Speaker 1: Reading about it in the news, I knew it was
Speaker 1: going to be bad, but we deal with the flu
Speaker 1: every year, so I was thinking, well, it's probably not
Speaker 1: that much worse than the flu. But seeing patients with
Speaker 1: COVID nineteen completely change my perspective and it's a lot
Speaker 1: more frightening. I have patients in their early forties, and yeah,
Speaker 1: I was kind of shocked. I'm seeing people who look
Speaker 1: relatively healthy with a minimal health history, and they're completely
Speaker 1: wiped out, like they've been hit by a truck. This
Speaker 1: is knocking out what should be perfectly fit, healthy people.
Speaker 1: Patients will be on minimal support, on a little bit
Speaker 1: of oxygen, and then all of a sudden, they go
Speaker 1: into complete respiratory arrest, shut down and can't breathe at all.
Speaker 1: It's called acute respiratory distress syndrome ARDS. That means that
Speaker 1: the lungs are filled with fluid. Patients with ARDS are
Speaker 1: extremely difficult to oxygen eight. It has a really high
Speaker 1: mortality rate, about forty percent. The way to manage it
Speaker 1: is to put a patient on a ventilator. The additional
Speaker 1: pressure helps the oxygen go into the bloodstream Normally. ARDS
Speaker 1: is something that happens over time as the lungs get
Speaker 1: more and more inflamed. But with this virus, it seems
Speaker 1: like it happens overnight. Typically with ards, the lungs become inflamed.
Speaker 1: It's like inflammation anywhere. If you have a burn on
Speaker 1: your arm, the skin around it turns red from additional
Speaker 1: blood flow. The body is sending it additional nutrients to heal.
Speaker 1: The problem is when that happens in your lungs, fluid
Speaker 1: and extra blood starts going to the lungs. It first
Speaker 1: struck me how different it was when I saw my
Speaker 1: first coronavirus patient go bad. I was like, holy crap,
Speaker 1: this is not the flu. Watching this relatively young guy
Speaker 1: gasping for air, pink, frothy secretions coming out of his
Speaker 1: tube and out of his mouth. The ventilator should have
Speaker 1: been doing the work of breathing, but he was still
Speaker 1: gasping for air, moving his mouth, moving his body, struggling.
Speaker 1: When you're in that mindset of struggling to breathe and
Speaker 1: delirious with fever, you don't know when someone is trying
Speaker 1: to help you, so you'll try to rip the breathing
Speaker 1: tube out because you feel like it's choking you, but
Speaker 1: you're drowning when someone has an infection, I'm used to
Speaker 1: seeing the normal colors you associate with it, greens and yellows.
Speaker 1: The coronavirus. Patients with aards have been having a lot
Speaker 1: of secretions that are actually pink because they're filled with
Speaker 1: blood cells that are leaking into their airways. They're essentially
Speaker 1: drowning in their own blood and fluids because their lungs
Speaker 1: are so full, so we're constantly having to suction out
Speaker 1: the secretions every time we go into their rooms. I
Speaker 1: worked a long stretch of days last week, and I
Speaker 1: watched it go from this novelty to a serious issue.
Speaker 1: We had one or two patients at our hospital, and
Speaker 1: then five to ten patients, and then twenty patients every day.
Speaker 1: The intensity kept ratcheting up, more patients, and the patients
Speaker 1: themselves are starting to get sicker and sicker. When it
Speaker 1: first started, we all had tons of equipment, tons of supplies,
Speaker 1: and as we started getting more patients, we started to
Speaker 1: run out. They had to ration supplies. At first, we
Speaker 1: were trying to use one mask per patient. Then it
Speaker 1: was just you get one mask for positive patients, another
Speaker 1: mask for everyone else, and now it's just you get
Speaker 1: one mask. Even if you survive AARDS. Although some damage
Speaker 1: can heal, it can also do long lasting damage to
Speaker 1: the lungs. They can get filled up with scar tissue.
Speaker 1: AARDS can lead to cognitive decline. Some people's muscles waste
Speaker 1: away and it takes them a long time to recover
Speaker 1: once they come off the ventilator. There is a very
Speaker 1: real possibility that we might run out of ICU beds,
Speaker 1: and at that point, I don't know what happens if
Speaker 1: patients get sick and need to be intubated and put
Speaker 1: on a ventilator. Is that person going to die because
Speaker 1: we don't have the equipment to keep them alive?
Speaker 2: Oh my gosh.
Speaker 1: Yeah. That was an account from a respiratory therapist at
Speaker 1: a hospital in Louisiana who remained anonymous. For that account,
Speaker 1: I found it on Pro Publica. It was published on
Speaker 1: March twenty first, And we'll put a link to the
Speaker 1: full description in our show notes and on our website,
Speaker 1: because that was just a small excerpt from the description.
Speaker 2: It's you know, it's very eerie to read and to hear,
Speaker 2: because what it does is it reminds me of a
Speaker 2: lot of the first hand accounts from the nineteen eighteen
Speaker 2: Luenzo which I know has been brought up. The comparisons
Speaker 2: have been brought up constantly, and some are inappropriate comparisons.
Speaker 2: But just that description of healthy individuals being struck down,
Speaker 2: all people of all ages being struck down, and the
Speaker 2: horrible thought of not being able to breathe, Yeah, and
Speaker 2: drowning in your own fluids.
Speaker 1: Yeah, it's really scary.
Speaker 2: I mean, it is scary. And we should introduce ourselves
Speaker 2: before getting too much into this.
Speaker 3: Yeah, we should.
Speaker 2: Hi, I'm erin Welsh and I'm erin Oman Updyke and
Speaker 2: this is this podcast will kill you.
Speaker 1: Welcome back everyone, or maybe welcome for the first time
Speaker 1: if you jump part way into series. If you're one
Speaker 1: of those people. This is our not so many minisod series,
Speaker 1: Anatomy of a Pandemic, where we're answering all of your
Speaker 1: listeners submitted questions about COVID nineteen, the disease caused by
Speaker 1: SARS COVID two. In our first chapter, we covered the
Speaker 1: virus itself, so all of the biology of SARS CoV two.
