Gregg Masters  00:04  This is PopHealth Week on HealthcareNOW Radio. Today’s episode is sponsored by Health Innovation Media. We bring your brand messaging alive on the ground and now in the virtual space for major trade show conference innovation summits and webinars via our signature pop up studio connect with us at www.popupstudio.productions. I’m Gregg Masters Managing Director of Health Innovation Media, publisher of ACOwatch.com and your  PopHealth Week co-host with my partner co-founder Fred Goldstein, President of Accountable Health LLC, a Jacksonville, Florida based consulting firm. On today’s show for a roundtable of sorts. Our guests are Dr. Nick van Terheyden, Fred Goldstein, and yours truly Gregg Masters, we discuss the latest developments in the COVID-19 global pandemic. So let’s get right to it. So I think it’s helpful perhaps to go back into a condensed timeline, which I’ve sourced from WHO because this has been a relatively short-lived and rather quickly disseminating now pandemic that began with a notice on the 30th of December 2019 for a patient who presented with a pneumonia of unknown origin. And that’s a surveillance definition established following the SARS outbreak of 2000 to 2003. This patient was admitted to a hospital in China some 70 days later on or about March 11, the WHO World Health Organization declared the coronavirus outbreak a global pandemic which had spread to more than 190 countries around the world. Interesting to note the last time WHO declared a pandemic was during the 2009 h1n1 swine flu outbreak WHO emphasized that COVID-19 is the first time a Coronavirus has caused pandemic. The 2000 to 2003 outbreak of SARS, which is also a Coronavirus, was contained enough to avoid that classification. So, the compressed timeline here is from patient zero, if you will the index patient to today we’ve seen explosive exponential growth in geographic clusters emerging at their own timetable and the diffusion of this disease now around the globe. So according to the Johns Hopkins School of Center for Science and Engineering, the total confirmed cases as we speak today, which is May 13, 2020. The global total confirmed cases are 4,315,679. With global deaths clocking in at 294,879. The US picture is rather dismal, total confirmed COVID-9 cases are 1,380,465 with a death count at 83,249. So let’s just put that out there as the footprint of where we stand on a global perspective. Nick, do you want to state why this one is different from the ground? the millstone?

Nick van Terheyden  03:27  Yeah, absolutely. So I would say just first off the bat, I think, while you’re relating of the patient zero is accurate based on what’s been reported. I think what we’re learning is that that may not be patient zero. And there is likely or potentially, earlier cases that may have been around that we weren’t aware of. Case in point, our best understanding today is that the spread of the virus in the United States actually came from the east coast, not the West Coast and came round the globe from that side not coming from China, not that it may or did not originate in China. I think we view that to be the case, but I think it was circulating before we actually had notice of it, and were tracking it. So this whole patient zero is extraordinarily important. And you know, Hollywood obviously does make a great job of making that point because that seems the entire movie plot in many of these pandemic movies, find the patient zero and you’ve solved the case. not entirely true, but you know, it’s a good proxy. Because of course, it’s important to understand that and that helps us source where this virus came from, as far as what it is, well, viruses different bacteria are inert. Essentially, they’re pieces of DNA covered in a lipid, or fatty kind of covering on their own. They can’t do much they actually need our cells to replicate. They’re much smaller than bacteria and importantly, are completely insensitive to antibiotics. One of the reasons that physicians resists treating patients that come in with flu or flu like symptoms with bacterial treatments, such as penicillin or equivalent antibiotics. So that’s one of the challenges that we have, we don’t have much in the way of treatment options for any of the viruses. And our mainstay of treatment is actually prevention. And it’s tied to vaccinations. And that’s why vaccinations are so important in terms of preventing disease, they save probably many more lives than any other innovation that we’ve come up with in medicine, in the entire history of medicine. I’d be delighted to be corrected on that. But I doubt with that the case, I think the value proposition of all of the vaccines that we’ve created has been extraordinary in terms of preventing disease. One of the challenges is, of course, the people have become a little bit complacent I would say, with regards to vaccination. And we’ve certainly seen a very large misinformation campaign around them to suggest that they cause disease, which they do not and all sorts of links that have been completely disproven and are linked to people that have no standing in science and being kicked out of the medical community for their misbehavior, what I would call just outrageous claims that are killing people. And unfortunately, in the case of Coronavirus, it’s new. That’s the term novel The first time that we as human beings have seen it, I think it may well have been circulating in other animals that certainly, we find these viruses all over the place in other animals and mammals. And in this case, it jumped somehow into the human population, it causes what looks very much like flu, but has some distinct variations to that. And that includes specifically, a much higher death rate, it kills more people seems to tick across the older age group and is linked or worse for patients that have chronic diseases. But in flu, that’s also true. So that’s not entirely unusual, it has some distinct symptoms that are quite different. And I think almost diagnostic at that point. One of them is the loss of smell, and taste that seems to be linked to this disease. So if you happen to have those symptoms associated with flu like symptoms, it’s fairly likely that you have the disease and with this higher mortality, and extraordinarily virulent and by virulence, I mean, it spreads easily, it is a significant problem. And it is spread worldwide. And as you rightly point out, Gregg, this is being defined as a pandemic. And the pandemic is essentially a variation in how much something has spread. And obviously, at this point, I think it’s worldwide, I’m not aware of any country that has managed to avoid it at this point, and maybe some isolated places, but really hit everywhere, and to varying degrees based on the different country reactions,

