March 23, 2020 • 48 mins
This marks the second installment in our Anatomy of a Pandemic series, in which we discuss the various aspects of the COVID-19 pandemic. In this second chapter, we explore what we currently know about the disease itself, from symptom progression to incubation period and the role that asymptomatic individuals play in the transmission of disease. Our firsthand account, told from the perspective of a respiratory therapist, illustrates the severity of this disease and the frightening, yet very real, prospect of running out of medical equipment, protective gear, and hospital beds. We then discuss what we currently know about COVID-19 from a clinical disease perspective. We are joined by Dr. Colleen Kraft (interview recorded March 19, 2020), whose voice you may recognize from our first episode on coronaviruses. She helps to break down some of the disease-related questions sent in by our listeners. We wrap up the episode by discussing the top five things we learned from our expert. To help you get a better idea of the topics covered in this episode, we have listed the questions below:
- What does "respiratory droplet" transmission mean, and how is this different from something with "airborne" transmission? (15:08)
- What are the symptoms of COVID-19? (16:48)
- How long is the disease course, and how does this vary between mild vs severe symptoms? (18:45)
- What does "supportive care" mean in the context of caring for people who fall severely ill from COVID-19? (19:40)
- How much does viral load correlate with the severity of symptoms? (20:47)
- What is the incubation period of this disease, how long do people remain infectious, and are asymptomatic people contributing to the spread of disease? (22:22)
- What are the groups that are particularly at risk for severe disease? (24:00)
- Why do children seem to be more resistant to this infection? What about children who are immunocompromised, are they at risk? (27:40)
- What is the case fatality rate, and how might we expect it to change throughout the course of this pandemic? (29:09)
- Are there long term complications associated with COVID-19? (31:58)
- Is it possible to get re-infected if you get this virus and then recover? (32:54)
The full article our firsthand account came from can be found here: https://www.propublica.org/article/a-medical-worker-describes--terrifying-lung-failure-from-covid19-even-in-his-young-patients
See omnystudio.com/listener for privacy information.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:02):
Reading about it in the news, I knew it was
going to be bad, but we deal with the flu
every year, so I was thinking, well, it's probably not
that much worse than the flu. But seeing patients with
COVID nineteen completely change my perspective and it's a lot
more frightening. I have patients in their early forties, and yeah,
I was kind of shocked. I'm seeing people who look
relatively healthy with a minimal health history, and they're completely
(00:24):
wiped out, like they've been hit by a truck. This
is knocking out what should be perfectly fit, healthy people.
Patients will be on minimal support, on a little bit
of oxygen, and then all of a sudden, they go
into complete respiratory arrest, shut down and can't breathe at all.
It's called acute respiratory distress syndrome ARDS. That means that
(00:45):
the lungs are filled with fluid. Patients with ARDS are
extremely difficult to oxygen eight. It has a really high
mortality rate, about forty percent. The way to manage it
is to put a patient on a ventilator. The additional
pressure helps the oxygen go into the bloodstream Normally. ARDS
is something that happens over time as the lungs get
(01:06):
more and more inflamed. But with this virus, it seems
like it happens overnight. Typically with ards, the lungs become inflamed.
It's like inflammation anywhere. If you have a burn on
your arm, the skin around it turns red from additional
blood flow. The body is sending it additional nutrients to heal.
The problem is when that happens in your lungs, fluid
(01:27):
and extra blood starts going to the lungs. It first
struck me how different it was when I saw my
first coronavirus patient go bad. I was like, holy crap,
this is not the flu. Watching this relatively young guy
gasping for air, pink, frothy secretions coming out of his
tube and out of his mouth. The ventilator should have
(01:47):
been doing the work of breathing, but he was still
gasping for air, moving his mouth, moving his body, struggling.
When you're in that mindset of struggling to breathe and
delirious with fever, you don't know when someone is trying
to help you, so you'll try to rip the breathing
tube out because you feel like it's choking you, but
you're drowning when someone has an infection, I'm used to
(02:08):
seeing the normal colors you associate with it, greens and yellows.
The coronavirus. Patients with aards have been having a lot
of secretions that are actually pink because they're filled with
blood cells that are leaking into their airways. They're essentially
drowning in their own blood and fluids because their lungs
are so full, so we're constantly having to suction out
the secretions every time we go into their rooms. I
(02:30):
worked a long stretch of days last week, and I
watched it go from this novelty to a serious issue.
We had one or two patients at our hospital, and
then five to ten patients, and then twenty patients every day.
The intensity kept ratcheting up, more patients, and the patients
themselves are starting to get sicker and sicker. When it
first started, we all had tons of equipment, tons of supplies,
(02:52):
and as we started getting more patients, we started to
run out. They had to ration supplies. At first, we
were trying to use one mask per patient. Then it
was just you get one mask for positive patients, another
mask for everyone else, and now it's just you get
one mask. Even if you survive AARDS. Although some damage
(03:12):
can heal, it can also do long lasting damage to
the lungs. They can get filled up with scar tissue.
AARDS can lead to cognitive decline. Some people's muscles waste
away and it takes them a long time to recover
once they come off the ventilator. There is a very
real possibility that we might run out of ICU beds,
and at that point, I don't know what happens if
patients get sick and need to be intubated and put
(03:34):
on a ventilator. Is that person going to die because
we don't have the equipment to keep them alive?
Speaker 2 (04:23):
Oh my gosh.
Speaker 1 (04:25):
Yeah. That was an account from a respiratory therapist at
a hospital in Louisiana who remained anonymous. For that account,
I found it on Pro Publica. It was published on
March twenty first, And we'll put a link to the
full description in our show notes and on our website,
because that was just a small excerpt from the description.
Speaker 2 (04:48):
It's you know, it's very eerie to read and to hear,
because what it does is it reminds me of a
lot of the first hand accounts from the nineteen eighteen
Luenzo which I know has been brought up. The comparisons
have been brought up constantly, and some are inappropriate comparisons.
But just that description of healthy individuals being struck down,
(05:12):
all people of all ages being struck down, and the
horrible thought of not being able to breathe, Yeah, and
drowning in your own fluids.
Speaker 1 (05:23):
Yeah, it's really scary.
Speaker 2 (05:26):
I mean, it is scary. And we should introduce ourselves
before getting too much into this.
Speaker 3 (05:33):
Yeah, we should.
Speaker 2 (05:34):
Hi, I'm erin Welsh and I'm erin Oman Updyke and
this is this podcast will kill you.
Speaker 1 (05:40):
Welcome back everyone, or maybe welcome for the first time
if you jump part way into series. If you're one
of those people. This is our not so many minisod series,
Anatomy of a Pandemic, where we're answering all of your
listeners submitted questions about COVID nineteen, the disease caused by
SARS COVID two. In our first chapter, we covered the
(06:02):
virus itself, so all of the biology of SARS CoV two.
In this episode, chapter two, we're going to talk about
the disease that this virus causes, what it looks like,
how it's spread, and how physicians and healthcare workers are
dealing with this outbreak.
Speaker 2 (06:19):
But first, as always, it's quarantiny time.
Speaker 1 (06:23):
It's quarantine ay time.
Speaker 2 (06:24):
In this episode, we are drinking the creatively named quarantine
y two, Quarantining number two. Aaron, what is in Quarantining
number two?
Speaker 1 (06:36):
You know, Aaron, It's kind of a whiskey ginge.
Speaker 2 (06:39):
Yeah, I mean I would, I would call it a
Kentucky mule perhaps if you happen to have a copper mug.
I did not, so the picture is disappointingly non copper.
Speaker 1 (06:51):
It's all right, you did your best, thank you.
Speaker 4 (06:55):
Yeah.
Speaker 2 (06:55):
So it's basically ginger ale whisky of whatever kind of
whiskey you want, and some lime.
Speaker 1 (07:00):
And we'll post the full recipe for that quarantine as
well as our non alcoholic plusy Breta on our website
and all of our social media channels as always as always.
Speaker 2 (07:11):
Okay, So, as we mentioned, we've talked about the virus itself,
so now let's talk about the disease that this virus
is causing, COVID nineteen. And I do think that's a
particularly important distinction because, as we'll hear more about this
virus can infect you without necessarily causing severe disease, and
that's super important in understanding the spread of the virus,
(07:33):
because people who appear asymptomatic and otherwise healthy or just
have very mild cases could still be infected with and
therefore sneezing or coughing out the virus and spreading it
to other people. So we talked to doctor Colleenkraft, who
many of you may recognize from our first coronavirus episode,
and she's going to walk us through a lot of
(07:54):
your questions about the clinical disease that this virus causes.
Let's go over some of the basics first, so shall we?
Speaker 1 (08:01):
Let's we shall? So one big question is what is
the timeline of this illness? And what you're going to
see is that we still don't have the answers to
every question when it comes to this disease, and the
timeline is kind of one of those that we don't
fully know, but we do have a better handle on
(08:23):
it than we did in our episode that we released
back in February. So, first of all, it seems like
the incubation period is on average about five days an
incubation period is the time from when you're first exposed
to that disease to when you first start showing symptoms
of that disease. Okay, so on average this is about
(08:47):
five days. It can range most studies, it seems like
the max range is about eleven. So when you hear
about being quarantined for fourteen days, that's because we think
and we're pretty sure that after fourteen days, if you
haven't started to show symptoms, you're probably not going to
show symptoms. So that's kind of the max range to
(09:08):
make sure that you don't spread this disease unknowingly to
someone else if you're exposed. And this number like around
fourteen days, that's consistent with what we saw with SARS one,
SARS classic.
Speaker 4 (09:20):
Okay.
Speaker 1 (09:22):
Now, the other thing is that from a retrospective study
of people that had COVID, the severe disease. This study
looked at people who were hospitalized for COVID, so pretty
severely ill. The median time from when symptoms first started
to discharge from the hospital was twenty two days. So
(09:44):
that's a long time for somebody to be in the hospital.