Speaker 1: In this episode, chapter two, we're going to talk about
Speaker 1: the disease that this virus causes, what it looks like,
Speaker 1: how it's spread, and how physicians and healthcare workers are
Speaker 1: dealing with this outbreak.
Speaker 2: But first, as always, it's quarantiny time.
Speaker 1: It's quarantine ay time.
Speaker 2: In this episode, we are drinking the creatively named quarantine
Speaker 2: y two, Quarantining number two. Aaron, what is in Quarantining
Speaker 2: number two?
Speaker 1: You know, Aaron, It's kind of a whiskey ginge.
Speaker 2: Yeah, I mean I would, I would call it a
Speaker 2: Kentucky mule perhaps if you happen to have a copper mug.
Speaker 2: I did not, so the picture is disappointingly non copper.
Speaker 1: It's all right, you did your best, thank you.
Speaker 4: Yeah.
Speaker 2: So it's basically ginger ale whisky of whatever kind of
Speaker 2: whiskey you want, and some lime.
Speaker 1: And we'll post the full recipe for that quarantine as
Speaker 1: well as our non alcoholic plusy Breta on our website
Speaker 1: and all of our social media channels as always as always.
Speaker 2: Okay, So, as we mentioned, we've talked about the virus itself,
Speaker 2: so now let's talk about the disease that this virus
Speaker 2: is causing, COVID nineteen. And I do think that's a
Speaker 2: particularly important distinction because, as we'll hear more about this
Speaker 2: virus can infect you without necessarily causing severe disease, and
Speaker 2: that's super important in understanding the spread of the virus,
Speaker 2: because people who appear asymptomatic and otherwise healthy or just
Speaker 2: have very mild cases could still be infected with and
Speaker 2: therefore sneezing or coughing out the virus and spreading it
Speaker 2: to other people. So we talked to doctor Colleenkraft, who
Speaker 2: many of you may recognize from our first coronavirus episode,
Speaker 2: and she's going to walk us through a lot of
Speaker 2: your questions about the clinical disease that this virus causes.
Speaker 2: Let's go over some of the basics first, so shall we?
Speaker 1: Let's we shall? So one big question is what is
Speaker 1: the timeline of this illness? And what you're going to
Speaker 1: see is that we still don't have the answers to
Speaker 1: every question when it comes to this disease, and the
Speaker 1: timeline is kind of one of those that we don't
Speaker 1: fully know, but we do have a better handle on
Speaker 1: it than we did in our episode that we released
Speaker 1: back in February. So, first of all, it seems like
Speaker 1: the incubation period is on average about five days an
Speaker 1: incubation period is the time from when you're first exposed
Speaker 1: to that disease to when you first start showing symptoms
Speaker 1: of that disease. Okay, so on average this is about
Speaker 1: five days. It can range most studies, it seems like
Speaker 1: the max range is about eleven. So when you hear
Speaker 1: about being quarantined for fourteen days, that's because we think
Speaker 1: and we're pretty sure that after fourteen days, if you
Speaker 1: haven't started to show symptoms, you're probably not going to
Speaker 1: show symptoms. So that's kind of the max range to
Speaker 1: make sure that you don't spread this disease unknowingly to
Speaker 1: someone else if you're exposed. And this number like around
Speaker 1: fourteen days, that's consistent with what we saw with SARS one,
Speaker 1: SARS classic.
Speaker 4: Okay.
Speaker 1: Now, the other thing is that from a retrospective study
Speaker 1: of people that had COVID, the severe disease. This study
Speaker 1: looked at people who were hospitalized for COVID, so pretty
Speaker 1: severely ill. The median time from when symptoms first started
Speaker 1: to discharge from the hospital was twenty two days. So
Speaker 1: that's a long time for somebody to be in the hospital.
Speaker 1: And I think that that's an important indication that for
Speaker 1: people who get seriously sick, they can be sick for
Speaker 1: quite a long time. The other thing that this study
Speaker 1: looked at was viral shedding, so at least some measure
Speaker 1: of how long somebody might potentially be infectious, and they
Speaker 1: found that the median number of days that people were
Speaker 1: shedding virus was twenty days from the onset of symptoms,
Speaker 1: which is again a pretty long time if somebody is symptomatic,
Speaker 1: that is a long time yep, and longer than fourteen days.
Speaker 2: Yeah, that's I think. But I think the other thing
Speaker 2: that you mentioned that it's sort of this is just
Speaker 2: looking at people who had severe disease curR exactly, Yes, okay,
Speaker 2: So I wonder I think. I mean, of course, as
Speaker 2: this pandemic progresses, we're going to get more information about
Speaker 2: those people who have milder cases or are asymptomatic and
Speaker 2: how much virus they're shedding at various points throughout their
Speaker 2: course of infection.
Speaker 1: Exactly, Yeah, exactly. Okay, So then the question is what
Speaker 1: are some of these symptoms?
Speaker 2: Okay, So the biggest symptoms are the ones that most
Speaker 2: people have probably heard about in the news quite a lot,
Speaker 2: so fever, which, by the way, the death definition of
Speaker 2: a fever is a temperature of over one hundred point
Speaker 2: four degrees fahrenheit or thirty eight degrees celsius. Then there's
Speaker 2: also cough, generally a dry cough, not a super wet
Speaker 2: or a super productive cough, and then shortness of breath.
Speaker 2: So these are the general symptoms of the disease that
Speaker 2: we call COVID nineteen.
Speaker 4: But we know.
