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Novel Coronavirus
5 Plays6 years ago
In this episode of Critical Matters we discuss the outbreak of a novel coronavirus (2019-nCoV), a rapidly evolving epidemic that originated in China and now declared a health care emergency by the World Health Organization (WHO). In this episode, we discuss current understanding regarding the virus and its clinical impact.
Our guest is Dr. Raquel Nahra, a critical care and infectious disease specialist. Dr. Nahra is faculty at the Cooper Medical School of Rowan University. In addition to her clinical roles, Dr. Nahra is the Hospital Epidemiologist at Cooper University Hospital in Camden NJ.
Additional Resources:
World Health Organization (WHO) - Coronavirus Status Updates: http://bit.ly/2UJKj4b
Centers for Disease Control (CDC)- Resources and Information on 2019-nCoV: http://bit.ly/2OMGsPO
Lancet - Articles and Clinical Information on 2019-nCoV: http://bit.ly/3bxyiEE
Johns Hopkins University - Novel Coronavirus Information: http://bit.ly/39xETxn
Jama Network - Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China:
http://bit.ly/2SAKOL8
Books Mentioned in this Episode:
Waiting for Godot: A Tragicomedy in Two Acts by Samuel Beckett: https://amzn.to/2HhnUD8
Recommended
Transcript
Introduction and Purpose
00:00:06
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Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
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Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
00:00:20
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To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:27
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And now your host, Dr. Sergio Zanotti.
Coronavirus Emergence and Global Response
00:00:33
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On December 31st, 2019,
00:00:35
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China reported a cluster of cases of pneumonia associated with the Hunan seafood wholesale market in Wuhan.
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On January 7, 2020, Chinese health authorities confirmed that this cluster was associated with a novel coronavirus named 2019-nCoV.
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Since then, the number of cases and fatalities has increased, and the World Health Organization has declared the coronavirus outbreak a public health emergency of international concern.
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Several cases have now been reported in the United States.
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In today's episode of Critical Matters, we will discuss the current status and our current understanding of this novel coronavirus outbreak, especially how it might apply to patients being admitted to ICUs.
Expert Insights on Reliable Information
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Our guest is Dr. Raquel Nara, an infectious disease and critical care physician.
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Dr. Nara is Assistant Professor of Medicine in the Divisions of Infectious Disease and Critical Care Medicine at Cooper Medical School of Rowan University.
00:01:33
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She's a practicing critical care and infectious disease physician, as well as a hospital epidemiologist at Cooper University Hospital in Camden, New Jersey.
00:01:42
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Raquel, welcome to Critical Matters.
00:01:45
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Thank you, Sergio.
00:01:47
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So I'm sure that there's a lot of information that is coming in at a very rapid pace over the last several weeks with this coronavirus.
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And I think that one of the first things that I would like to get at
00:02:01
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is what the World Health Association has called an infodemic of really bad information out there in the internet and the press.
00:02:09
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And if you can maybe start by telling us where are you getting your best information and some resources that we'll later link in the podcast.
00:02:17
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So one of the best sites for the information is a website put in by John Hopkins from CSSE.
00:02:26
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And it is compilation of data sources from WHO, CDC, ECDC, which is the European CDC, NHS, NHC.
00:02:37
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And it allows us to give and gives you a very up-to-date information regarding where we are in terms of numbers, how many have deaths,
00:02:46
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how many people recovered, where's that, while it also gives you information about the critically ill patients, so on and so forth.
00:02:54
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So that's a very good website.
00:02:56
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The Lancet also, if you provide the link, has a little coronavirus library where you can put a lot of information there.
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ID Society will have all of the most recent publications regarding the 2019 novel coronavirus, and it will pull all the literature that has been published as of
Global Statistics and Historical Context
00:03:19
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now.
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So it will pull from JAMA and New England Journal, so on and so forth.
00:03:26
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The CDC has good information relevant for practitioners in the U.S. In a sense, this is where you're going to get your information
00:03:34
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person under investigation criteria, and it's been updated almost like on a, like the, which the criteria change, I think, on February 2nd for the first time.
00:03:49
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But any other update that in regards to how you want to practice and test in the U.S. will be through the CDC website.
00:03:56
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So it's a good resource to have.
00:03:59
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Excellent.