And I think that that's an important indication that for
people who get seriously sick, they can be sick for
quite a long time. The other thing that this study
looked at was viral shedding, so at least some measure
of how long somebody might potentially be infectious, and they
found that the median number of days that people were
(10:06):
shedding virus was twenty days from the onset of symptoms,
which is again a pretty long time if somebody is symptomatic,
that is a long time yep, and longer than fourteen days.
Speaker 2 (10:21):
Yeah, that's I think. But I think the other thing
that you mentioned that it's sort of this is just
looking at people who had severe disease curR exactly, Yes, okay,
So I wonder I think. I mean, of course, as
this pandemic progresses, we're going to get more information about
those people who have milder cases or are asymptomatic and
how much virus they're shedding at various points throughout their
(10:43):
course of infection.
Speaker 1 (10:44):
Exactly, Yeah, exactly. Okay, So then the question is what
are some of these symptoms?
Speaker 2 (10:51):
Okay, So the biggest symptoms are the ones that most
people have probably heard about in the news quite a lot,
so fever, which, by the way, the death definition of
a fever is a temperature of over one hundred point
four degrees fahrenheit or thirty eight degrees celsius. Then there's
also cough, generally a dry cough, not a super wet
(11:11):
or a super productive cough, and then shortness of breath.
So these are the general symptoms of the disease that
we call COVID nineteen.
Speaker 4 (11:19):
But we know.
Speaker 2 (11:20):
Now that SARS covy two, the virus like SARS one
and MERS, can infect your lung tissue and cause a
lower respiratory disease, not only an upper respiratory infection the
way most of the common coronaviruses do. Okay, So what
does that mean, Well, it means the possibility of very
severe disease like we heard about in the first hand account,
(11:42):
and in the case of this virus, it seems that
about twenty percent of cases are severe. And that doesn't
mean that twenty percent of cases need ICEE you and
ventilator care, but it does mean that potentially up to
twenty percent of cases may need at least hospitalization and
some oxygen support or some IV fluid support. An analysis
(12:03):
from China suggest that there at least about fourteen percent
of cases were severe and five percent were critical, And
that means the same kind of picture that we talked
about in our coronavirus episode when we talked about SARS,
and the same description you heard in the first hand
account so ards, ground glass opacities on X rays, potentially
(12:25):
needing intubation. It's serious. It's a serious, serious disease, and
people can also go into shock, which we've talked about
a lot on the podcast. But essentially what that means
is that your organs aren't getting enough blood flow in
this case because of overwhelming infection, which leads to leakage
of fluids and then hypoperfusion, and then of course there
(12:46):
is also always the risk of a secondary infection on
top of this viral infection.
Speaker 1 (12:51):
It can be pretty gnarly. But also in this case,
what we see that is different from SARS and mers
and what in our first episode about coronaviruses was still
kind of a gray zone. That's a lot more clear
now is that asymptomatic or very mildly symptomatic infection is
not only possible, but it's likely actually responsible for quite
(13:15):
a lot of the spread of this disease. It's estimated
that about eighty percent of cases are mild, which, while
that's great news for the majority of people who get infected,
it means you're not necessarily going to be looking at
such a severe disease. It also means that this disease
is easier to spread since not everyone who's sick maybe
(13:35):
even realizes that they're sick. And how does this disease spread.
Speaker 2 (13:39):
Erin well, respiratory droplets as we well know, but we're
not going to go into that. We're going to allow
our expert, doctor Collingcraft from Emory University to explain how
respiratory droplets work, as well as other characteristics of this disease,
(14:00):
how wo'ds spread, how we're testing for it, who we're
testing for it, and finally, how we treat it.
Speaker 1 (14:05):
Right after this break, my.
Speaker 4 (14:35):
Name is Colleen Kraft and I'm the Associate chief Medical
Officer at Emory University Hospital. My training is in infectious
diseases and clinical microbiology.
Speaker 2 (14:45):
Thank you again, so so much for joining us. We
know that you have just been swamped with work and
so we really appreciate you taking the time to kind
of talk about COVID nineteen. I mean since our first
interview with you, which has been you know, about a
month and a half ago. A lot has happened.
Speaker 4 (15:03):
Yes, like a lifetime has happened. That's how I feel.
Speaker 1 (15:06):
Yeah, yeah, so we'll jump right in. We are talking today,
of course, about SARS COVID two, the virus that causes
COVID nineteen. So we know that it's transmitted through respiratory
droplets or direct contact with somebody's respiratory droplets, like other coronaviruses.
Can you tell us a little bit about what that
(15:26):
means in contrast to viruses that are airborne and when
people talk about respiratory droplets, like what exactly does that include?
Speaker 4 (15:36):
Sure? So I think it's it was really funny to hear.
I've been to a number of town halls around Emory
and I had one of my audience members best described
it as, you know, it's your saliva, So it's sort
of I view respiratory droplets as being sort of the
wet aspects of our coughs and sneeze, and that's that.
(15:58):
I thought that was very well described that way by
this employee. And I didn't answer your your airborne question.
So what happens is when we cough or sneeze, it's those,
it's like a wet, heavy droplet, and that kind of
goes to the ground right sooner because it's heavy. But
when they are really small, then they can aerosolize and
(16:19):
they can actually sort of hang around in the air
for longer. And so that's why every time there's a
new respiratory virus we sort of pretend like it's airborne,
just to make sure it's not airborne, because that is
sort of a different transmission route that that can hang
in the air longer and it can go farther. But
you know, from what everything we know, this coronavirus still
(16:41):
behaves like our droplet spread coronaviruses, gotcha.
Speaker 2 (16:48):
So at this point we have a better idea of
what a typical course of COVID nineteen looks like. Can
you walk us through what that is like? You know,
day one, day two, what do you typically see?
Speaker 4 (17:01):
Yeah, so we're seeing the same things as being seen
and observed in other parts of the world. And so
we have the vast majority of these individuals have a cold.
It may be an unpleasant cold more than for others,
but most people have a very mild illness, probably most
similar to our common cold. In general. We are seeing
(17:22):
people though, that come in with basically a viral pneumonia
type picture. Viral pneumonia should really make the hairs on
the back of your neck stand up, because that's probably
what happened in the nineteen eighteen Spanish flu. And this
is again along with the airborne aspect, this is what
we're always looking for in these new viruses. Does it
have a propensity to cause lower respiratory tract infection? If
(17:46):
it does, that makes us scared because we can't. While
we can do a lot with bacterial pneumonia, a viral
pneumonia is very scary because usually don't we can't treat
most of the viruses that we get, and so we
definitely don't it down and the lung where it can
cause scarring and difficulty breathing. And so for a subset
of people that for the most part tend to be
(18:07):
ill ill at baseline, we have a group of people
that also are getting symptomatic lower respiratory tracts syndrome who
are not quite as ill as the typical person we're
hearing about that is succumbing to this disease. So we've
had a number of individuals that yes, they have other
medical problems, but they don't necessarily have respiratory medical problems,
(18:29):
and they are having you know, sort of a viral
pneumonia picture, and we have had a few that have
been needed to have mechanical ventilation or a breathing tube.
Speaker 2 (18:40):
Gotcha about how long does is the course of disease?
You know, I know that for some people who have
milder cases it may be shorter than for others. But
what do we see on average or what does it
look like for the people with more mild symptoms compared
to the people with more severe outcomes.
Speaker 4 (18:59):
I would say it's it's that typical three day kind
of feeling bad, achy, and then the next day is
maybe a little bit better, not great, and then the
next day you're sort of back to feeling like you're
among the living. And then you know, then we also
recommend for at least for our employees to sort of,
you know, kind of self isolate for a few more days,
(19:20):
just to make sure you're not sort of still having
those secretions coffin sneeze because we don't want to keep
spreading it. And so that's sort of a mild course.
The more severe courses tend to be you know, I
think the damage is done within the first week, and
then what we're doing is trying to support the body
so the body can mend after that.
Speaker 2 (19:41):
What does that supportive care look like, both in terms
of that during that first week of intense symptoms and
then the sort of you know, the healing stage.
Speaker 4 (19:52):
Right, So it sounds like it's your grandmother patting your hand,
is what supportive care sounds like, I think to most people.
But in the case of some individuals that have severe disease,
it may mean that they have a breathing tube, they're
in an ICU, they have many other things that are
helping support their body until the body can kind of
get rid of the virus itself. So this is sort
(20:13):
of how we describe things back in the bola days,
where you know, most of the time what we're doing
is just supporting, like with life support, basically to try
to keep things going until the body can create and
clear that virus. That's what happened during a bola with coronavirus.
It's sort of similar. So supportive care when you're at
home maybe niquil and television, which sounds really great to
(20:37):
me right now, and when you're in the hospital. Though.
What that is is if we need to help one
of your body systems function, we will do that.
Speaker 1 (20:47):
Okay, do we know at this point how much things
like viral load might correlate with the severity of symptoms?
Are the people that have milder cases, are they as
infectious to others? Are they shedding as much viral particles
as these more severe cases?
Speaker 4 (21:03):
Right? So, I think this is a great question. And
I think as this is where you're going to see,
my laboratory in side come out quite a bit. So
it's really easy when we talk about viral load in
the blood or plasma or serum to sort of understand
how to standardize that by copies per mili liter or
something like that. When we're doing a respiratory swab. I
(21:26):
think it's really hard to standardize. And because this test
is so new, we don't have the test standardize in
and of itself, So the testing results at our institution
may be a little bit variable compared to another institution,
and that's because we don't have a gold standard yet
to compare on all of the machines. So I agree
with you. However, we have seen very anecdotally that we've
(21:48):
had people with very high viral loads that basically didn't
even look like they were sick, and we question whether
or not we should even swab them. And I had
extremely high amounts in their nose, whereas we've also had
people that have had moderate amounts that are sick and
on a ventilator. And so, while I think there's an
(22:08):
aspect that correlates, I think the way that we obtained
the swab is going to make this difficult unless there's
some sort of serum or plasma or surrogate tests we
can use that can be very standardized with its input.