Speaker 2: Now that SARS covy two, the virus like SARS one
Speaker 2: and MERS, can infect your lung tissue and cause a
Speaker 2: lower respiratory disease, not only an upper respiratory infection the
Speaker 2: way most of the common coronaviruses do. Okay, So what
Speaker 2: does that mean, Well, it means the possibility of very
Speaker 2: severe disease like we heard about in the first hand account,
Speaker 2: and in the case of this virus, it seems that
Speaker 2: about twenty percent of cases are severe. And that doesn't
Speaker 2: mean that twenty percent of cases need ICEE you and
Speaker 2: ventilator care, but it does mean that potentially up to
Speaker 2: twenty percent of cases may need at least hospitalization and
Speaker 2: some oxygen support or some IV fluid support. An analysis
Speaker 2: from China suggest that there at least about fourteen percent
Speaker 2: of cases were severe and five percent were critical, And
Speaker 2: that means the same kind of picture that we talked
Speaker 2: about in our coronavirus episode when we talked about SARS,
Speaker 2: and the same description you heard in the first hand
Speaker 2: account so ards, ground glass opacities on X rays, potentially
Speaker 2: needing intubation. It's serious. It's a serious, serious disease, and
Speaker 2: people can also go into shock, which we've talked about
Speaker 2: a lot on the podcast. But essentially what that means
Speaker 2: is that your organs aren't getting enough blood flow in
Speaker 2: this case because of overwhelming infection, which leads to leakage
Speaker 2: of fluids and then hypoperfusion, and then of course there
Speaker 2: is also always the risk of a secondary infection on
Speaker 2: top of this viral infection.
Speaker 1: It can be pretty gnarly. But also in this case,
Speaker 1: what we see that is different from SARS and mers
Speaker 1: and what in our first episode about coronaviruses was still
Speaker 1: kind of a gray zone. That's a lot more clear
Speaker 1: now is that asymptomatic or very mildly symptomatic infection is
Speaker 1: not only possible, but it's likely actually responsible for quite
Speaker 1: a lot of the spread of this disease. It's estimated
Speaker 1: that about eighty percent of cases are mild, which, while
Speaker 1: that's great news for the majority of people who get infected,
Speaker 1: it means you're not necessarily going to be looking at
Speaker 1: such a severe disease. It also means that this disease
Speaker 1: is easier to spread since not everyone who's sick maybe
Speaker 1: even realizes that they're sick. And how does this disease spread.
Speaker 2: Erin well, respiratory droplets as we well know, but we're
Speaker 2: not going to go into that. We're going to allow
Speaker 2: our expert, doctor Collingcraft from Emory University to explain how
Speaker 2: respiratory droplets work, as well as other characteristics of this disease,
Speaker 2: how wo'ds spread, how we're testing for it, who we're
Speaker 2: testing for it, and finally, how we treat it.
Speaker 1: Right after this break, my.
Speaker 4: Name is Colleen Kraft and I'm the Associate chief Medical
Speaker 4: Officer at Emory University Hospital. My training is in infectious
Speaker 4: diseases and clinical microbiology.
Speaker 2: Thank you again, so so much for joining us. We
Speaker 2: know that you have just been swamped with work and
Speaker 2: so we really appreciate you taking the time to kind
Speaker 2: of talk about COVID nineteen. I mean since our first
Speaker 2: interview with you, which has been you know, about a
Speaker 2: month and a half ago. A lot has happened.
Speaker 4: Yes, like a lifetime has happened. That's how I feel.
Speaker 1: Yeah, yeah, so we'll jump right in. We are talking today,
Speaker 1: of course, about SARS COVID two, the virus that causes
Speaker 1: COVID nineteen. So we know that it's transmitted through respiratory
Speaker 1: droplets or direct contact with somebody's respiratory droplets, like other coronaviruses.
Speaker 1: Can you tell us a little bit about what that
Speaker 1: means in contrast to viruses that are airborne and when
Speaker 1: people talk about respiratory droplets, like what exactly does that include?
Speaker 4: Sure? So I think it's it was really funny to hear.
Speaker 4: I've been to a number of town halls around Emory
Speaker 4: and I had one of my audience members best described
Speaker 4: it as, you know, it's your saliva, So it's sort
Speaker 4: of I view respiratory droplets as being sort of the
Speaker 4: wet aspects of our coughs and sneeze, and that's that.
Speaker 4: I thought that was very well described that way by
Speaker 4: this employee. And I didn't answer your your airborne question.
Speaker 4: So what happens is when we cough or sneeze, it's those,
Speaker 4: it's like a wet, heavy droplet, and that kind of
Speaker 4: goes to the ground right sooner because it's heavy. But
Speaker 4: when they are really small, then they can aerosolize and
Speaker 4: they can actually sort of hang around in the air
Speaker 4: for longer. And so that's why every time there's a
Speaker 4: new respiratory virus we sort of pretend like it's airborne,
Speaker 4: just to make sure it's not airborne, because that is
Speaker 4: sort of a different transmission route that that can hang
Speaker 4: in the air longer and it can go farther. But
Speaker 4: you know, from what everything we know, this coronavirus still
Speaker 4: behaves like our droplet spread coronaviruses, gotcha.
Speaker 2: So at this point we have a better idea of
Speaker 2: what a typical course of COVID nineteen looks like. Can
Speaker 2: you walk us through what that is like? You know,
Speaker 2: day one, day two, what do you typically see?
Speaker 4: Yeah, so we're seeing the same things as being seen
Speaker 4: and observed in other parts of the world. And so
Speaker 4: we have the vast majority of these individuals have a cold.
Speaker 4: It may be an unpleasant cold more than for others,
Speaker 4: but most people have a very mild illness, probably most
Speaker 4: similar to our common cold. In general. We are seeing
Speaker 4: people though, that come in with basically a viral pneumonia
Speaker 4: type picture. Viral pneumonia should really make the hairs on
Speaker 4: the back of your neck stand up, because that's probably
Speaker 4: what happened in the nineteen eighteen Spanish flu. And this
Speaker 4: is again along with the airborne aspect, this is what
Speaker 4: we're always looking for in these new viruses. Does it
Speaker 4: have a propensity to cause lower respiratory tract infection? If
Speaker 4: it does, that makes us scared because we can't. While
Speaker 4: we can do a lot with bacterial pneumonia, a viral
Speaker 4: pneumonia is very scary because usually don't we can't treat
Speaker 4: most of the viruses that we get, and so we
Speaker 4: definitely don't it down and the lung where it can
Speaker 4: cause scarring and difficulty breathing. And so for a subset
Speaker 4: of people that for the most part tend to be
Speaker 4: ill ill at baseline, we have a group of people
Speaker 4: that also are getting symptomatic lower respiratory tracts syndrome who
Speaker 4: are not quite as ill as the typical person we're
Speaker 4: hearing about that is succumbing to this disease. So we've
Speaker 4: had a number of individuals that yes, they have other
Speaker 4: medical problems, but they don't necessarily have respiratory medical problems,
Speaker 4: and they are having you know, sort of a viral
Speaker 4: pneumonia picture, and we have had a few that have
Speaker 4: been needed to have mechanical ventilation or a breathing tube.
