On the subject of COVID-19 the wide-ranging discussion of interest to all health care workers included “universal masking,” a national response as opposed to state-led responses…
Newswise this week featured the webinar “Summer of COVID: The 2nd Wave, BLM, the Economy, and Politics” with panelists Anne Bailey Ph.D, professor, Binghamton University; Eli Rosenberg Ph.D, associate professor in the Department of Epidemiology and Biostatistics, University at Albany; and Kevin Smith, MD, FACP, FAAP, chief medical officer, Loyola University Medical Center.
On the subject of COVID-19 the wide-ranging discussion of interest to all health care workers included “universal masking,” a national response as opposed to state-led responses, surges in states, ICU issues, the potential for seasonal disruptions and more.
The following is an edited transcript regarding the discussion on COVID-19. A link to the entire transcript can be found at the bottom of the page.
Moderator: I want to go and start first with Dr. Rosenburg. Dr. Rosenburg is an expert in epidemiology and we want to talk a little bit about this recent uptick in cases. Dr. Rosenburg, big news just in the last couple of days, the governors of New York, New Jersey and Connecticut have implemented a 14-day quarantine for visitors from out of state, specifically states that are currently surging in COVID cases — Texas, Florida and others. Is it your opinion that those states reopened too soon and how else can we explain these rising case numbers?
Dr. Rosenburg: Great question, so I’ll start just by saying that it’s really hard to make a blanket statement. The truth is our national epidemic — there’s really a collection of many epidemics at the state level or smaller, so it’s really hard to make a single statement that applies to all states that aggressively reopened — did so too quickly. That being said, at the same time many of the states — at the time that many of the states that are currently surging had reopened and many which were in the lead up to Memorial Day, the epidemiologic data were not in favor of them reopening to such a liberal and broad degree.
Reopening seemed to be more driven by political, economic and public pressures and frankly fatigue. I think part of that is — maybe in the way that we shut down, which is that many states shut down in a very short time frame, even though the epidemic was not surging in all of those places, so it increased the amount of fatigue that everyone has. I will say though at the time many epidemiologists, myself included thought that we would see a resurgence after such drastic reopening about a month later and here it is. So, I think yeah — speaks for itself.
Moderator: And do you think the move to issue a quarantine like this was warranted and would we likely see further interventions needed?
Dr. Rosenburg: That’s really hard to say, I work very closely with officials here in New York, I won’t comment or criticize frankly at this point. I think vigilance — and first of all these are all — some of these measures are compulsory but they’re very hard to enforce, so we’re really relying on a lot of cooperation, which is actually going to limit any such measure. I think these are sort of potential stop gap measures, what we really need is national coordination that for states to unilaterally act is a very difficult position to be in.
Moderator: Thank you, Dr. Rosenberg. I want to go next to Deb Wood from Nurse Zone. And she has a question for Dr. Smith. Go ahead, Deb.
Deb: During a Florida governor’s press conference this week, one of the Orlando doctors on the call said because we know so much more about how to care for COVID patients, fewer are needing ICU level care. They’re being treated on med surge units. Is this true nationally or in other communities? Or don’t you — or just tell me about Chicago?
Dr. Smith: Yeah. Deb, that’s a really great question. It’s a really great point. So, I agree with you is that we do know tremendously more about COVID and the pathophysiology of COVID now than we did when New York was hit, or even when Chicago was hit, and I think there is some truth in that. I think we do know that if you’re pruning patients and that’s where you basically put them face down in a hospital bed and you’re using oxygen — those patients it does seem like are recovering a little bit faster or not progressing quite in the same way. Additionally, medications like remdesivir, which has shown benefits, at least in some of the earlier studies, does look like that might help people who are not quite at that intubation level, but sort of before intubation when you’re on mechanical ventilation.
So, I think we are in a better place overall, when it comes to COVID. That being said, I don’t think that all of these interventions are the turnaround where we’re not going to see any ICU level patients. I mean, even looking at the data, not all patients respond to remdesivir, and I know anecdotally, not all patients respond to proning. Now, what percentage we might be able to see a decrease in ICU utilization because of these techniques — I don’t know — I think best guess for anybody — so I still worry about ICU surging and ICU capacity, but I’m sure there’s going to be some patients that aren’t going to need it because of these newer interventions that we have.