Speaker 2 (22:23):
And so going revisiting this aspect of perhaps asymptomatic individuals
or people with very very mild cases of this, can
you talk about sort of the incubation period when people
might start becoming infectious, how long they remain infectious, and
then sort of how much do you think asymptomatic individuals
(22:44):
might be contributing to the spread of disease.
Speaker 4 (22:48):
So I think they probably are contributing to the spread
of disease. I think that's why some of these more
dramatic things that we're seeing are the social distancing and
being really aware of your even more so just your
own hand hygiene, just your own persona as it relates
to anybody else. And so I think that we are
taking measures to have that not happen. Right school's closing.
(23:11):
Let's talk about where there could be a lot of
asymptomatic spread of disease. That would be a school. So
you got a bunch of kids shedding virus everywhere in
close proximity, with limited hand and face and everything hygiene,
And you can tell I have children, and that's just like,
that's just a setup for transmission. So I do think
(23:33):
that while asymptomatic people are shedding, we're really taking dramatic
efforts on like I've ever seen in my short lifetime.
I suppose really to even work on stopping that. I mean,
hospitals aren't allowing very many visitors, you know, public places
of all but canceled everything. So we're actually really trying
to break that cycle, which I think has to me
(23:56):
never been really done to this extreme. Yeah.
Speaker 1 (24:00):
Yeah, And you mentioned as well that it seems at
this point pretty well established that it's older people and
people with other underlying health conditions or people that are
otherwise immunal compromise that are more likely to experience this
severe disease. But we've gotten a lot of people asking
us for a bit more clarity about these groups, like
(24:21):
what age is it that people are considered elderly or
at risk? And is it any sort of immune compromise
that makes you more vulnerable? Or what are these pre
existing health conditions that we're most concerned with in terms
of the higher risk categories for this disease.
Speaker 4 (24:38):
Right, So, I think the way to do that, and
the way I've been gut checking a number of these
questions that we really just don't know yet because we
don't know everything about this virus, is to think about
influenza and sort of start there. Right, So, in older adults,
influenza tends to be more severe because it's sort of
tipping off chronic conditions that get worse. So if you
(25:01):
have bad heart disease and you get a respiratory virus infection,
sometimes people even have heart attacks from viruses, which is
very rare, but we think probably happens more than we understand,
but it may basically, you know, they may be in
sort of a tenuous balance, like everything's kind of holding together,
but it's it's it doesn't take much to push over
(25:22):
into feeling a lot worse. And so I just think
about the people that are at risk for our typical
seasonal influencer are going to be the same people they
are at risk, So anybody that has lung problems, anybody
who's immune system can't fight it off. I think it's
hard to say to actual groups, and you know, we're
seeing that many older people are being spared and and
(25:43):
some younger people that are younger than we thought are
getting it. So it's really I think we're you know,
we're trying to define the syndrome, as we're trying to
diagnose cases, as we're trying to bring up testing, and
so I think, you know, we will by the end
of this outbreak have more resolution on what that looks like.
But I think right now, you know, and it's probably
at this point near seasonal influenza, gotcha.
Speaker 2 (26:05):
There were two groups specifically that we got a lot
of emails about and questions about, and one of those
groups was people with diabetes type one, and they were wondering,
you know, people, I keep seeing that people with diabetes
are more at risk, does that include me? And then
the other group that we got a lot of questions
from were people who were pregnant or people with newborns.
Speaker 4 (26:25):
Right, So the pregnancy thing, I think is always a
we always are concerned about it very highly. I don't
think that there's been any data that actually shows there's
poorer outcomes. I know that doctor Denise Jamison from Emory
has published a little bit about this, at least what's
known from stars and mers, And while early trimester is
(26:47):
always concerning for anything, there's no evidence that anybody again
has had any pregnancy complications from this. However, in general
we don't like to test that theory, and so we
tend to be protective around pregnant women for sure. In
terms of those with diabetes, I think it's it's again
(27:11):
not quite known what the aspects of diabetes, except that
there's some level of sluggish immune and response. I wouldn't
say immune compromise entirely. I think it depends on how
well your blood sugars are controlled, how many complications you
already have from diabetes. Do you have type one diabetes,
(27:31):
which can tend to be much more severe than type
two diabetes. I think some of those questions, you know,
may be elucidated as things progress.
Speaker 2 (27:39):
Gotcha, so you know on these in this discussion of
high risk groups and low risk groups or varying risk
in general. One of the things that we've seen is
that children seem to experience a milder disease than some
of the other age groups. Do we know why that is?
Our immuno compromised kids just asvulnerable as immunocompromise people of
(28:02):
other ages.
Speaker 4 (28:03):
I should have read my pediatric textbook a little bit more,
But there are definitely a number of viruses that are
much worse than adults than kids. And then we sort
of have vice versa where kids tend to have maybe
an increased predilection, or maybe it's just because by the
time you're an adult that you're immune to it, and
when you're a kid you're sort of seeing it for
the first time. So there is always this dichotomy of
is it worse in kids are better in kids? This
(28:27):
scenario really seems to be that the kids are these
asymptomatic probably shedds, right, But we already discussed a little
bit earlier, and so this virus just for whatever reason,
is not that severe in children. But again, it may
be that most coronaviruses aren't. We just haven't studied them
because we kind of haven't cared because they haven't done
that severe in adults, and in terms of immunocompromised kids,
(28:50):
I suppose that they are more at risk, but I
suppose that they may also become increased vectors. They may
just shed longer. But again, I'm not a pediatrician, so
I hesitate to sort of fully answer that one with confidence.
Speaker 3 (29:07):
Yeah, that makes sense.
Speaker 1 (29:09):
So can you explain a little bit about how we
are getting the numbers for things like the case fatality
rate right now? Is that something that is still a
moving target? Do you think that we might be able
to see that number decrease as more asymptomatic or mild
cases are identified, since at this point it seems like
testing is mostly focused on the severe cases exactly.
Speaker 4 (29:33):
Yeah, so I think this is you know where again
my laboratory and background and the logic of this is
really interesting in a is it interesting as anything can
get right now? So what really I think is interesting
is we really do have a decrease in throughput ability
right now with our diagnostic testing. That's because we're building
(29:56):
the car as we drive it, right So, there's been
all this contrived controversy about test kit shortage. Well, we
just discovered this virus and we just made a test
for it, and when we make tests that are new,
we have to go back to old school methods, which
are a bit slow, and so I think I don't
know what expectation we had that we had to have
(30:17):
like a rapid test the next day. I think it
was a little bit. I don't know who's stettying that standard,
but the standard is unattainable, and so I think that
by virtue of the fact that we're going to start
testing more and more people over the next month, we
are going to see that that denominator is going to
stretch out. So we're going to have people that are asymptomatic,
barely symptomatic that are going to be positive, and that
(30:40):
will make that case fatality rate drop. I think it
can look higher. Again, it's exactly what you said. It's
selection bias. So when you're only testing the sickest of
the sick, then you're only going to find a high
case fatality rate. I personally am the current gatekeeper to
who gets on our daily test in house that we've developed,
(31:02):
and we only have room as of today. This probably
is actually going to change tomorrow. So you know, I
have to gatekeep and prioritize who gets on our in
house run which takes twenty four hours versus send out
to a referral lab, which may take seven days. Well,
who do I prioritize? I mean, who would you guys prioritize?
So we're going to do impatients because we're also using
(31:24):
a lot of personal protective equipment to care for these individuals,
and so we want to be able to take them
out of that if they don't need it, and then
we can keep our supplied. You know, we need less
supplies if we do it that way. And then we're
also tests prioritizing our workforce, right, so we want to
make sure that the physical therapists and the respiratory therapists
(31:45):
and the you know, tech and everybody can come back
to work because we want to make sure we can
keep taking care of these sick patients when they come in.
Mm hm hm.
Speaker 1 (31:56):
That makes sense.
Speaker 2 (31:58):
So I know that it's early stages yet again in
this pandemic, but do what do we know so far
about longer term health consequences for people who have gotten sick,
maybe have gotten mild or severe in particular, disease, and
are there long term health consequences they have, like lung
damage or other issues.
Speaker 4 (32:19):
So the logic that I use is that anything that
damages the lung can cause long term consequences. So the
lung only knows how to do one thing when it's damaged,
and that's to scar down. And so that's why our
bodies have this lovely cough reflex so that all that
stuff doesn't go into our lungs and cost scarring and damage.
(32:40):
So when we have a virus that's infecting our lung cells,
then that's going to cause this scarring to happen, and
we potentially could see long term damage. But that's the
same as sort of anything that comes and damages the lung.
Speaker 1 (32:53):
Okay, So another question that a lot of people had,
and I know we probably don't fully know the end
answer to this, but maybe we can sort of estimate
based on what we know so far about coronaviruses in
general or from you know, the previous outbreaks. Is do
we know about whether it seems possible to become reinfected
(33:13):
with this virus if you get it and then recover
from that infection.