Gregg Masters  07:51  which are interesting in and of themselves, and notably being United States reaction versus what we saw in South Korea, and Italy, and now Spain, France, Portugal.So let’s talk a little bit a little bit about that. One of the problems that we’ve had is this is a novel virus, which has a disease profile that is unfolding in real time, it seems like every day, we’re learning more about its virulence. And its ability to spread rather easily with an R0 of somewhere between two to three, and has exponential DNA within our not meaning replication rate of the one person affects two or three others. And that grows rather quickly. So Fred, let me ask you this, maybe from a population health perspective, the situation in China being top down is quite different from the situation in the United States, which is a bubble up, if you will, in a bubble up in an environment where senior leadership at the federal level has spent a good deal of time essentially, discounting and minimizing threat. Yet now we lead the world in cases and deaths. So how would you account for that from a population perspective? Why is the footprint and the disease occurrence, so different from country to country,

Fred Goldstein  09:11  I think it really gets back to the country’s, you know, makeup, how they do things, what they consider important, and those underlying things around, you know, in the United States, we tend to have a lot more individuality than perhaps some other countries and have always been sort of that rugged, individual approach. And I think that leads to at least in this case, it makes it easier for something like this to take a hold, and, you know, much harder to say, we’re going to close down an area or we’re going to stop work or we’re going to shut down a system of transportation or require masks. And so that’s really been it you know, each country is sort of us sort of seen what that country’s social makeup is like, and how they, how they react to things like this. So yeah, I mean, early on, I think we’ve obviously had some problems here in the United States. We’ve had this thing gets pretty far out, you can see which states, I think there were some studies that showed, for example, in Washington State, they probably shut down a week earlier than New York data in a specific period of time as to when the virus was there. And so New York has a much higher rate of infections and and also has other issues, you’ve got a really dense population in that city, you have a transportation system that tons of people use very close spacing in those things. And so a lot of it gets to that. And I think it’s really, you know, now, it’s really about how far you can move in one direction or the other, given the structure and the social organization of the countries of any country to handle it. You saw in Italy, it was pretty late, and some of those elderly communities and they got hammered, and then shut stuff down. It’s kind of we’re at where we’re at now. Now, the question is, what do we do on a go forward basis? And how do we ensure that, especially given the calls to reopen the economy and the impact we’re seeing on everyday people’s jobs? How do you potentially consider doing that, and we’re seeing again, in the United States, each state may be experimenting in a slightly different way as to timing and what’s allowed and what’s not. And given that we’re learning every day, there are things we don’t know. And even in the presentation before the Senate yesterday that Dr. Fauci talked about, you know, we just don’t know everything. So everybody’s sort of making these guesses, some based more on science, maybe some based less. But in many ways, there are things we do know, and there’s still a lot we don’t so as we learn more, I think, you know, one of the things we’re learning is there may be considerably less risk. We don’t know for sure. Outdoors versus indoors, especially if you’re spacing yourself. So that may be something that somebody says, well, gosh, we’ll open up the outdoors, keep spacing, and it may be okay. Whereas Clearly, we know that in indoor situations that may be highly risky if you reopen that today. So I think we’re still learning and states in particular, the states are going to try something a little bit different. So be interesting to watch over time.