00:03:59
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I think that we will definitely link all these, Raquel, but I think I wanted to start with that because
00:04:04
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Obviously, a lot of our listeners may have not seen a case of this novel coronavirus and might be hearing in the lay press a lot of information and misinformation.
00:04:15
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And I think as clinicians, obviously, we want to have good sources and up-to-date sources, especially in a very fluid situation as an outbreak such as this one.
00:04:26
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So just to give context to our listeners, we're recording this on February the 10th.
00:04:33
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And as of today, the latest report from the WHO indicated that there were 37,000 cases.
00:04:44
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Of those, the majority were in China.
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Outside of China, there's over 300 cases.
00:04:50
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And the fatality rate overall in China was around 800 deaths.
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And this, I'm sure, will be updated very quickly because this is information as of yesterday, which is February 9th.
00:05:01
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So before we start diving into what we know about the coronavirus, maybe you could just give us a very short synopsis of how do we get to this point and what has happened historically with this coronavirus.
00:05:17
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So that's a very good question.
00:05:19
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So just to go back a little bit in time, and I know you gave us an absence of how we got started there.
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I think the Chinese started in Hubei started to notice an increase in cases as of December 8th.
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From December 8th to December 31st,
00:05:42
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most of the cases were linked to having a contact with the seafood market.
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When on January 31st, they made a link, the market was closed on January 1st.
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On January 7th, the novel coronavirus was officially announced as the causative pathogen for the outbreak by China CDC.
00:06:07
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Moving forward from the
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January 7 onward, the number of cases that had a direct link to the Wuhan market has decreased.
Containment Measures and Virus Characteristics
00:06:23
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And I think the last link that I can see was maybe on January 13, where there was a possible contact with somebody who was incubating the infection after being last involved with the market, the Wuhan seafood market.
00:06:41
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And as you know, things have evolved to the point that now the Chinese government has quarantined several cities in China, including Wuhan.
00:06:57
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They have their emergency response at the level one since January 15.
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We've been having strict checking of people going in and out.
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you know, mostly out of China and other places in the world have established have established a path, either some kind of travel restriction for people coming back from China or very strict criteria about how, when they enter the U.S. In a sense, like if you come in and you have a fever or something of that sort, a cough, and you've been
00:07:41
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in China in the past 14 months, you are going to be checked for the coronavirus.
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But even if you're asymptomatic and you come from China, you might be asked to be quarantined at your own house or quarantined in a federal institution for the 14 days that will take to incubate the virus.
00:08:03
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So in terms of diving more into this specific novel outbreak,
00:08:08
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Maybe you could just give us a little bit of context in terms of coronaviruses in general and how they cause disease.
00:08:14
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There's obviously a lot of coronaviruses that cause very mild respiratory disease in humans, but there's also been some novel outbreaks over the last decades that are associated specifically with very severe respiratory distress and something that would be of great interest for critical care physicians in which this might be more like those.
00:08:32
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Can you talk a little bit about that, Raquel?
00:08:34
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Sure.
00:08:35
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So what do we know about the current virus or the coronavirus?
00:08:39
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It's usually, it has the name coronavirus because of the way it looks under electron microscopy, which has a spiked appearance that looks like a crown.
00:08:49
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It's usually a zoonotic transmission where it comes from usually a bat and you have an intermediary host for each one.
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I'll go over that in a minute.
00:09:04
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an intermediary host before it comes to humans.
00:09:07
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So as for very severe coronaviruses in the past, we have heard about SARS and MERS.
00:09:15
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Both of them had been implicated in outbreaks, SARS in 2002, 2003, and MERS later on in 2012.
00:09:24
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However, I just want to take you back a little bit further.
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Like in 2015, the New England Journal of Medicine published a case, published an article on the causes, causative pathogens of pneumonia.
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And in that paper,
Comparisons with Past Outbreaks
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you can see that coronavirus is associated, as a family, has been associated in pneumonia and
00:09:53
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in a significant percentage of cases.
00:10:02
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I wouldn't say 53%, I'm sorry about that.
00:10:05
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It's in a significant number of cases where you do not have a culture positive, bacterial culture positive.
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Moving from there, and just to focus a little bit on MERS,
00:10:21
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and SARS, because most of our clinical knowledge currently now that we are using has been extrapolated from those outbreaks.