Speaker 2: Gotcha about how long does is the course of disease?
Speaker 2: You know, I know that for some people who have
Speaker 2: milder cases it may be shorter than for others. But
Speaker 2: what do we see on average or what does it
Speaker 2: look like for the people with more mild symptoms compared
Speaker 2: to the people with more severe outcomes.
Speaker 4: I would say it's it's that typical three day kind
Speaker 4: of feeling bad, achy, and then the next day is
Speaker 4: maybe a little bit better, not great, and then the
Speaker 4: next day you're sort of back to feeling like you're
Speaker 4: among the living. And then you know, then we also
Speaker 4: recommend for at least for our employees to sort of,
Speaker 4: you know, kind of self isolate for a few more days,
Speaker 4: just to make sure you're not sort of still having
Speaker 4: those secretions coffin sneeze because we don't want to keep
Speaker 4: spreading it. And so that's sort of a mild course.
Speaker 4: The more severe courses tend to be you know, I
Speaker 4: think the damage is done within the first week, and
Speaker 4: then what we're doing is trying to support the body
Speaker 4: so the body can mend after that.
Speaker 2: What does that supportive care look like, both in terms
Speaker 2: of that during that first week of intense symptoms and
Speaker 2: then the sort of you know, the healing stage.
Speaker 4: Right, So it sounds like it's your grandmother patting your hand,
Speaker 4: is what supportive care sounds like, I think to most people.
Speaker 4: But in the case of some individuals that have severe disease,
Speaker 4: it may mean that they have a breathing tube, they're
Speaker 4: in an ICU, they have many other things that are
Speaker 4: helping support their body until the body can kind of
Speaker 4: get rid of the virus itself. So this is sort
Speaker 4: of how we describe things back in the bola days,
Speaker 4: where you know, most of the time what we're doing
Speaker 4: is just supporting, like with life support, basically to try
Speaker 4: to keep things going until the body can create and
Speaker 4: clear that virus. That's what happened during a bola with coronavirus.
Speaker 4: It's sort of similar. So supportive care when you're at
Speaker 4: home maybe niquil and television, which sounds really great to
Speaker 4: me right now, and when you're in the hospital. Though.
Speaker 4: What that is is if we need to help one
Speaker 4: of your body systems function, we will do that.
Speaker 1: Okay, do we know at this point how much things
Speaker 1: like viral load might correlate with the severity of symptoms?
Speaker 1: Are the people that have milder cases, are they as
Speaker 1: infectious to others? Are they shedding as much viral particles
Speaker 1: as these more severe cases?
Speaker 4: Right? So, I think this is a great question. And
Speaker 4: I think as this is where you're going to see,
Speaker 4: my laboratory in side come out quite a bit. So
Speaker 4: it's really easy when we talk about viral load in
Speaker 4: the blood or plasma or serum to sort of understand
Speaker 4: how to standardize that by copies per mili liter or
Speaker 4: something like that. When we're doing a respiratory swab. I
Speaker 4: think it's really hard to standardize. And because this test
Speaker 4: is so new, we don't have the test standardize in
Speaker 4: and of itself, So the testing results at our institution
Speaker 4: may be a little bit variable compared to another institution,
Speaker 4: and that's because we don't have a gold standard yet
Speaker 4: to compare on all of the machines. So I agree
Speaker 4: with you. However, we have seen very anecdotally that we've
Speaker 4: had people with very high viral loads that basically didn't
Speaker 4: even look like they were sick, and we question whether
Speaker 4: or not we should even swab them. And I had
Speaker 4: extremely high amounts in their nose, whereas we've also had
Speaker 4: people that have had moderate amounts that are sick and
Speaker 4: on a ventilator. And so, while I think there's an
Speaker 4: aspect that correlates, I think the way that we obtained
Speaker 4: the swab is going to make this difficult unless there's
Speaker 4: some sort of serum or plasma or surrogate tests we
Speaker 4: can use that can be very standardized with its input.
Speaker 2: And so going revisiting this aspect of perhaps asymptomatic individuals
Speaker 2: or people with very very mild cases of this, can
Speaker 2: you talk about sort of the incubation period when people
Speaker 2: might start becoming infectious, how long they remain infectious, and
Speaker 2: then sort of how much do you think asymptomatic individuals
Speaker 2: might be contributing to the spread of disease.
Speaker 4: So I think they probably are contributing to the spread
Speaker 4: of disease. I think that's why some of these more
Speaker 4: dramatic things that we're seeing are the social distancing and
Speaker 4: being really aware of your even more so just your
Speaker 4: own hand hygiene, just your own persona as it relates
Speaker 4: to anybody else. And so I think that we are
Speaker 4: taking measures to have that not happen. Right school's closing.
Speaker 4: Let's talk about where there could be a lot of
Speaker 4: asymptomatic spread of disease. That would be a school. So
Speaker 4: you got a bunch of kids shedding virus everywhere in
Speaker 4: close proximity, with limited hand and face and everything hygiene,
Speaker 4: And you can tell I have children, and that's just like,
Speaker 4: that's just a setup for transmission. So I do think
Speaker 4: that while asymptomatic people are shedding, we're really taking dramatic
Speaker 4: efforts on like I've ever seen in my short lifetime.
Speaker 4: I suppose really to even work on stopping that. I mean,
Speaker 4: hospitals aren't allowing very many visitors, you know, public places
Speaker 4: of all but canceled everything. So we're actually really trying
Speaker 4: to break that cycle, which I think has to me
Speaker 4: never been really done to this extreme. Yeah.