Speaker 4 (33:18):
Yeah, So I was just on another alumni call today
and have this very same question. We probably get this
question every day, and so in general we probably don't
know for sure. I think because this is a novel
coronavirus introduced to the population, we will likely understand more
because there's more attention to it. My understanding is that
(33:39):
when we have viral infections, we do become immune to them,
but remember that it depends on how systemically ill we
are as well. So you know, it's a complicated immunology
at this at our nasal source. Right. We talked already
about how trying to say the viral load from the
nose is not a very consistently sampled area, and so
(34:01):
I think in the same way that immunology may be
difficult to totally separate out because there may be an
aspect of our mucosal immunology that plays a large role
in whether or not that virus comes back to us. Right,
So we may have just symptomatically gotten through it, but
did we actually form true defense against it? And again,
(34:22):
I think, you know I would. I don't pretend to
know that much about immunology except the big picture stuff.
So I hope that was helpful.
Speaker 2 (34:32):
Yeah, absolutely so. In our first episode on coronaviruses, we
ended it by asking you, what about this disease concerns
you and what about it you know, makes you say
hold off on the panic or maybe as reason for optimism.
Has your answer changed at all since that time?
Speaker 4 (34:51):
My answer has changed, Dear Errands. I think that we
do see that it causes laura respiratory tract infection, much
like other viruses that we know, such as influenza, and
so I am happy to say that it's not as
severe as stars or mers, but it's not insignificant, and
(35:14):
we are seeing a lot of individuals you know, in
the hospital that have this. I think my optimism is
that I'm trying to be optimistic every day. The supply
chain issues and the personal finance issues and the childcare issues,
to me, are making this very personally difficult for a
(35:35):
lot of people. It's one thing to sort of have
a bad blue season and us to have sort of
sicker patients or more patients, but the personal protective equipment
and you know, no visitors to the hospital, all those
things really are stressing people personally. And so I'm just
trying to be optimistic that a lot of this social
(35:56):
isolation that we have implemented will act actually make a difference,
because you know, we're sort of, at least in Georgia,
we're sort of coming into the surge part of it
for our location, and I think everybody's going to go
through that and you know, have to just come out
on the other side. But there's a lot of things
that you know, when I was bubbly three weeks ago
(36:18):
or whenever that was, I could not have imagined the
stress of like not having swabs to test, or you know,
I could have understood and foreseen not having enough tests
or having a low throughput on test. That's something we
deal with with other scenarios that's not that uncommon. But
I think the financial personal tolls that are occurring in
(36:40):
the midst of trying this being very busy, like during
a respiratory season, it's been a lot more difficult. So
I'm just hoping that our interventions, while initially seeing meing
very dramatic, will actually sort of alleviate the stress.
Speaker 2 (37:21):
That was fantastic. Thank you so much doctor Kraft for
joining us and taking time out of your ridiculously busy schedule.
We really appreciate it.
Speaker 1 (37:30):
We can't believe that you made time for us. We
really really appreciate it.
Speaker 2 (37:33):
Yeah, we do, all right. So things we learned. Number one,
one of the big gray areas that we didn't fully
know the answer to in our first coronavirus episode back
in February was whether or not people were infectious before
they were symptomatic, and whether there was asymptomatic spread or
even super mild infections contributing to the transmission. So in
(37:57):
this interview, we learned that although we don't know exactly
how much virus people might be shedding throughout their infection,
that there are asymptomatic or very mildly symptomatic individuals and
that they're contributing to the spread. That is super clear.
At this point, Doctor Kraft mentioned testing someone who seemed
perfectly healthy and finding a ton of virus in comparison
(38:21):
to someone else who was more severely ill and had
a lot less virus in their sample. And there are
some difficulties with this in terms of standardizing the test
and whether that person who had less virus did actually
have less virus. We don't know much about the viral
load changes throughout the infection, but this I still think
personally is alarming or at least is going to make
(38:45):
transmission of this disease much more difficult to stop. Absolutely,
And there was actually a nice modeling study that used
data from Muhan and fits some mathematical models to the
actual infection data, and it suggested that up to like
eighty six percent, eighty six percent of the spread of
infection was likely due to unidentified cases.
Speaker 1 (39:07):
That's a lot.
Speaker 2 (39:08):
It's a lot, And it makes sense that this is
possible if we know that asymptomatic or mild infections are
possible and common.
Speaker 1 (39:16):
Absolutely. Number two. Another big thing I think to take
away from what we talked about with doctor Craft and
what we heard in the first hand account is that
in people who get severely ill from this disease, these
people really need to be hospitalized. And that's what's really
scary about this and why you hear a lot. And
(39:38):
we'll talk more in the future about why we're trying
so hard to flatten this curve, because if our hospitals
get overrun, then more people could die simply because there
aren't enough beds, or there aren't enough staff, or there
isn't enough equipment to actually care for them. So for
people that need to be hospitalized for supportive care, like
(39:58):
doctor Craft was talking about. But that means that these
people aren't able to breathe well enough on their own,
so they either need a tube down their throat and
to be on a respirator, or even if they don't
need that maximal support, they still need supplemental oxygen or
a positive pressure face mask. All of these things you
can only get in the hospital. And the other thing
(40:21):
is that even if people don't need help breathing, they
might end up needing ivy fluid support as well. When
you get sick, when you're not eating, not drinking normally,
and you're spiking high fevers, your body is working really
hard to fight off an infection and you can end
up severely dehydrated pretty quickly. So for some people, if
they get very sick, just drinking fluids isn't going to
(40:42):
be enough to repleate that volume. So another way that
we see supportive care in the hospital is support from
ivy fluids as well. And all of these are support
measures just to help your body get through this process,
not even addressing the virus itself. And we'll talk in
a future episode about what's being done on those types
of treatments, but I think understanding that people who get
(41:04):
severely ill really need the resources that are available in
hospitals is an important aspect.
Speaker 2 (41:09):
Of this disease absolutely. Number three. So looking at these
different risk groups, I think there are a couple of
important things to keep in mind. One is that we
don't fully know the risks across different groups, and part
of that is because this is so new and we
don't have a ton of data. And another part is
(41:31):
that because, like doctor Rasmussen said in our episode about
the virus biology, there's a lot of variation in host
response that we can't always predict. On top of that,
we have these, as we mentioned, a bunch of these
asymptomatic or very mildly symptomatic individuals that are contributing to
the spread of this virus. That means that we all
(41:51):
kind of have to assume that we are potentially infectious
at any point, because it's our job to help protect
those around us that might be more vulnerable. And another
thing I want to point out is that in the
US so far, like thirty eight percent of people that
are hospitalized with COVID nineteen right now are under fifty five.
Speaker 1 (42:11):
That's a lot of young people.
Speaker 2 (42:13):
It's a lot. It's a lot, And I think that's
not necessarily been what the messaging has suggested in terms of, oh,
if you're not old, if you don't have underlying health conditions,
then you're safe. Which, first of all, that's kind of
mean to the people who are older and who do
have these underlying health conditions that you're like, oh, well,
you know, go ahead and die, I'm going to be fine, right, Like.
Speaker 1 (42:35):
These are still human beings we're talking about.
Speaker 2 (42:38):
Here, human beings. Yeah, And so I think that that
messaging that everyone is susceptible is really important and everyone
can possibly contribute to the spread of this disease exactly. So,
there was a nice retrospective analysis of this disease from
patients in Wuhan, and in this analysis, the median age
of people who were hospitalized with COVID was fifty six.
(43:01):
So although there are some good data that suggests that
older ages are especially at risk for dying from COVID nineteen,
this is by no means a disease only of older people,
and it's not only older people who become severely ill
from this virus.
Speaker 1 (43:20):
Number four, speaking of who gets super sick, we also
talked with doctor Kraft about the case fatality rate. So
I'm going to define that really quickly. The case fatality
rate that you're probably hearing a lot about is the
number of deaths divided by the total number of cases
in a period of time. So that denominator, the total
(43:43):
number of cases in a period of time, is determined
by the number of people that we know are infected.
And as doctor Kraft said, in this case, if we're
only testing the most severely symptomatic people, then that denominator
is going to be small relative to the total number
of people who might actually be infected. So then the numerator,
(44:03):
the number on top the number of deaths, is going
to be proportionally larger. So the bottom line is, we
still don't know exactly how deadly this disease is, especially
here in the US where we're only testing severely ill individuals.
For the most part, we do have some preliminary data
in the US. This is from March sixteenth. This data,
(44:27):
it suggests that mortality is definitely highest in people over
eighty five, but in this group mortality ranges from ten
to twenty seven percent, and in people between sixty five
and eighty four, it ranged from three to eleven percent
and it went down from there. But again, all this
(44:49):
data is biased by the fact that we're only testing
the most severe cases. And as you've probably heard in
the news, the case fatality rate thus far has been
different in different countries, and that's likely because of both
differences in ages of the population that gets ill in
those countries, but also differences in their testing strategies as well.
Speaker 2 (45:07):
Mm hmm, yeah, which brings us to number five. Our
last point, and that is that we do not have
enough resources period period. We don't have enough resources, and
that is super problematic, and it's no fault of the
clinicians or the laboratorians who are now faced with having
(45:28):
to decide who they can test with their limited supplies.
And the thing is, if we don't stem this infection,
that lack of supplies is only going to get worse.
And that's what we have seen in Italy. It's illustrated
this perfectly because in some areas they don't have enough
ventilators and they're having to decide who they're going to
(45:48):
intubate and ventilate. That's a decision that no physician should
ever have to make and We'll talk more in some
of our future episodes about what has led to the
shortage and why we are facing it. But there's no
doubt that it's making it harder to get this epidemic
under control, and it's an enormous stressor on hospitals and
healthcare workers.
Speaker 1 (46:08):
Yeah, it's pretty major. Okay, sources, sources, Aaron, we have
a lot for this episode. So there was an article
by lower at All. All of these are from twenty twenty. Okay,
they're all written in the last month. There's an article
from Lawer at All that was in Annals of Internal Medicine.