Gregg Masters  09:35  And Nick, let me ask you, if this death toll is finally easing which there’s some evidence  that of late like, Are we out of the woods here, and if you’re just tuning in, you’re listening to PopHealth Week on HealthcareNOW  Radio, this COVID-19 update features Dr. Nick van Terheyden, Fred Goldstein, and yours truly, Gregg Masters, we discuss the latest developments in the COVID-19 global pandemic.

Nick van Terheyden  12:24  I’m sorry to laugh, I don’t mean to be flippant about it. But I think it’s a clear response of Hell no, I feel like I need to channel my inner John Wayne and, you know, the hell it is, is unfortunately, you know, the reality of this is it’s a novel Coronavirus. We have so little in our armament of how we approach the challenge of those tracking, tracing and then treating people with this disease, the timeline to develop those things, even with the best possible will in the world. And all the luck that you could possibly ask for is not going to be a the presence of a vaccine in relatively short order, which is our mainstay of, of treatment. We have barely any antiviral medic medications, because we’ve essentially discounted that whole area of research for economic reasons. It just it’s failed to sort of generate enough activity. And we fail to take account of all the warning signs and the warnings that were posted by people that paid attention to this for many years, multiple times that Ebola has emerged. You know, there was a point in time when Ebola arrived on the shores of the United States very briefly, there was a lot of focus, but you know, much like everything else that hit the news cycle, once it died down, people stopped paying attention. We defunded everything. So our capacity to sort of fight this is severely limited. That’s the bad news. The good news is that we’re a highly innovative set of people. We have extraordinarily bright folks who for the most part are working together. And I think we’ll come up with some clever, impressive solutions. Case in point and one that I highlighted. This essentially just got published recently. In fact, I think it’s still a pre published paper. But we’ve already discovered that anticoagulation the thinning of blood has a highly positive effect on outcome and outcome in this instance, is about decreasing mortality of people that are admitted to hospital and specifically admitted to ICU. Both those groups of patients reduced mortality by 50%. In a study that was pre published out of Mount Sinai in New York, that’s very exciting. I know that’s only half a saving. So one in two, but given that we were looking at 70 to 80% mortality of patients being admitted to the intensive care unit for  ventilation, that’s a big saving. And whilst it’s not an endpoint in itself, it’s very exciting, it offers us some hope. It also gives us some additional insights into this disease. So this is not just about respiratory systems, it turns out that it’s about coagulation and clotting and throwing off clots that are causing other problems, and other organs that are involved in this disease. So it gives us some other markers and areas to sort of focus on. So I laugh, not because I find any of this humorous at all. But I do, you know, somewhat sadly, laugh at this, because there is this sort of desire to hope. And I don’t mean to depress folks. But I think we have to sort of face this realistically. And that’s why it’s so important, as we reopen, that we do so in an appropriate way that is led by science. If you want an example of where that’s been the case, I would say New Zealand is absolutely driven by science, has science that is in the leadership, helping guide process, and importantly, is customized based on individual circumstances. So as we open up our workplaces, we do so the guidance of people that understand this can interpret this and are not armchair epidemiologists aren’t armchair physicians who don’t fully understand all of the intricacies of this. And people derive their insights from folks that really know what they’re talking about to help them guide that process. If you look at South Korea, you mentioned them as one of the examples, I think their site is one of the places that does have done a really good job, guess what they’re struggling with reopening, because it’s not quite as simple as saying, hey, we’ve driven the disease out, they reopened a little bit, and they’ve seen a increase in the number of cases. And that’s true in a number of other countries. And I think we’re going to have to be extraordinarily cautious. And I think we’re seeing some of that already in the United States. And unless we do this in appropriate way, and to have a excellent, scientifically driven plan that is customized down to individual businesses, groups, and so forth. We’re going to look at recurring increases in this disease, and also the associated deaths.