Speaker 1: Yeah, And you mentioned as well that it seems at
Speaker 1: this point pretty well established that it's older people and
Speaker 1: people with other underlying health conditions or people that are
Speaker 1: otherwise immunal compromise that are more likely to experience this
Speaker 1: severe disease. But we've gotten a lot of people asking
Speaker 1: us for a bit more clarity about these groups, like
Speaker 1: what age is it that people are considered elderly or
Speaker 1: at risk? And is it any sort of immune compromise
Speaker 1: that makes you more vulnerable? Or what are these pre
Speaker 1: existing health conditions that we're most concerned with in terms
Speaker 1: of the higher risk categories for this disease.
Speaker 4: Right, So, I think the way to do that, and
Speaker 4: the way I've been gut checking a number of these
Speaker 4: questions that we really just don't know yet because we
Speaker 4: don't know everything about this virus, is to think about
Speaker 4: influenza and sort of start there. Right, So, in older adults,
Speaker 4: influenza tends to be more severe because it's sort of
Speaker 4: tipping off chronic conditions that get worse. So if you
Speaker 4: have bad heart disease and you get a respiratory virus infection,
Speaker 4: sometimes people even have heart attacks from viruses, which is
Speaker 4: very rare, but we think probably happens more than we understand,
Speaker 4: but it may basically, you know, they may be in
Speaker 4: sort of a tenuous balance, like everything's kind of holding together,
Speaker 4: but it's it's it doesn't take much to push over
Speaker 4: into feeling a lot worse. And so I just think
Speaker 4: about the people that are at risk for our typical
Speaker 4: seasonal influencer are going to be the same people they
Speaker 4: are at risk, So anybody that has lung problems, anybody
Speaker 4: who's immune system can't fight it off. I think it's
Speaker 4: hard to say to actual groups, and you know, we're
Speaker 4: seeing that many older people are being spared and and
Speaker 4: some younger people that are younger than we thought are
Speaker 4: getting it. So it's really I think we're you know,
Speaker 4: we're trying to define the syndrome, as we're trying to
Speaker 4: diagnose cases, as we're trying to bring up testing, and
Speaker 4: so I think, you know, we will by the end
Speaker 4: of this outbreak have more resolution on what that looks like.
Speaker 4: But I think right now, you know, and it's probably
Speaker 4: at this point near seasonal influenza, gotcha.
Speaker 2: There were two groups specifically that we got a lot
Speaker 2: of emails about and questions about, and one of those
Speaker 2: groups was people with diabetes type one, and they were wondering,
Speaker 2: you know, people, I keep seeing that people with diabetes
Speaker 2: are more at risk, does that include me? And then
Speaker 2: the other group that we got a lot of questions
Speaker 2: from were people who were pregnant or people with newborns.
Speaker 4: Right, So the pregnancy thing, I think is always a
Speaker 4: we always are concerned about it very highly. I don't
Speaker 4: think that there's been any data that actually shows there's
Speaker 4: poorer outcomes. I know that doctor Denise Jamison from Emory
Speaker 4: has published a little bit about this, at least what's
Speaker 4: known from stars and mers, And while early trimester is
Speaker 4: always concerning for anything, there's no evidence that anybody again
Speaker 4: has had any pregnancy complications from this. However, in general
Speaker 4: we don't like to test that theory, and so we
Speaker 4: tend to be protective around pregnant women for sure. In
Speaker 4: terms of those with diabetes, I think it's it's again
Speaker 4: not quite known what the aspects of diabetes, except that
Speaker 4: there's some level of sluggish immune and response. I wouldn't
Speaker 4: say immune compromise entirely. I think it depends on how
Speaker 4: well your blood sugars are controlled, how many complications you
Speaker 4: already have from diabetes. Do you have type one diabetes,
Speaker 4: which can tend to be much more severe than type
Speaker 4: two diabetes. I think some of those questions, you know,
Speaker 4: may be elucidated as things progress.
Speaker 2: Gotcha, so you know on these in this discussion of
Speaker 2: high risk groups and low risk groups or varying risk
Speaker 2: in general. One of the things that we've seen is
Speaker 2: that children seem to experience a milder disease than some
Speaker 2: of the other age groups. Do we know why that is?
Speaker 2: Our immuno compromised kids just asvulnerable as immunocompromise people of
Speaker 2: other ages.
Speaker 4: I should have read my pediatric textbook a little bit more,
Speaker 4: But there are definitely a number of viruses that are
Speaker 4: much worse than adults than kids. And then we sort
Speaker 4: of have vice versa where kids tend to have maybe
Speaker 4: an increased predilection, or maybe it's just because by the
Speaker 4: time you're an adult that you're immune to it, and
Speaker 4: when you're a kid you're sort of seeing it for
Speaker 4: the first time. So there is always this dichotomy of
Speaker 4: is it worse in kids are better in kids? This
Speaker 4: scenario really seems to be that the kids are these
Speaker 4: asymptomatic probably shedds, right, But we already discussed a little
Speaker 4: bit earlier, and so this virus just for whatever reason,
Speaker 4: is not that severe in children. But again, it may
Speaker 4: be that most coronaviruses aren't. We just haven't studied them
Speaker 4: because we kind of haven't cared because they haven't done
Speaker 4: that severe in adults, and in terms of immunocompromised kids,
Speaker 4: I suppose that they are more at risk, but I
Speaker 4: suppose that they may also become increased vectors. They may
Speaker 4: just shed longer. But again, I'm not a pediatrician, so
Speaker 4: I hesitate to sort of fully answer that one with confidence.
Speaker 3: Yeah, that makes sense.
Speaker 1: So can you explain a little bit about how we
Speaker 1: are getting the numbers for things like the case fatality
Speaker 1: rate right now? Is that something that is still a
Speaker 1: moving target? Do you think that we might be able
Speaker 1: to see that number decrease as more asymptomatic or mild
Speaker 1: cases are identified, since at this point it seems like
Speaker 1: testing is mostly focused on the severe cases exactly.