(46:30):
From by at All in jama from Jao at All
in the Lancet. We've got one from Wu and Magoogin
in Jama Kong and Argowol in Radiology cardiothoracic Imaging. That
one's great if you want some pictures of those ground
glass opacities. Le at All in Science. And then the
(46:52):
CDC's MMWR report from March eighteenth is where I got
those numbers on the age stratified deaths in the US
so far.
Speaker 2 (47:01):
So we'll post all of those references on our website.
This podcast will kill You dot Com so if you
want to read up a little bit more, you know
where to find them.
Speaker 1 (47:10):
Yep. Thank you again to doctor Colleen Kraft for taking
the time out of your schedule to speak with us
and to share what you have learned with our listeners.
We really really appreciate it, we really do.
Speaker 2 (47:23):
And thanks to Bloodmobile for providing the music for this
episode and all of our episodes.
Speaker 1 (47:28):
And thank you for sticking through chapter two. We'll see
you next time chapter three.
Speaker 2 (47:37):
Until chapter three, wash your hands.
Speaker 3 (47:40):
You filthy animals.
Speaker 1 (48:00):
Ou
Reading about it in the news, I knew it was
going to be bad, but we deal with the flu
every year, so I was thinking, well, it's probably not
that much worse than the flu. But seeing patients with
COVID nineteen completely change my perspective and it's a lot
more frightening. I have patients in their early forties, and yeah,
I was kind of shocked. I'm seeing people who look
relatively healthy with a minimal health history, and they're completely
(00:24):
wiped out, like they've been hit by a truck. This
is knocking out what should be perfectly fit, healthy people.
Patients will be on minimal support, on a little bit
of oxygen, and then all of a sudden, they go
into complete respiratory arrest, shut down and can't breathe at all.
It's called acute respiratory distress syndrome ARDS. That means that
(00:45):
the lungs are filled with fluid. Patients with ARDS are
extremely difficult to oxygen eight. It has a really high
mortality rate, about forty percent. The way to manage it
is to put a patient on a ventilator. The additional
pressure helps the oxygen go into the bloodstream Normally. ARDS
is something that happens over time as the lungs get
(01:06):
more and more inflamed. But with this virus, it seems
like it happens overnight. Typically with ards, the lungs become inflamed.
It's like inflammation anywhere. If you have a burn on
your arm, the skin around it turns red from additional
blood flow. The body is sending it additional nutrients to heal.
The problem is when that happens in your lungs, fluid
(01:27):
and extra blood starts going to the lungs. It first
struck me how different it was when I saw my
first coronavirus patient go bad. I was like, holy crap,
this is not the flu. Watching this relatively young guy
gasping for air, pink, frothy secretions coming out of his
tube and out of his mouth. The ventilator should have
(01:47):
been doing the work of breathing, but he was still
gasping for air, moving his mouth, moving his body, struggling.
When you're in that mindset of struggling to breathe and
delirious with fever, you don't know when someone is trying
to help you, so you'll try to rip the breathing
tube out because you feel like it's choking you, but
you're drowning when someone has an infection, I'm used to
(02:08):
seeing the normal colors you associate with it, greens and yellows.
The coronavirus. Patients with aards have been having a lot
of secretions that are actually pink because they're filled with
blood cells that are leaking into their airways. They're essentially
drowning in their own blood and fluids because their lungs
are so full, so we're constantly having to suction out
the secretions every time we go into their rooms. I
(02:30):
worked a long stretch of days last week, and I
watched it go from this novelty to a serious issue.
We had one or two patients at our hospital, and
then five to ten patients, and then twenty patients every day.
The intensity kept ratcheting up, more patients, and the patients
themselves are starting to get sicker and sicker. When it
first started, we all had tons of equipment, tons of supplies,
(02:52):
and as we started getting more patients, we started to
run out. They had to ration supplies. At first, we
were trying to use one mask per patient. Then it
was just you get one mask for positive patients, another
mask for everyone else, and now it's just you get
one mask. Even if you survive AARDS. Although some damage
(03:12):
can heal, it can also do long lasting damage to
the lungs. They can get filled up with scar tissue.
AARDS can lead to cognitive decline. Some people's muscles waste
away and it takes them a long time to recover
once they come off the ventilator. There is a very
real possibility that we might run out of ICU beds,
and at that point, I don't know what happens if
patients get sick and need to be intubated and put
(03:34):
on a ventilator. Is that person going to die because
we don't have the equipment to keep them alive?
Speaker 2 (04:23):
Oh my gosh.
Speaker 1 (04:25):
Yeah. That was an account from a respiratory therapist at
a hospital in Louisiana who remained anonymous. For that account,
I found it on Pro Publica. It was published on
March twenty first, And we'll put a link to the
full description in our show notes and on our website,
because that was just a small excerpt from the description.
Speaker 2 (04:48):
It's you know, it's very eerie to read and to hear,
because what it does is it reminds me of a
lot of the first hand accounts from the nineteen eighteen
Luenzo which I know has been brought up. The comparisons
have been brought up constantly, and some are inappropriate comparisons.
But just that description of healthy individuals being struck down,
(05:12):
all people of all ages being struck down, and the
horrible thought of not being able to breathe, Yeah, and
drowning in your own fluids.
Speaker 1 (05:23):
Yeah, it's really scary.
Speaker 2 (05:26):
I mean, it is scary. And we should introduce ourselves
before getting too much into this.
Speaker 3 (05:33):
Yeah, we should.
Speaker 2 (05:34):
Hi, I'm erin Welsh and I'm erin Oman Updyke and
this is this podcast will kill you.
Speaker 1 (05:40):
Welcome back everyone, or maybe welcome for the first time
if you jump part way into series. If you're one
of those people. This is our not so many minisod series,
Anatomy of a Pandemic, where we're answering all of your
listeners submitted questions about COVID nineteen, the disease caused by
SARS COVID two. In our first chapter, we covered the
(06:02):
virus itself, so all of the biology of SARS CoV two.
In this episode, chapter two, we're going to talk about
the disease that this virus causes, what it looks like,
how it's spread, and how physicians and healthcare workers are
dealing with this outbreak.
Speaker 2 (06:19):
But first, as always, it's quarantiny time.
Speaker 1 (06:23):
It's quarantine ay time.
Speaker 2 (06:24):
In this episode, we are drinking the creatively named quarantine
y two, Quarantining number two. Aaron, what is in Quarantining
number two?
Speaker 1 (06:36):
You know, Aaron, It's kind of a whiskey ginge.
Speaker 2 (06:39):
Yeah, I mean I would, I would call it a
Kentucky mule perhaps if you happen to have a copper mug.
I did not, so the picture is disappointingly non copper.
Speaker 1 (06:51):
It's all right, you did your best, thank you.
Speaker 4 (06:55):
Yeah.
Speaker 2 (06:55):
So it's basically ginger ale whisky of whatever kind of
whiskey you want, and some lime.
Speaker 1 (07:00):
And we'll post the full recipe for that quarantine as
well as our non alcoholic plusy Breta on our website
and all of our social media channels as always as always.
Speaker 2 (07:11):
Okay, So, as we mentioned, we've talked about the virus itself,
so now let's talk about the disease that this virus
is causing, COVID nineteen. And I do think that's a
particularly important distinction because, as we'll hear more about this
virus can infect you without necessarily causing severe disease, and
that's super important in understanding the spread of the virus,
(07:33):
because people who appear asymptomatic and otherwise healthy or just
have very mild cases could still be infected with and
therefore sneezing or coughing out the virus and spreading it
to other people. So we talked to doctor Colleenkraft, who
many of you may recognize from our first coronavirus episode,
and she's going to walk us through a lot of
(07:54):
your questions about the clinical disease that this virus causes.
Let's go over some of the basics first, so shall we?
Speaker 1 (08:01):
Let's we shall? So one big question is what is
the timeline of this illness? And what you're going to
see is that we still don't have the answers to
every question when it comes to this disease, and the
timeline is kind of one of those that we don't
fully know, but we do have a better handle on
(08:23):
it than we did in our episode that we released
back in February. So, first of all, it seems like
the incubation period is on average about five days an
incubation period is the time from when you're first exposed
to that disease to when you first start showing symptoms
of that disease. Okay, so on average this is about
(08:47):
five days. It can range most studies, it seems like
the max range is about eleven. So when you hear
about being quarantined for fourteen days, that's because we think
and we're pretty sure that after fourteen days, if you
haven't started to show symptoms, you're probably not going to
show symptoms. So that's kind of the max range to
(09:08):
make sure that you don't spread this disease unknowingly to
someone else if you're exposed. And this number like around
fourteen days, that's consistent with what we saw with SARS one,
SARS classic.
Speaker 4 (09:20):
Okay.
Speaker 1 (09:22):
Now, the other thing is that from a retrospective study
of people that had COVID, the severe disease. This study
looked at people who were hospitalized for COVID, so pretty
severely ill. The median time from when symptoms first started
to discharge from the hospital was twenty two days. So
(09:44):
that's a long time for somebody to be in the hospital.
And I think that that's an important indication that for
people who get seriously sick, they can be sick for
quite a long time. The other thing that this study
looked at was viral shedding, so at least some measure
of how long somebody might potentially be infectious, and they
found that the median number of days that people were
(10:06):
shedding virus was twenty days from the onset of symptoms,
which is again a pretty long time if somebody is symptomatic,
that is a long time yep, and longer than fourteen days.
Speaker 2 (10:21):
Yeah, that's I think. But I think the other thing
that you mentioned that it's sort of this is just
looking at people who had severe disease curR exactly, Yes, okay,
So I wonder I think. I mean, of course, as
this pandemic progresses, we're going to get more information about
those people who have milder cases or are asymptomatic and
how much virus they're shedding at various points throughout their
(10:43):
course of infection.
Speaker 1 (10:44):
Exactly, Yeah, exactly. Okay, So then the question is what
are some of these symptoms?