Moderator: Thanks for your question, Deb. Dr. Smith, during early phases of the pandemic, especially in the high density, urban areas on the coasts, and then moving toward Detroit and Chicago and other major metropolitan areas, hospitals were reported to be surging their capacity. I wonder if you could help us to understand what that surging term means. And are hospitals in more rural areas in smaller cities able to do that quite at the same level as hospitals in Manhattan, for example.
Dr. Smith: Yeah, that’s a good question. So, the surging basically just means that you’re seeing a large increase in the number of patients that are coming into the hospital that can either be through the emergency department as hospital transfers, admissions from clinic, etc. And so, it’s just seeing a large number. You know, this also happened at the time when we were shutting down elective surgeries and procedures and patients were scared to come into clinic. So, we were seeing decreases in those types of patients, but we were seeing increases in the number of patients who either had COVID or suspected to have COVID and we were waiting to see if the test would come back positive. And when you surge in that circumstance, you’re really filling beds. And also, importantly — as I talked about before is really pulling staff in a coverage model that maybe they’re not used to working in.
In urban areas, even though we have a higher density of patients, we are a little bit in a better place when it comes to surging. One is we tend to have more beds in general, because we expect that we need them for our larger population, and there also can be some coordination between the different hospitals in urban areas as well — I know in Chicago we had the benefit of having — actually, in some ways depending on if you look at it, maybe more beds than we actually need for our population. So, there is a way to move patients around in urban areas a little bit more. If you’re talking about rural areas, especially critical access hospitals, you are potentially talking about a small number of beds both on the floor as well as the ICU, as well as maybe a hospital that you’re going to transfer to, that could be hours away from that hospital. And I think the other piece of a rural hospital is they tend to have less number of staff as well.
So if you are talking about somebody who may have caught COVID, either in the community or from a health care interaction, and they go down or need to be a quarantined, that could be a potential significant amount of your staff that then goes down and is not able to take care of those patients.
And so, you know, I feel for some of these rural areas that are really seeing a surge because they just don’t have the same level of resources that many of urban areas have.
Moderator: Thank you, Dr. Smith. Dr. Rosenberg, I’m hoping you can help us to understand a little bit about how the pandemic is kind of moving throughout the country, and while we may see a number of new cases dropping in New York, it’s rising in Florida, in Texas and other states. In your opinion, is this, what we would call that second wave that’s been discussed? Or is this really part of the first wave as it spreads throughout the country and that first wave just hasn’t dropped as low nationally as we’d like it to?
Dr. Rosenberg: Yeah. That’s a great question. So I think, again, as I sort of alluded to earlier, I think it’s really important that to wrap around, that there really isn’t a national epidemic that this is playing out locally across the U.S. and it’s hard to give single labels like first wave or second wave to the nation at large.
I think to have a second wave means you’ve successfully fought a first wave. I think that’s the really important piece to — that’s my starting definition. And I think in some places like Seattle, like here in New York State, we are to a large extent on the other side of the mountain as it were — not fully there, I would say, but we’re really — we’ve made it very far on the other side of that mountain, and that was due to massive public health efforts. And so now if we saw a resurgence after being all the way on that other side of the mountain, you might say — Yeah, we’ll call that a second wave. And it probably happened some time from now. It would have to happen sometime from now.
I think in many of the places that we’re talking about in the past few weeks to pick on Florida since that’s come up already. Texas, Arizona — those places that we’re seeing these massive increases did not have that big decline that we’ve seen in Seattle or New York. They were still on the way up or leveled out, but there was sort of not — there was not that first conquering of a mountain. And I think it’s really, this is really better characterized as really a period of acceleration and that first wave from not really having fully controlled the initial outbreak.
Moderator: Thank you, Dr. Rosenberg. Also, on kind of that idea about the acceleration, one of the things that it seems like a lot of people were counting on was for this disease to have a seasonal fluctuation, lower risk of transmission in the summer months, which comparing to the flu, standard influenza, right? What was wrong with this assumption?