Speaker 4: Yeah, so I think this is you know where again
Speaker 4: my laboratory and background and the logic of this is
Speaker 4: really interesting in a is it interesting as anything can
Speaker 4: get right now? So what really I think is interesting
Speaker 4: is we really do have a decrease in throughput ability
Speaker 4: right now with our diagnostic testing. That's because we're building
Speaker 4: the car as we drive it, right So, there's been
Speaker 4: all this contrived controversy about test kit shortage. Well, we
Speaker 4: just discovered this virus and we just made a test
Speaker 4: for it, and when we make tests that are new,
Speaker 4: we have to go back to old school methods, which
Speaker 4: are a bit slow, and so I think I don't
Speaker 4: know what expectation we had that we had to have
Speaker 4: like a rapid test the next day. I think it
Speaker 4: was a little bit. I don't know who's stettying that standard,
Speaker 4: but the standard is unattainable, and so I think that
Speaker 4: by virtue of the fact that we're going to start
Speaker 4: testing more and more people over the next month, we
Speaker 4: are going to see that that denominator is going to
Speaker 4: stretch out. So we're going to have people that are asymptomatic,
Speaker 4: barely symptomatic that are going to be positive, and that
Speaker 4: will make that case fatality rate drop. I think it
Speaker 4: can look higher. Again, it's exactly what you said. It's
Speaker 4: selection bias. So when you're only testing the sickest of
Speaker 4: the sick, then you're only going to find a high
Speaker 4: case fatality rate. I personally am the current gatekeeper to
Speaker 4: who gets on our daily test in house that we've developed,
Speaker 4: and we only have room as of today. This probably
Speaker 4: is actually going to change tomorrow. So you know, I
Speaker 4: have to gatekeep and prioritize who gets on our in
Speaker 4: house run which takes twenty four hours versus send out
Speaker 4: to a referral lab, which may take seven days. Well,
Speaker 4: who do I prioritize? I mean, who would you guys prioritize?
Speaker 4: So we're going to do impatients because we're also using
Speaker 4: a lot of personal protective equipment to care for these individuals,
Speaker 4: and so we want to be able to take them
Speaker 4: out of that if they don't need it, and then
Speaker 4: we can keep our supplied. You know, we need less
Speaker 4: supplies if we do it that way. And then we're
Speaker 4: also tests prioritizing our workforce, right, so we want to
Speaker 4: make sure that the physical therapists and the respiratory therapists
Speaker 4: and the you know, tech and everybody can come back
Speaker 4: to work because we want to make sure we can
Speaker 4: keep taking care of these sick patients when they come in.
Speaker 4: Mm hm hm.
Speaker 1: That makes sense.
Speaker 2: So I know that it's early stages yet again in
Speaker 2: this pandemic, but do what do we know so far
Speaker 2: about longer term health consequences for people who have gotten sick,
Speaker 2: maybe have gotten mild or severe in particular, disease, and
Speaker 2: are there long term health consequences they have, like lung
Speaker 2: damage or other issues.
Speaker 4: So the logic that I use is that anything that
Speaker 4: damages the lung can cause long term consequences. So the
Speaker 4: lung only knows how to do one thing when it's damaged,
Speaker 4: and that's to scar down. And so that's why our
Speaker 4: bodies have this lovely cough reflex so that all that
Speaker 4: stuff doesn't go into our lungs and cost scarring and damage.
Speaker 4: So when we have a virus that's infecting our lung cells,
Speaker 4: then that's going to cause this scarring to happen, and
Speaker 4: we potentially could see long term damage. But that's the
Speaker 4: same as sort of anything that comes and damages the lung.
Speaker 1: Okay, So another question that a lot of people had,
Speaker 1: and I know we probably don't fully know the end
Speaker 1: answer to this, but maybe we can sort of estimate
Speaker 1: based on what we know so far about coronaviruses in
Speaker 1: general or from you know, the previous outbreaks. Is do
Speaker 1: we know about whether it seems possible to become reinfected
Speaker 1: with this virus if you get it and then recover
Speaker 1: from that infection.
Speaker 4: Yeah, So I was just on another alumni call today
Speaker 4: and have this very same question. We probably get this
Speaker 4: question every day, and so in general we probably don't
Speaker 4: know for sure. I think because this is a novel
Speaker 4: coronavirus introduced to the population, we will likely understand more
Speaker 4: because there's more attention to it. My understanding is that
Speaker 4: when we have viral infections, we do become immune to them,
Speaker 4: but remember that it depends on how systemically ill we
Speaker 4: are as well. So you know, it's a complicated immunology
Speaker 4: at this at our nasal source. Right. We talked already
Speaker 4: about how trying to say the viral load from the
Speaker 4: nose is not a very consistently sampled area, and so
Speaker 4: I think in the same way that immunology may be
Speaker 4: difficult to totally separate out because there may be an
Speaker 4: aspect of our mucosal immunology that plays a large role
Speaker 4: in whether or not that virus comes back to us. Right,
Speaker 4: So we may have just symptomatically gotten through it, but
Speaker 4: did we actually form true defense against it? And again,
Speaker 4: I think, you know I would. I don't pretend to
Speaker 4: know that much about immunology except the big picture stuff.
Speaker 4: So I hope that was helpful.
Speaker 2: Yeah, absolutely so. In our first episode on coronaviruses, we
Speaker 2: ended it by asking you, what about this disease concerns
Speaker 2: you and what about it you know, makes you say
Speaker 2: hold off on the panic or maybe as reason for optimism.
Speaker 2: Has your answer changed at all since that time?