Speaker 2 (10:51):
Okay, So the biggest symptoms are the ones that most
people have probably heard about in the news quite a lot,
so fever, which, by the way, the death definition of
a fever is a temperature of over one hundred point
four degrees fahrenheit or thirty eight degrees celsius. Then there's
also cough, generally a dry cough, not a super wet
(11:11):
or a super productive cough, and then shortness of breath.
So these are the general symptoms of the disease that
we call COVID nineteen.
Speaker 4 (11:19):
But we know.
Speaker 2 (11:20):
Now that SARS covy two, the virus like SARS one
and MERS, can infect your lung tissue and cause a
lower respiratory disease, not only an upper respiratory infection the
way most of the common coronaviruses do. Okay, So what
does that mean, Well, it means the possibility of very
severe disease like we heard about in the first hand account,
(11:42):
and in the case of this virus, it seems that
about twenty percent of cases are severe. And that doesn't
mean that twenty percent of cases need ICEE you and
ventilator care, but it does mean that potentially up to
twenty percent of cases may need at least hospitalization and
some oxygen support or some IV fluid support. An analysis
(12:03):
from China suggest that there at least about fourteen percent
of cases were severe and five percent were critical, And
that means the same kind of picture that we talked
about in our coronavirus episode when we talked about SARS,
and the same description you heard in the first hand
account so ards, ground glass opacities on X rays, potentially
(12:25):
needing intubation. It's serious. It's a serious, serious disease, and
people can also go into shock, which we've talked about
a lot on the podcast. But essentially what that means
is that your organs aren't getting enough blood flow in
this case because of overwhelming infection, which leads to leakage
of fluids and then hypoperfusion, and then of course there
(12:46):
is also always the risk of a secondary infection on
top of this viral infection.
Speaker 1 (12:51):
It can be pretty gnarly. But also in this case,
what we see that is different from SARS and mers
and what in our first episode about coronaviruses was still
kind of a gray zone. That's a lot more clear
now is that asymptomatic or very mildly symptomatic infection is
not only possible, but it's likely actually responsible for quite
(13:15):
a lot of the spread of this disease. It's estimated
that about eighty percent of cases are mild, which, while
that's great news for the majority of people who get infected,
it means you're not necessarily going to be looking at
such a severe disease. It also means that this disease
is easier to spread since not everyone who's sick maybe
(13:35):
even realizes that they're sick. And how does this disease spread.
Speaker 2 (13:39):
Erin well, respiratory droplets as we well know, but we're
not going to go into that. We're going to allow
our expert, doctor Collingcraft from Emory University to explain how
respiratory droplets work, as well as other characteristics of this disease,
(14:00):
how wo'ds spread, how we're testing for it, who we're
testing for it, and finally, how we treat it.
Speaker 1 (14:05):
Right after this break, my.
Speaker 4 (14:35):
Name is Colleen Kraft and I'm the Associate chief Medical
Officer at Emory University Hospital. My training is in infectious
diseases and clinical microbiology.
Speaker 2 (14:45):
Thank you again, so so much for joining us. We
know that you have just been swamped with work and
so we really appreciate you taking the time to kind
of talk about COVID nineteen. I mean since our first
interview with you, which has been you know, about a
month and a half ago. A lot has happened.
Speaker 4 (15:03):
Yes, like a lifetime has happened. That's how I feel.
Speaker 1 (15:06):
Yeah, yeah, so we'll jump right in. We are talking today,
of course, about SARS COVID two, the virus that causes
COVID nineteen. So we know that it's transmitted through respiratory
droplets or direct contact with somebody's respiratory droplets, like other coronaviruses.
Can you tell us a little bit about what that
(15:26):
means in contrast to viruses that are airborne and when
people talk about respiratory droplets, like what exactly does that include?
Speaker 4 (15:36):
Sure? So I think it's it was really funny to hear.
I've been to a number of town halls around Emory
and I had one of my audience members best described
it as, you know, it's your saliva, So it's sort
of I view respiratory droplets as being sort of the
wet aspects of our coughs and sneeze, and that's that.
(15:58):
I thought that was very well described that way by
this employee. And I didn't answer your your airborne question.
So what happens is when we cough or sneeze, it's those,
it's like a wet, heavy droplet, and that kind of
goes to the ground right sooner because it's heavy. But
when they are really small, then they can aerosolize and
(16:19):
they can actually sort of hang around in the air
for longer. And so that's why every time there's a
new respiratory virus we sort of pretend like it's airborne,
just to make sure it's not airborne, because that is
sort of a different transmission route that that can hang
in the air longer and it can go farther. But
you know, from what everything we know, this coronavirus still
(16:41):
behaves like our droplet spread coronaviruses, gotcha.
Speaker 2 (16:48):
So at this point we have a better idea of
what a typical course of COVID nineteen looks like. Can
you walk us through what that is like? You know,
day one, day two, what do you typically see?
Speaker 4 (17:01):
Yeah, so we're seeing the same things as being seen
and observed in other parts of the world. And so
we have the vast majority of these individuals have a cold.
It may be an unpleasant cold more than for others,
but most people have a very mild illness, probably most
similar to our common cold. In general. We are seeing
(17:22):
people though, that come in with basically a viral pneumonia
type picture. Viral pneumonia should really make the hairs on
the back of your neck stand up, because that's probably
what happened in the nineteen eighteen Spanish flu. And this
is again along with the airborne aspect, this is what
we're always looking for in these new viruses. Does it
have a propensity to cause lower respiratory tract infection? If
(17:46):
it does, that makes us scared because we can't. While
we can do a lot with bacterial pneumonia, a viral
pneumonia is very scary because usually don't we can't treat
most of the viruses that we get, and so we
definitely don't it down and the lung where it can
cause scarring and difficulty breathing. And so for a subset
of people that for the most part tend to be
(18:07):
ill ill at baseline, we have a group of people
that also are getting symptomatic lower respiratory tracts syndrome who
are not quite as ill as the typical person we're
hearing about that is succumbing to this disease. So we've
had a number of individuals that yes, they have other
medical problems, but they don't necessarily have respiratory medical problems,
(18:29):
and they are having you know, sort of a viral
pneumonia picture, and we have had a few that have
been needed to have mechanical ventilation or a breathing tube.
Speaker 2 (18:40):
Gotcha about how long does is the course of disease?
You know, I know that for some people who have
milder cases it may be shorter than for others. But
what do we see on average or what does it
look like for the people with more mild symptoms compared
to the people with more severe outcomes.
Speaker 4 (18:59):
I would say it's it's that typical three day kind
of feeling bad, achy, and then the next day is
maybe a little bit better, not great, and then the
next day you're sort of back to feeling like you're
among the living. And then you know, then we also
recommend for at least for our employees to sort of,
you know, kind of self isolate for a few more days,
(19:20):
just to make sure you're not sort of still having
those secretions coffin sneeze because we don't want to keep
spreading it. And so that's sort of a mild course.
The more severe courses tend to be you know, I
think the damage is done within the first week, and
then what we're doing is trying to support the body
so the body can mend after that.
Speaker 2 (19:41):
What does that supportive care look like, both in terms
of that during that first week of intense symptoms and
then the sort of you know, the healing stage.
Speaker 4 (19:52):
Right, So it sounds like it's your grandmother patting your hand,
is what supportive care sounds like, I think to most people.
But in the case of some individuals that have severe disease,
it may mean that they have a breathing tube, they're
in an ICU, they have many other things that are
helping support their body until the body can kind of
get rid of the virus itself. So this is sort
(20:13):
of how we describe things back in the bola days,
where you know, most of the time what we're doing
is just supporting, like with life support, basically to try
to keep things going until the body can create and
clear that virus. That's what happened during a bola with coronavirus.
It's sort of similar. So supportive care when you're at
home maybe niquil and television, which sounds really great to
(20:37):
me right now, and when you're in the hospital. Though.
What that is is if we need to help one
of your body systems function, we will do that.
Speaker 1 (20:47):
Okay, do we know at this point how much things
like viral load might correlate with the severity of symptoms?
Are the people that have milder cases, are they as
infectious to others? Are they shedding as much viral particles
as these more severe cases?
Speaker 4 (21:03):
Right? So, I think this is a great question. And
I think as this is where you're going to see,
my laboratory in side come out quite a bit. So
it's really easy when we talk about viral load in
the blood or plasma or serum to sort of understand
how to standardize that by copies per mili liter or
something like that. When we're doing a respiratory swab. I
(21:26):
think it's really hard to standardize. And because this test
is so new, we don't have the test standardize in
and of itself, So the testing results at our institution
may be a little bit variable compared to another institution,
and that's because we don't have a gold standard yet
to compare on all of the machines. So I agree
with you. However, we have seen very anecdotally that we've
(21:48):
had people with very high viral loads that basically didn't
even look like they were sick, and we question whether
or not we should even swab them. And I had
extremely high amounts in their nose, whereas we've also had
people that have had moderate amounts that are sick and
on a ventilator. And so, while I think there's an
(22:08):
aspect that correlates, I think the way that we obtained
the swab is going to make this difficult unless there's
some sort of serum or plasma or surrogate tests we
can use that can be very standardized with its input.
Speaker 2 (22:23):
And so going revisiting this aspect of perhaps asymptomatic individuals
or people with very very mild cases of this, can
you talk about sort of the incubation period when people
might start becoming infectious, how long they remain infectious, and
then sort of how much do you think asymptomatic individuals
(22:44):
might be contributing to the spread of disease.
Speaker 4 (22:48):
So I think they probably are contributing to the spread
of disease. I think that's why some of these more
dramatic things that we're seeing are the social distancing and
being really aware of your even more so just your
own hand hygiene, just your own persona as it relates
to anybody else. And so I think that we are
taking measures to have that not happen. Right school's closing.