Dr. Rosenberg: Yeah, I don’t know if it’s necessarily a wrong assumption still, I think it just may not be a full assumption. So, what I mean by that is — a number of studies have shown looking at weather patterns, that transmission does seem to track with temperature, precipitation, humidity and the ways that you might expect from experience with seasonal influenza. However, it’s not a full effect that it does — it may be — the weather may have some impact, but it’s not enough to outright halter — greatly diminish transmission during the warmer months, right? We’re seeing its summer and we have large scale transmission in Houston. Right. That’s counterintuitive.
So, we’re still seeing transmission despite some modest weather and seasonal effects. And it may be suggests that what we’re seeing across the nation now may yet have been worse if this was the middle of the winter. We’re seeing obviously a very troubling pattern and it could have been worse then — so it’s, I would say that the assumption wasn’t wrong, but it was insufficient. There wasn’t enough to remove the transmission that we’re seeing now.
Moderator: Thank you, Dr. Rosenberg. Back to Dr. Smith for one more question…on the subject of those ICU beds and in these kinds of more rural areas, smaller hospitals, less staff, fewer beds to increase their capacity — what happens with those patients — a COVID patient in a waiting room, or in an exam room or somewhere that’s not as fully functional to protect staff and other patients from contact with them. Are those patients while they’re waiting for a bed or a transfer to another hospital — are they likely to come into contact with others and potentially spread the virus in those conditions?
Dr. Smith: I think you know, theoretically, yes. I mean, prolonged contact, it appears with somebody who has COVID — it definitely can increase your risk of transmission. And so theoretically, being stuck in a waiting room could do that. However, hospitals have tried to do different interventions to try to reduce the risk of transmission — I can’t say eliminate, but definitely have tried to reduce it. I mean, we’ve gone to really universal masking for anybody in a health care setting. We try to — also when people come into the hospital, we’re screening them right away, performing temperature checks — and that’s at least one way that we can say, okay, well, could this person have COVID based on reported history as well as whether they have a fever, and then you do your best to try to separate those people from people who don’t screen positive for that. And so those are sort of the techniques that different hospitals have used.
I think you mentioned about the rural hospitals and if you are trying to transfer to another hospital, inherently there’s always delays in the transfers, no matter how good of a health system you are, when it comes to coordinating a transfer, a patient from one bed to another bed — it’s just natural delays, whether that’s waiting for the transport — the ambulance transport or helicopter transport or whatever it is that you’re going to use, and so I can imagine is, when other hospitals have a very full ICU and you’re waiting for a bed to open up, those delays could get longer and therefore could put that patient at risk of deterioration even if they do have COVID.
Moderator: It seems like the more pressure the hospital is under the more vigilant they have to be about adherence to those practices, right?
Dr. Smith: Absolutely. Absolutely. I mean, that’s why things like PPE were such a big deal and why there was such worry in places like New York when we were seeing there are shortages in PPE, is that’s the way you protect your staff and that’s the way you protect your other patients — so making sure either the patients are using PPE, when it comes to a mask or making sure your colleagues have PPE, that’s one of the ways to really prevent transmission.
Moderator: Dr. Rosenberg — why is it so important for a coherent national strategy versus leaving so many of these decisions and logistics up to the states?
Dr. Rosenberg: No that’s critical. I can’t overstate the importance of national coordination at times like this. Although the federal government is not officially charged with running public health response to COVID-19, public health is traditionally a state role and has a large potential to play in providing critical advice, scientific data and logistical support and really conveying a coherent coordinate national plan, so that the coordination is really the piece. The federal government doesn’t have to command, but it can coordinate.
I think the department of health and human services and some of its agencies like NIH and CDC have done this well in prior outbreaks and national health crisis and they can do it again. I think the challenge here is that we’re right now — with the current level of federal leadership, the U.S. will continue to be a checkerboard of state responses and that’s not good. We’re going to have different epidemics, and as people travel state to state — one states victory in getting over that mountain can be compromised by another states lack of progress and we’ll going in cycles. So that’s really on the epidemic side tragedy. I think on the other sides of this — a federal coordination and stock piling in distribution and negotiating — which has become very important — negotiation prices for vital resources like personal protective equipment — PPE and testing supplies, can really hamper and frankly make impossible local efforts. So, if you have different states outbidding each other on ventilators costs, no state can afford something — it just doesn’t make sense — so the federal government — that’s why we have a federal government, to step in and help resolve those issues, it’s really important and just critical.
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