Speaker 4: My answer has changed, Dear Errands. I think that we
Speaker 4: do see that it causes laura respiratory tract infection, much
Speaker 4: like other viruses that we know, such as influenza, and
Speaker 4: so I am happy to say that it's not as
Speaker 4: severe as stars or mers, but it's not insignificant, and
Speaker 4: we are seeing a lot of individuals you know, in
Speaker 4: the hospital that have this. I think my optimism is
Speaker 4: that I'm trying to be optimistic every day. The supply
Speaker 4: chain issues and the personal finance issues and the childcare issues,
Speaker 4: to me, are making this very personally difficult for a
Speaker 4: lot of people. It's one thing to sort of have
Speaker 4: a bad blue season and us to have sort of
Speaker 4: sicker patients or more patients, but the personal protective equipment
Speaker 4: and you know, no visitors to the hospital, all those
Speaker 4: things really are stressing people personally. And so I'm just
Speaker 4: trying to be optimistic that a lot of this social
Speaker 4: isolation that we have implemented will act actually make a difference,
Speaker 4: because you know, we're sort of, at least in Georgia,
Speaker 4: we're sort of coming into the surge part of it
Speaker 4: for our location, and I think everybody's going to go
Speaker 4: through that and you know, have to just come out
Speaker 4: on the other side. But there's a lot of things
Speaker 4: that you know, when I was bubbly three weeks ago
Speaker 4: or whenever that was, I could not have imagined the
Speaker 4: stress of like not having swabs to test, or you know,
Speaker 4: I could have understood and foreseen not having enough tests
Speaker 4: or having a low throughput on test. That's something we
Speaker 4: deal with with other scenarios that's not that uncommon. But
Speaker 4: I think the financial personal tolls that are occurring in
Speaker 4: the midst of trying this being very busy, like during
Speaker 4: a respiratory season, it's been a lot more difficult. So
Speaker 4: I'm just hoping that our interventions, while initially seeing meing
Speaker 4: very dramatic, will actually sort of alleviate the stress.
Speaker 2: That was fantastic. Thank you so much doctor Kraft for
Speaker 2: joining us and taking time out of your ridiculously busy schedule.
Speaker 2: We really appreciate it.
Speaker 1: We can't believe that you made time for us. We
Speaker 1: really really appreciate it.
Speaker 2: Yeah, we do, all right. So things we learned. Number one,
Speaker 2: one of the big gray areas that we didn't fully
Speaker 2: know the answer to in our first coronavirus episode back
Speaker 2: in February was whether or not people were infectious before
Speaker 2: they were symptomatic, and whether there was asymptomatic spread or
Speaker 2: even super mild infections contributing to the transmission. So in
Speaker 2: this interview, we learned that although we don't know exactly
Speaker 2: how much virus people might be shedding throughout their infection,
Speaker 2: that there are asymptomatic or very mildly symptomatic individuals and
Speaker 2: that they're contributing to the spread. That is super clear.
Speaker 2: At this point, Doctor Kraft mentioned testing someone who seemed
Speaker 2: perfectly healthy and finding a ton of virus in comparison
Speaker 2: to someone else who was more severely ill and had
Speaker 2: a lot less virus in their sample. And there are
Speaker 2: some difficulties with this in terms of standardizing the test
Speaker 2: and whether that person who had less virus did actually
Speaker 2: have less virus. We don't know much about the viral
Speaker 2: load changes throughout the infection, but this I still think
Speaker 2: personally is alarming or at least is going to make
Speaker 2: transmission of this disease much more difficult to stop. Absolutely,
Speaker 2: And there was actually a nice modeling study that used
Speaker 2: data from Muhan and fits some mathematical models to the
Speaker 2: actual infection data, and it suggested that up to like
Speaker 2: eighty six percent, eighty six percent of the spread of
Speaker 2: infection was likely due to unidentified cases.
Speaker 1: That's a lot.
Speaker 2: It's a lot, And it makes sense that this is
Speaker 2: possible if we know that asymptomatic or mild infections are
Speaker 2: possible and common.
Speaker 1: Absolutely. Number two. Another big thing I think to take
Speaker 1: away from what we talked about with doctor Craft and
Speaker 1: what we heard in the first hand account is that
Speaker 1: in people who get severely ill from this disease, these
Speaker 1: people really need to be hospitalized. And that's what's really
Speaker 1: scary about this and why you hear a lot. And
Speaker 1: we'll talk more in the future about why we're trying
Speaker 1: so hard to flatten this curve, because if our hospitals
Speaker 1: get overrun, then more people could die simply because there
Speaker 1: aren't enough beds, or there aren't enough staff, or there
Speaker 1: isn't enough equipment to actually care for them. So for
Speaker 1: people that need to be hospitalized for supportive care, like
Speaker 1: doctor Craft was talking about. But that means that these
Speaker 1: people aren't able to breathe well enough on their own,
Speaker 1: so they either need a tube down their throat and
Speaker 1: to be on a respirator, or even if they don't
Speaker 1: need that maximal support, they still need supplemental oxygen or
Speaker 1: a positive pressure face mask. All of these things you
Speaker 1: can only get in the hospital. And the other thing
Speaker 1: is that even if people don't need help breathing, they
Speaker 1: might end up needing ivy fluid support as well. When
Speaker 1: you get sick, when you're not eating, not drinking normally,
Speaker 1: and you're spiking high fevers, your body is working really
Speaker 1: hard to fight off an infection and you can end
Speaker 1: up severely dehydrated pretty quickly. So for some people, if
Speaker 1: they get very sick, just drinking fluids isn't going to
Speaker 1: be enough to repleate that volume. So another way that
Speaker 1: we see supportive care in the hospital is support from
Speaker 1: ivy fluids as well. And all of these are support
Speaker 1: measures just to help your body get through this process,
Speaker 1: not even addressing the virus itself. And we'll talk in
Speaker 1: a future episode about what's being done on those types
Speaker 1: of treatments, but I think understanding that people who get
Speaker 1: severely ill really need the resources that are available in
Speaker 1: hospitals is an important aspect.
Speaker 2: Of this disease absolutely. Number three. So looking at these
Speaker 2: different risk groups, I think there are a couple of
Speaker 2: important things to keep in mind. One is that we
Speaker 2: don't fully know the risks across different groups, and part
Speaker 2: of that is because this is so new and we
Speaker 2: don't have a ton of data. And another part is
Speaker 2: that because, like doctor Rasmussen said in our episode about
Speaker 2: the virus biology, there's a lot of variation in host
Speaker 2: response that we can't always predict. On top of that,
Speaker 2: we have these, as we mentioned, a bunch of these
Speaker 2: asymptomatic or very mildly symptomatic individuals that are contributing to
Speaker 2: the spread of this virus. That means that we all
Speaker 2: kind of have to assume that we are potentially infectious
Speaker 2: at any point, because it's our job to help protect
Speaker 2: those around us that might be more vulnerable. And another
Speaker 2: thing I want to point out is that in the
Speaker 2: US so far, like thirty eight percent of people that
Speaker 2: are hospitalized with COVID nineteen right now are under fifty five.