(23:11):
Let's talk about where there could be a lot of
asymptomatic spread of disease. That would be a school. So
you got a bunch of kids shedding virus everywhere in
close proximity, with limited hand and face and everything hygiene,
And you can tell I have children, and that's just like,
that's just a setup for transmission. So I do think
(23:33):
that while asymptomatic people are shedding, we're really taking dramatic
efforts on like I've ever seen in my short lifetime.
I suppose really to even work on stopping that. I mean,
hospitals aren't allowing very many visitors, you know, public places
of all but canceled everything. So we're actually really trying
to break that cycle, which I think has to me
(23:56):
never been really done to this extreme. Yeah.
Speaker 1 (24:00):
Yeah, And you mentioned as well that it seems at
this point pretty well established that it's older people and
people with other underlying health conditions or people that are
otherwise immunal compromise that are more likely to experience this
severe disease. But we've gotten a lot of people asking
us for a bit more clarity about these groups, like
(24:21):
what age is it that people are considered elderly or
at risk? And is it any sort of immune compromise
that makes you more vulnerable? Or what are these pre
existing health conditions that we're most concerned with in terms
of the higher risk categories for this disease.
Speaker 4 (24:38):
Right, So, I think the way to do that, and
the way I've been gut checking a number of these
questions that we really just don't know yet because we
don't know everything about this virus, is to think about
influenza and sort of start there. Right, So, in older adults,
influenza tends to be more severe because it's sort of
tipping off chronic conditions that get worse. So if you
(25:01):
have bad heart disease and you get a respiratory virus infection,
sometimes people even have heart attacks from viruses, which is
very rare, but we think probably happens more than we understand,
but it may basically, you know, they may be in
sort of a tenuous balance, like everything's kind of holding together,
but it's it's it doesn't take much to push over
(25:22):
into feeling a lot worse. And so I just think
about the people that are at risk for our typical
seasonal influencer are going to be the same people they
are at risk, So anybody that has lung problems, anybody
who's immune system can't fight it off. I think it's
hard to say to actual groups, and you know, we're
seeing that many older people are being spared and and
(25:43):
some younger people that are younger than we thought are
getting it. So it's really I think we're you know,
we're trying to define the syndrome, as we're trying to
diagnose cases, as we're trying to bring up testing, and
so I think, you know, we will by the end
of this outbreak have more resolution on what that looks like.
But I think right now, you know, and it's probably
at this point near seasonal influenza, gotcha.
Speaker 2 (26:05):
There were two groups specifically that we got a lot
of emails about and questions about, and one of those
groups was people with diabetes type one, and they were wondering,
you know, people, I keep seeing that people with diabetes
are more at risk, does that include me? And then
the other group that we got a lot of questions
from were people who were pregnant or people with newborns.
Speaker 4 (26:25):
Right, So the pregnancy thing, I think is always a
we always are concerned about it very highly. I don't
think that there's been any data that actually shows there's
poorer outcomes. I know that doctor Denise Jamison from Emory
has published a little bit about this, at least what's
known from stars and mers, And while early trimester is
(26:47):
always concerning for anything, there's no evidence that anybody again
has had any pregnancy complications from this. However, in general
we don't like to test that theory, and so we
tend to be protective around pregnant women for sure. In
terms of those with diabetes, I think it's it's again
(27:11):
not quite known what the aspects of diabetes, except that
there's some level of sluggish immune and response. I wouldn't
say immune compromise entirely. I think it depends on how
well your blood sugars are controlled, how many complications you
already have from diabetes. Do you have type one diabetes,
(27:31):
which can tend to be much more severe than type
two diabetes. I think some of those questions, you know,
may be elucidated as things progress.
Speaker 2 (27:39):
Gotcha, so you know on these in this discussion of
high risk groups and low risk groups or varying risk
in general. One of the things that we've seen is
that children seem to experience a milder disease than some
of the other age groups. Do we know why that is?
Our immuno compromised kids just asvulnerable as immunocompromise people of
(28:02):
other ages.
Speaker 4 (28:03):
I should have read my pediatric textbook a little bit more,
But there are definitely a number of viruses that are
much worse than adults than kids. And then we sort
of have vice versa where kids tend to have maybe
an increased predilection, or maybe it's just because by the
time you're an adult that you're immune to it, and
when you're a kid you're sort of seeing it for
the first time. So there is always this dichotomy of
is it worse in kids are better in kids? This
(28:27):
scenario really seems to be that the kids are these
asymptomatic probably shedds, right, But we already discussed a little
bit earlier, and so this virus just for whatever reason,
is not that severe in children. But again, it may
be that most coronaviruses aren't. We just haven't studied them
because we kind of haven't cared because they haven't done
that severe in adults, and in terms of immunocompromised kids,
(28:50):
I suppose that they are more at risk, but I
suppose that they may also become increased vectors. They may
just shed longer. But again, I'm not a pediatrician, so
I hesitate to sort of fully answer that one with confidence.
Speaker 3 (29:07):
Yeah, that makes sense.
Speaker 1 (29:09):
So can you explain a little bit about how we
are getting the numbers for things like the case fatality
rate right now? Is that something that is still a
moving target? Do you think that we might be able
to see that number decrease as more asymptomatic or mild
cases are identified, since at this point it seems like
testing is mostly focused on the severe cases exactly.
Speaker 4 (29:33):
Yeah, so I think this is you know where again
my laboratory and background and the logic of this is
really interesting in a is it interesting as anything can
get right now? So what really I think is interesting
is we really do have a decrease in throughput ability
right now with our diagnostic testing. That's because we're building
(29:56):
the car as we drive it, right So, there's been
all this contrived controversy about test kit shortage. Well, we
just discovered this virus and we just made a test
for it, and when we make tests that are new,
we have to go back to old school methods, which
are a bit slow, and so I think I don't
know what expectation we had that we had to have
(30:17):
like a rapid test the next day. I think it
was a little bit. I don't know who's stettying that standard,
but the standard is unattainable, and so I think that
by virtue of the fact that we're going to start
testing more and more people over the next month, we
are going to see that that denominator is going to
stretch out. So we're going to have people that are asymptomatic,
barely symptomatic that are going to be positive, and that
(30:40):
will make that case fatality rate drop. I think it
can look higher. Again, it's exactly what you said. It's
selection bias. So when you're only testing the sickest of
the sick, then you're only going to find a high
case fatality rate. I personally am the current gatekeeper to
who gets on our daily test in house that we've developed,
(31:02):
and we only have room as of today. This probably
is actually going to change tomorrow. So you know, I
have to gatekeep and prioritize who gets on our in
house run which takes twenty four hours versus send out
to a referral lab, which may take seven days. Well,
who do I prioritize? I mean, who would you guys prioritize?
So we're going to do impatients because we're also using
(31:24):
a lot of personal protective equipment to care for these individuals,
and so we want to be able to take them
out of that if they don't need it, and then
we can keep our supplied. You know, we need less
supplies if we do it that way. And then we're
also tests prioritizing our workforce, right, so we want to
make sure that the physical therapists and the respiratory therapists
(31:45):
and the you know, tech and everybody can come back
to work because we want to make sure we can
keep taking care of these sick patients when they come in.
Mm hm hm.
Speaker 1 (31:56):
That makes sense.
Speaker 2 (31:58):
So I know that it's early stages yet again in
this pandemic, but do what do we know so far
about longer term health consequences for people who have gotten sick,
maybe have gotten mild or severe in particular, disease, and
are there long term health consequences they have, like lung
damage or other issues.
Speaker 4 (32:19):
So the logic that I use is that anything that
damages the lung can cause long term consequences. So the
lung only knows how to do one thing when it's damaged,
and that's to scar down. And so that's why our
bodies have this lovely cough reflex so that all that
stuff doesn't go into our lungs and cost scarring and damage.
(32:40):
So when we have a virus that's infecting our lung cells,
then that's going to cause this scarring to happen, and
we potentially could see long term damage. But that's the
same as sort of anything that comes and damages the lung.
Speaker 1 (32:53):
Okay, So another question that a lot of people had,
and I know we probably don't fully know the end
answer to this, but maybe we can sort of estimate
based on what we know so far about coronaviruses in
general or from you know, the previous outbreaks. Is do
we know about whether it seems possible to become reinfected
(33:13):
with this virus if you get it and then recover
from that infection.
Speaker 4 (33:18):
Yeah, So I was just on another alumni call today
and have this very same question. We probably get this
question every day, and so in general we probably don't
know for sure. I think because this is a novel
coronavirus introduced to the population, we will likely understand more
because there's more attention to it. My understanding is that
(33:39):
when we have viral infections, we do become immune to them,
but remember that it depends on how systemically ill we
are as well. So you know, it's a complicated immunology
at this at our nasal source. Right. We talked already
about how trying to say the viral load from the
nose is not a very consistently sampled area, and so
(34:01):
I think in the same way that immunology may be
difficult to totally separate out because there may be an
aspect of our mucosal immunology that plays a large role
in whether or not that virus comes back to us. Right,
So we may have just symptomatically gotten through it, but
did we actually form true defense against it? And again,
(34:22):
I think, you know I would. I don't pretend to
know that much about immunology except the big picture stuff.
So I hope that was helpful.
Speaker 2 (34:32):
Yeah, absolutely so. In our first episode on coronaviruses, we
ended it by asking you, what about this disease concerns
you and what about it you know, makes you say
hold off on the panic or maybe as reason for optimism.
Has your answer changed at all since that time?
