address that next week in our discussion group. I want to thank everyone for joining please. And, you know, we’d love to see you join us next week, send in the questions, etc. And if you have anything in between that, feel free to email us and we’ll be happy to respond to you. Yeah,
Luis Saldana 32:52
thank you for thanks for joining the conversation, everybody.
Nick van Terheyden 32:55
Thank you.