Speaker 1: That's a lot of young people.
Speaker 2: It's a lot. It's a lot, And I think that's
Speaker 2: not necessarily been what the messaging has suggested in terms of, oh,
Speaker 2: if you're not old, if you don't have underlying health conditions,
Speaker 2: then you're safe. Which, first of all, that's kind of
Speaker 2: mean to the people who are older and who do
Speaker 2: have these underlying health conditions that you're like, oh, well,
Speaker 2: you know, go ahead and die, I'm going to be fine, right, Like.
Speaker 1: These are still human beings we're talking about.
Speaker 2: Here, human beings. Yeah, And so I think that that
Speaker 2: messaging that everyone is susceptible is really important and everyone
Speaker 2: can possibly contribute to the spread of this disease exactly. So,
Speaker 2: there was a nice retrospective analysis of this disease from
Speaker 2: patients in Wuhan, and in this analysis, the median age
Speaker 2: of people who were hospitalized with COVID was fifty six.
Speaker 2: So although there are some good data that suggests that
Speaker 2: older ages are especially at risk for dying from COVID nineteen,
Speaker 2: this is by no means a disease only of older people,
Speaker 2: and it's not only older people who become severely ill
Speaker 2: from this virus.
Speaker 1: Number four, speaking of who gets super sick, we also
Speaker 1: talked with doctor Kraft about the case fatality rate. So
Speaker 1: I'm going to define that really quickly. The case fatality
Speaker 1: rate that you're probably hearing a lot about is the
Speaker 1: number of deaths divided by the total number of cases
Speaker 1: in a period of time. So that denominator, the total
Speaker 1: number of cases in a period of time, is determined
Speaker 1: by the number of people that we know are infected.
Speaker 1: And as doctor Kraft said, in this case, if we're
Speaker 1: only testing the most severely symptomatic people, then that denominator
Speaker 1: is going to be small relative to the total number
Speaker 1: of people who might actually be infected. So then the numerator,
Speaker 1: the number on top the number of deaths, is going
Speaker 1: to be proportionally larger. So the bottom line is, we
Speaker 1: still don't know exactly how deadly this disease is, especially
Speaker 1: here in the US where we're only testing severely ill individuals.
Speaker 1: For the most part, we do have some preliminary data
Speaker 1: in the US. This is from March sixteenth. This data,
Speaker 1: it suggests that mortality is definitely highest in people over
Speaker 1: eighty five, but in this group mortality ranges from ten
Speaker 1: to twenty seven percent, and in people between sixty five
Speaker 1: and eighty four, it ranged from three to eleven percent
Speaker 1: and it went down from there. But again, all this
Speaker 1: data is biased by the fact that we're only testing
Speaker 1: the most severe cases. And as you've probably heard in
Speaker 1: the news, the case fatality rate thus far has been
Speaker 1: different in different countries, and that's likely because of both
Speaker 1: differences in ages of the population that gets ill in
Speaker 1: those countries, but also differences in their testing strategies as well.
Speaker 2: Mm hmm, yeah, which brings us to number five. Our
Speaker 2: last point, and that is that we do not have
Speaker 2: enough resources period period. We don't have enough resources, and
Speaker 2: that is super problematic, and it's no fault of the
Speaker 2: clinicians or the laboratorians who are now faced with having
Speaker 2: to decide who they can test with their limited supplies.
Speaker 2: And the thing is, if we don't stem this infection,
Speaker 2: that lack of supplies is only going to get worse.
Speaker 2: And that's what we have seen in Italy. It's illustrated
Speaker 2: this perfectly because in some areas they don't have enough
Speaker 2: ventilators and they're having to decide who they're going to
Speaker 2: intubate and ventilate. That's a decision that no physician should
Speaker 2: ever have to make and We'll talk more in some
Speaker 2: of our future episodes about what has led to the
Speaker 2: shortage and why we are facing it. But there's no
Speaker 2: doubt that it's making it harder to get this epidemic
Speaker 2: under control, and it's an enormous stressor on hospitals and
Speaker 2: healthcare workers.
Speaker 1: Yeah, it's pretty major. Okay, sources, sources, Aaron, we have
Speaker 1: a lot for this episode. So there was an article
Speaker 1: by lower at All. All of these are from twenty twenty. Okay,
Speaker 1: they're all written in the last month. There's an article
Speaker 1: from Lawer at All that was in Annals of Internal Medicine.
Speaker 1: From by at All in jama from Jao at All
Speaker 1: in the Lancet. We've got one from Wu and Magoogin
Speaker 1: in Jama Kong and Argowol in Radiology cardiothoracic Imaging. That
Speaker 1: one's great if you want some pictures of those ground
Speaker 1: glass opacities. Le at All in Science. And then the
Speaker 1: CDC's MMWR report from March eighteenth is where I got
Speaker 1: those numbers on the age stratified deaths in the US
Speaker 1: so far.
Speaker 2: So we'll post all of those references on our website.
Speaker 2: This podcast will kill You dot Com so if you
Speaker 2: want to read up a little bit more, you know
Speaker 2: where to find them.
Speaker 1: Yep. Thank you again to doctor Colleen Kraft for taking
Speaker 1: the time out of your schedule to speak with us
Speaker 1: and to share what you have learned with our listeners.
Speaker 1: We really really appreciate it, we really do.
Speaker 2: And thanks to Bloodmobile for providing the music for this
Speaker 2: episode and all of our episodes.
Speaker 1: And thank you for sticking through chapter two. We'll see
Speaker 1: you next time chapter three.
Speaker 2: Until chapter three, wash your hands.
Speaker 3: You filthy animals.
Speaker 1: Ou