00:10:30
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SARS, as I said, the thought is it's a bat virus that got, whose intermediary animal was a civet.
00:10:40
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Civet is a form of cat.
00:10:44
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At that time, when it happened in 2002, 2003, it made more than 8,000 people ill.
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was around 800 deaths.
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So it had a mortality of around 10%.
00:10:55
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The way it's presented, it's a biphasic illness with the patient becoming viremic and subsequently systemically ill with recurrent fever.
00:11:04
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And that progressed to hypoxia and pneumonia in up to 20% of cases.
00:11:10
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We'll progress to ARDS.
00:11:12
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Now, with SARS, we saw a lot of household and healthcare providers being infected.
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And that created the concept of super spreaders that I think we can address at some point.
00:11:27
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With MERS coronavirus, it's also from bats.
00:11:32
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And however, the intermediary host is a camel.
00:11:39
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It made around, in 2012 till now, we had approximately 2,500 persons with 850 deaths.
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Most of those cases happened in Saudi Arabia.
00:11:55
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When we first identified it was in Korea, one patient, a single patient went to an ED there and from there infected around 80 other patients.
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approximately 80 other healthcare providers slash patients.
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In the U.S., we had two cases.
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It usually presents a severe acute respiratory illness, fever and cough and shortness of breath.
00:12:23
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And as I mentioned, it did show some household and healthcare work spread.
00:12:30
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However, it was not sustained as much as we saw it with SARS or what we're seeing right now with the new coronavirus.
00:12:40
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Now, why we say that this 2019 new coronavirus is a little bit, it's not SARS.
00:12:49
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So they did phylogenetics analysis where they looked at the genome of the 2019 new coronavirus and they compared it to different, to other coronavirus.
00:13:03
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And the sequencing clearly showed that
00:13:09
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It's a coronavirus, but it's a different coronavirus than the one with SARS and MERS.
00:13:16
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It does suggest, though, that there is a lineage to BAS.
00:13:20
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That's why I'm saying it probably came through the BAS.
00:13:24
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We don't know yet what is the intermediary host.
Understanding Epidemics and Pandemics
00:13:29
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Excellent.
00:13:30
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And in terms of diving a little bit more into this specific outbreak,
00:13:34
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Before we talk about Dota, there were some terms I wanted to ask you about because I've been reading about this in the last several weeks, and these are obviously things that I think are very common in the world of epidemiology, but I think are relevant, especially as clinicians try to understand what's going on and how this compares to some of the coronavirus outbreaks that you mentioned.
00:13:55
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And the first, I mean, would be just what's the difference between an epidemic and a pandemic, and where are we today?
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Okay, so an epidemic is a...
00:14:05
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sudden increase in the number of cases of a disease above your normal.
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So for instance, if you see a spike in diabetes, like in kids, you link that to obesity and you see an epidemic of obesity in kids in the US, that would be an epidemic.
00:14:22
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So you have a sudden spike from what your endemic rate is.
00:14:26
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And that's what we saw with SARS in 2003.
00:14:29
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And that's what we're seeing now with the coronavirus.
00:14:34
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We've never seen cases of the 2019 new coronavirus, and suddenly we see this huge increase that will make concern for epidemic.
00:14:46
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The pandemic, though, it refers to an epidemic that has spread over several countries and continents and maintained transmission in those places.
00:14:57
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So the reason the current epidemic is not the pandemic yet is because even though we have
00:15:05
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more than 27 other countries involved, we did not see sustained transmission of the virus in those other countries.
00:15:14
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It was the exception of few countries like in Hong Kong and Macau, but it's not something that's been sustained and been to the point that we can call it a pandemic.
00:15:26
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So just to give you an idea of an example of a pandemic,
00:15:30
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HIV AIDS in the 1980s was considered a pandemic.
00:15:34
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The way it was spreading and how many countries were involved, that put in the pandemic.
00:15:40
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H1N1, back in the 2008, 2009 time, also was considered a pandemic.
00:15:47
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Spanish flu in 1918 was considered a pandemic.
00:15:50
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So it's really depending on transmission to other countries and sustaining transmission amongst the population.
00:15:59
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That's very useful.
00:16:00
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And in terms of understanding the specific dynamics of the epidemic itself, two terms that came up several times in multiple of these or first studies were the epidemic doubling time and the basic reproductive number.