Speaker 4 (34:51):
My answer has changed, Dear Errands. I think that we
do see that it causes laura respiratory tract infection, much
like other viruses that we know, such as influenza, and
so I am happy to say that it's not as
severe as stars or mers, but it's not insignificant, and
(35:14):
we are seeing a lot of individuals you know, in
the hospital that have this. I think my optimism is
that I'm trying to be optimistic every day. The supply
chain issues and the personal finance issues and the childcare issues,
to me, are making this very personally difficult for a
(35:35):
lot of people. It's one thing to sort of have
a bad blue season and us to have sort of
sicker patients or more patients, but the personal protective equipment
and you know, no visitors to the hospital, all those
things really are stressing people personally. And so I'm just
trying to be optimistic that a lot of this social
(35:56):
isolation that we have implemented will act actually make a difference,
because you know, we're sort of, at least in Georgia,
we're sort of coming into the surge part of it
for our location, and I think everybody's going to go
through that and you know, have to just come out
on the other side. But there's a lot of things
that you know, when I was bubbly three weeks ago
(36:18):
or whenever that was, I could not have imagined the
stress of like not having swabs to test, or you know,
I could have understood and foreseen not having enough tests
or having a low throughput on test. That's something we
deal with with other scenarios that's not that uncommon. But
I think the financial personal tolls that are occurring in
(36:40):
the midst of trying this being very busy, like during
a respiratory season, it's been a lot more difficult. So
I'm just hoping that our interventions, while initially seeing meing
very dramatic, will actually sort of alleviate the stress.
Speaker 2 (37:21):
That was fantastic. Thank you so much doctor Kraft for
joining us and taking time out of your ridiculously busy schedule.
We really appreciate it.
Speaker 1 (37:30):
We can't believe that you made time for us. We
really really appreciate it.
Speaker 2 (37:33):
Yeah, we do, all right. So things we learned. Number one,
one of the big gray areas that we didn't fully
know the answer to in our first coronavirus episode back
in February was whether or not people were infectious before
they were symptomatic, and whether there was asymptomatic spread or
even super mild infections contributing to the transmission. So in
(37:57):
this interview, we learned that although we don't know exactly
how much virus people might be shedding throughout their infection,
that there are asymptomatic or very mildly symptomatic individuals and
that they're contributing to the spread. That is super clear.
At this point, Doctor Kraft mentioned testing someone who seemed
perfectly healthy and finding a ton of virus in comparison
(38:21):
to someone else who was more severely ill and had
a lot less virus in their sample. And there are
some difficulties with this in terms of standardizing the test
and whether that person who had less virus did actually
have less virus. We don't know much about the viral
load changes throughout the infection, but this I still think
personally is alarming or at least is going to make
(38:45):
transmission of this disease much more difficult to stop. Absolutely,
And there was actually a nice modeling study that used
data from Muhan and fits some mathematical models to the
actual infection data, and it suggested that up to like
eighty six percent, eighty six percent of the spread of
infection was likely due to unidentified cases.
Speaker 1 (39:07):
That's a lot.
Speaker 2 (39:08):
It's a lot, And it makes sense that this is
possible if we know that asymptomatic or mild infections are
possible and common.
Speaker 1 (39:16):
Absolutely. Number two. Another big thing I think to take
away from what we talked about with doctor Craft and
what we heard in the first hand account is that
in people who get severely ill from this disease, these
people really need to be hospitalized. And that's what's really
scary about this and why you hear a lot. And
(39:38):
we'll talk more in the future about why we're trying
so hard to flatten this curve, because if our hospitals
get overrun, then more people could die simply because there
aren't enough beds, or there aren't enough staff, or there
isn't enough equipment to actually care for them. So for
people that need to be hospitalized for supportive care, like
(39:58):
doctor Craft was talking about. But that means that these
people aren't able to breathe well enough on their own,
so they either need a tube down their throat and
to be on a respirator, or even if they don't
need that maximal support, they still need supplemental oxygen or
a positive pressure face mask. All of these things you
can only get in the hospital. And the other thing
(40:21):
is that even if people don't need help breathing, they
might end up needing ivy fluid support as well. When
you get sick, when you're not eating, not drinking normally,
and you're spiking high fevers, your body is working really
hard to fight off an infection and you can end
up severely dehydrated pretty quickly. So for some people, if
they get very sick, just drinking fluids isn't going to
(40:42):
be enough to repleate that volume. So another way that
we see supportive care in the hospital is support from
ivy fluids as well. And all of these are support
measures just to help your body get through this process,
not even addressing the virus itself. And we'll talk in
a future episode about what's being done on those types
of treatments, but I think understanding that people who get
(41:04):
severely ill really need the resources that are available in
hospitals is an important aspect.
Speaker 2 (41:09):
Of this disease absolutely. Number three. So looking at these
different risk groups, I think there are a couple of
important things to keep in mind. One is that we
don't fully know the risks across different groups, and part
of that is because this is so new and we
don't have a ton of data. And another part is
(41:31):
that because, like doctor Rasmussen said in our episode about
the virus biology, there's a lot of variation in host
response that we can't always predict. On top of that,
we have these, as we mentioned, a bunch of these
asymptomatic or very mildly symptomatic individuals that are contributing to
the spread of this virus. That means that we all
(41:51):
kind of have to assume that we are potentially infectious
at any point, because it's our job to help protect
those around us that might be more vulnerable. And another
thing I want to point out is that in the
US so far, like thirty eight percent of people that
are hospitalized with COVID nineteen right now are under fifty five.
Speaker 1 (42:11):
That's a lot of young people.
Speaker 2 (42:13):
It's a lot. It's a lot, And I think that's
not necessarily been what the messaging has suggested in terms of, oh,
if you're not old, if you don't have underlying health conditions,
then you're safe. Which, first of all, that's kind of
mean to the people who are older and who do
have these underlying health conditions that you're like, oh, well,
you know, go ahead and die, I'm going to be fine, right, Like.
Speaker 1 (42:35):
These are still human beings we're talking about.
Speaker 2 (42:38):
Here, human beings. Yeah, And so I think that that
messaging that everyone is susceptible is really important and everyone
can possibly contribute to the spread of this disease exactly. So,
there was a nice retrospective analysis of this disease from
patients in Wuhan, and in this analysis, the median age
of people who were hospitalized with COVID was fifty six.
(43:01):
So although there are some good data that suggests that
older ages are especially at risk for dying from COVID nineteen,
this is by no means a disease only of older people,
and it's not only older people who become severely ill
from this virus.
Speaker 1 (43:20):
Number four, speaking of who gets super sick, we also
talked with doctor Kraft about the case fatality rate. So
I'm going to define that really quickly. The case fatality
rate that you're probably hearing a lot about is the
number of deaths divided by the total number of cases
in a period of time. So that denominator, the total
(43:43):
number of cases in a period of time, is determined
by the number of people that we know are infected.
And as doctor Kraft said, in this case, if we're
only testing the most severely symptomatic people, then that denominator
is going to be small relative to the total number
of people who might actually be infected. So then the numerator,
(44:03):
the number on top the number of deaths, is going
to be proportionally larger. So the bottom line is, we
still don't know exactly how deadly this disease is, especially
here in the US where we're only testing severely ill individuals.
For the most part, we do have some preliminary data
in the US. This is from March sixteenth. This data,
(44:27):
it suggests that mortality is definitely highest in people over
eighty five, but in this group mortality ranges from ten
to twenty seven percent, and in people between sixty five
and eighty four, it ranged from three to eleven percent
and it went down from there. But again, all this
(44:49):
data is biased by the fact that we're only testing
the most severe cases. And as you've probably heard in
the news, the case fatality rate thus far has been
different in different countries, and that's likely because of both
differences in ages of the population that gets ill in
those countries, but also differences in their testing strategies as well.
Speaker 2 (45:07):
Mm hmm, yeah, which brings us to number five. Our
last point, and that is that we do not have
enough resources period period. We don't have enough resources, and
that is super problematic, and it's no fault of the
clinicians or the laboratorians who are now faced with having
(45:28):
to decide who they can test with their limited supplies.
And the thing is, if we don't stem this infection,
that lack of supplies is only going to get worse.
And that's what we have seen in Italy. It's illustrated
this perfectly because in some areas they don't have enough
ventilators and they're having to decide who they're going to
(45:48):
intubate and ventilate. That's a decision that no physician should
ever have to make and We'll talk more in some
of our future episodes about what has led to the
shortage and why we are facing it. But there's no
doubt that it's making it harder to get this epidemic
under control, and it's an enormous stressor on hospitals and
healthcare workers.
Speaker 1 (46:08):
Yeah, it's pretty major. Okay, sources, sources, Aaron, we have
a lot for this episode. So there was an article
by lower at All. All of these are from twenty twenty. Okay,
they're all written in the last month. There's an article
from Lawer at All that was in Annals of Internal Medicine.
(46:30):
From by at All in jama from Jao at All
in the Lancet. We've got one from Wu and Magoogin
in Jama Kong and Argowol in Radiology cardiothoracic Imaging. That
one's great if you want some pictures of those ground
glass opacities. Le at All in Science. And then the
(46:52):
CDC's MMWR report from March eighteenth is where I got
those numbers on the age stratified deaths in the US
so far.
Speaker 2 (47:01):
So we'll post all of those references on our website.
This podcast will kill You dot Com so if you
want to read up a little bit more, you know
where to find them.
Speaker 1 (47:10):
Yep. Thank you again to doctor Colleen Kraft for taking
the time out of your schedule to speak with us
and to share what you have learned with our listeners.
We really really appreciate it, we really do.
Speaker 2 (47:23):
And thanks to Bloodmobile for providing the music for this
episode and all of our episodes.
Speaker 1 (47:28):
And thank you for sticking through chapter two. We'll see
you next time chapter three.
Speaker 2 (47:37):
Until chapter three, wash your hands.
Speaker 3 (47:40):
You filthy animals.
Speaker 1 (48:00):
Ou
Hosts And Creators
Erin Welsh
Erin Allmann Updyke
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