Gregg Masters  17:14  Yeah. And I think, Nick, that raises some really interesting points. One of them is, you know, you may have seen in the news, Mark Cuban and this silent shoppers that he sent into secret shoppers that he sent around in Dallas, as businesses reopened and hired a firm and they went out to over 300 businesses and looked at what they were doing. And essentially found only 36% of the businesses that chose to reopen that period. But on average, stores only followed 58% of the recommended safety protocols. So even as you’re reopening, and we have all this information out there that says you should do this, or maybe you should do that. It’s not getting down to those individual locations. And he’s he noted that they even had variations within chain store companies, where this the the corporate organization said, here’s how we’re going to reopen those, and they saw differences. So it really does get down to that. And I think it’s also about as you said, it’s looking at what the data shows. So one of the things that’s interesting in Jacksonville as we’ve reopened, is that the mayor point is the fact that look, we’ve had the stores with this social distancing, the grocery stores open for quite a while and we have not seen a spike, we opened the beaches weeks ago. And we have not seen a spike. And so we’re I think certain places are beginning to find those few key points. Now, we may see something come up. But those may be easier things that demonstrate Here are ways to do some of that, you know, the the restaurants here reopened at 25%. The next phase would be 50. might that be too much might it be more having to do with seating patterns, and airflow is an indoor outdoor. Those are things I think that’ll be interesting and why it’s really important, as you pointed out for companies to look at this and really look at their situation, their community, the data in their community, the data on where their employees are, and develop that plan based on that,

Nick van Terheyden  19:08  right. And a lot of additional sort of layer on that, I think is being I think one of the most helpful for processes and people think through this that essentially determines risk based on the viral load of the exposure and the time of that exposure. Those are the two key elements to consider. So that you could have a very high viral load as an example of sneeze which generates enormous transmission of virus in somebody that has the infection. So people around it for a relatively short period of time, and that would increase and give you an exposure risk, but equally a low viral load of somebody that’s just breathing that has the disease, for example, somebody that’s asymptomatic, so they don’t have a temperature. We don’t know that they have the disease. Unless we tested for it and found it, so they sit in a restaurant, but they sit there for two hours breathing it out, or in the case of, I think it was the South Korean call center, and circulation of air, spread it to all the people locally and then, you know, is transmitted with the same level of transmissibility. So that, for me has been the most effective measure to help people understand, it’s not just about exposure, it’s about time of exposure and the viral load. And understanding that requires at least a detailed understanding of viruses, how they spread the impact of viral load and so forth.

Gregg Masters  20:37  So with that, no vaccine inside, say, for the next 12, 18 months, even though Trump is saying we’ll have one by the end of the year, I think it’s doubtful, there are no effective or approved treatments, per se remdesivir has gotten some recent attention, because of the reduction of the hospital stay from 15 to 11 days, one would assume these are desirable outcomes as there is a discharge but whether or not remdesivir actually improves mortality, I think is an open question, if I’m not mistaken, is that correct?

Nick van Terheyden  21:14  Yeah, I think it’s good to talk about that. It’s obviously raised its head. And unfortunately, we’ve seen a number of these instances of other drugs that were listed as an example and the saving grace, they’re not remdesivir is not, it certainly was good enough, interestingly, for a pretty solid trial that was International, multiple countries multi site and included a placebo arm. So for those listening, that don’t understand that placebo means that we give you the drug, and a proportion of the people getting the drug actually received what appears to be the drug, but it’s not. And nobody knows it’s blinded. So nobody is actually aware of who’s really getting the drug. And that really gives us a great understanding of whether something is effective, or whether it’s just appears to be effective. So it included a placebo arm, what’s positive about the news was that the data coming out was sufficiently positive for them to remove the placebo arm. So they changed the trial because it felt at this point, we were seeing positive enough outcome. So as you rightly say, Gregg, reduction in the length of duration of the disease, it didn’t change the endpoints of the mortality wasn’t as best as I understand. But it did reduce the severity of the disease by length, and that was sufficient for them to remove the placebo. So now everybody is getting the drug and the trial, because it felt inappropriate to be offering placebo, once we’ve shown that it was given this positive effect. But it’s not a treatment, it’s not changed the mortality, and you know, continues to require additional study. And that’s true, pretty much of all of these attempts to find drugs to treat the condition. Once you have it. Briefly, let’s talk about vaccination. And you know, the development, I think Moderna is the company that everybody’s got very excited about. They’re an RNA virus, target. And to be clear, I think if I recall, my readings on this, there are about seven variations on a theme of the types, not the number of trials as number of trials with some of the order of 70 or so for vaccines, that RNA is one of the targets. And that’s the specific focus on the piece of the virus that we’re essentially attacking or approaching as a target. And in this case, Moderna is going after the messenger RNA. But here’s my caution around that. This is something we’ve been trying to do with a number of other viruses for a considerable period of time. They’ve been trying to do this pre COVID-19, and today have got no successful trials as yet. That’s not to say that they can’t, and Gosh, I’m rooting for them. I really am. But I wouldn’t be backing that if my only course I think we have to think about other things and other ways to control this disease in the intervening period of time.

Gregg Masters  24:09  So I have to ask you, you did not mention hydroxychloroquine,  there’s been quite a bit of hype and hope, a mixed bag from some of the more credible studies that have been done in in the VA and elsewhere. But what’s your take on hydroxychloroquine is this an agent that has some promise? Or are the studies too tightly defined to actually in other words, what I’m saying is, some would say that if there’s early in the course, with a low relative viral load, then hydroxychloroquine supplemented by azithromycin shows some promising results. Can you give us any perspective on that?

Nick van Terheyden  24:50  Yeah, so to the best of my knowledge, there is no placebo based study so we have nothing to compare it against. And again, that creates an extraordinarily difficult data set to determine if there’s any efficacy. We know lots about hydroxychloroquine. And I’ve taken it in my past, I’ve lived in lots of malaria ridden countries, it was a standard, it’s not a particularly safe drug. That’s one of the problems. And part of the reason that I didn’t mention it is that mentioning, it seems to induce people to go after this, we’ve already seen certainly at least one death that seems to be associated with the promotion of this as a treatment. And, you know, something to take, as you described early, I think the clear medical advice here is, if this is an appropriate treatment, which it may be, and I don’t think we know, but we need to understand. And if it is, I can tell you, we will ramp up production and put people on it as early as possible, and you know, get that out as quickly as possible. But we need to do that, importantly, at this point safely, and that in a hospital, because it lengthens the QT interval, it has real potential to cause severe cardiac symptoms that need to be monitored on a healthcare setting. This is not something that people should be saying, I’m going to go out and buy and just protect myself, because I think I might have COVID-19, which is likely that you don’t unless you’ve got symptoms. So this is something that needs to be left to the medical professionals. And I think that’s very, very clear to me, I think if I had a wrap up is there is no, there’s no silver bullet, you are not going to find a single solution up until we have a vaccine. And this takes a concerted scientific based, thoughtful approach that is customized to individual circumstances.

Fred Goldstein  26:39  Yeah, and I would just add, at the end of the day, it’s up to us as individuals to do the right thing, or, you know, much of it is as much of this is based on our behavior. And so we have to go ahead and make sure that everybody understands what they should be doing in the appropriate situations based on where we’re at in this disease, and then do that.

Gregg Masters  27:03  The one thing I wanted to add, the disease profile has been made clear, we now understand that a patient asymptomatic transmission is a much higher risk than was initially thought. And unfortunately, that is what has driven the clinical versus public health model for testing at scale. The clinical model is let’s identify people who are symptomatic, so we can triage them appropriately in an acute setting. Whereas testing at scale from a public health perspective, is testing the entire population, not just those who present with symptoms. And I think the studies that have been reported today have evidence the fact that asymptomatic spread is a much bigger risk than was originally anticipated. In fact that drove all the messaging from CDC that the risk is low, the risk is low, we’re looking in the rearview mirror. We’re not testing anybody we’ve got less than 1% of people tested the United States but the risk is low.

Nick van Terheyden  28:02  Rule number six of Samuel Shem in the House of God, you won’t find the temperature if you don’t take it same with tha

Gregg Masters  28:09  That is the last word on today’s broadcast. I want to thank Dr. Nick van Terheyden and my colleague and co-host Fred Goldstein for their time and insights into the current state of the global pandemic including near term prospects for mitigation relief, effective treatment and ultimately prevention via proven vaccine. For more information go to www.pop HealthWeek.com to subscribe to our channel and follow our work on Twitter via at @pophealthweek @Dr.Nic1 @fsgoldstein and @2healthguru for  PopHealth Week, my colleagues Fred Goldstein, Dr. Nick and HealthcareNOW Radio. This is Gregg Masters saying stay safe you all, we’ll get better together if we toed the line with social distancing proper hygiene and by all means wear those masks when in public.