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Could you shed some light into those, Raquel?
00:16:19
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Yeah.
00:16:19
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So the epidemic doubling time characterized the sequence of times at which the incidence of the cases had doubled.
00:16:29
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So an increase in doubling time means that the outbreak is slowing down because it means that it's taking longer to infect more people.
00:16:40
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So that's for doubling time.
00:16:42
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For basic reproductive time, we're what we call an R0, and it's an R with a zero underscore in the lower part of the R. And this means the number of cases one person,
00:16:59
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can infect on average.
00:17:01
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So for instance, for the 2019 new coronavirus, the R0 has been ranging between 2.4 to 3.5.
00:17:09
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It depends on where you're talking in the outbreak, in time in the outbreak.
00:17:14
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At this point in time, it's around 2.4, meaning each person will spread the virus to 2.4 persons.
00:17:22
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Anything above one would suggest that the epidemic is still progressing and we did not control it.
00:17:29
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We know we controlled an epidemic when the R0 is under 1.
00:17:34
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So this is a way of looking at the progression of an outbreak.
00:17:41
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And I think that another aspect of this that's very important is as we're very early in identifying a novel outbreak, there's also numbers that are just related to reporting and identification, right?
00:17:55
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We don't really know yet.
00:17:57
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I mean, there's more and more people are being tested now
00:17:59
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But it's very hard, I mean, to really know what the R0 is right now because that's a very fluid number, I would presume.
00:18:08
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Absolutely.
00:18:08
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So
Clinical Features of Coronavirus
00:18:09
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the R0 and the epidemic double time is very much affected about how many cases are there that we don't know about.
00:18:16
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So it's all dependent on how good we are about testing.
00:18:21
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Right now, the testing is geared towards people who are sick or, you know, sick with fever or cough.
00:18:28
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There just recently published a paper, you know, one patient presented with abdominal pain, had no cough and no fever.
00:18:36
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So how many of those cases we are missing and we don't know about?
00:18:41
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And it's going to be hard to know.
00:18:43
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So the doubling time, as well as the R0, are affected by our limitations in testing for the virus.
00:18:51
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whether it's availability of the testing kits or bringing those patients up to our attention.
00:19:00
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Because remember, as opposed to SARS, where if you had the infection or the virus, you will show symptoms.
00:19:11
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So your pyramid, because we talk a lot about pyramids in epidemics, your pyramid, surveillance pyramid,
00:19:20
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has a tipped shape, which means the tip of the pyramid is facing down, meaning the clinical detection for SARS is very high.
00:19:29
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You have the virus, often you have clinical symptoms.
00:19:33
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With this new coronavirus, which seems to be the case, is a certain number of people are presenting with severe and fatal disease, but there is a significant number of people that we don't know who they are.
00:19:47
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that might have mild or asymptomatic presentation.
00:19:52
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A group of that would be children, for instance.
00:19:57
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Excellent.
00:19:57
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And I think that we'll dive into a little bit more, but I have two more questions or two more terms that I wanted to get your thoughts on.
00:20:04
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So there's this concept of pneumonia of unknown etiology, which I think from a surveillance standpoint was very important because that is what tipped people in China
00:20:14
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into something was going on and led to the identification of this novel coronavirus.
00:20:19
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Could you tell us a little bit about what it really stands for?
00:20:22
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What is an example?
00:20:23
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What are the characteristics of a pneumonia of unknown origin and how people should think about these?
00:20:29
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So pneumonia of unknown etiology would be a pneumonia where you do sputum cultures and you do other available PCRs and you do not find any clear etiology for those.
00:20:43
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And that's what I think tipped, was those patients had similar presentation, similar scan findings, and yet, and they presented in high numbers, and yet we couldn't find the culture or any of the PCRs that will, even the SARS coronavirus, that will suggest that it has a known etiology.
00:21:08
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So I think when SARS first
00:21:12
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came up, it was also known etiology until the virus was identified.
00:21:17
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And I think that's what happened with the 2019 new coronavirus, which, by the way, still doesn't have a final name.
00:21:26
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This is just a temporary name.
00:21:30
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That was identified in those sputum when you have regular workup for pneumonia, which would be sputum culture, influenza, PCR, so on and so forth.
00:21:41
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And I think also, just to recap for our clinicians, because if you see a case, right, like this in terms of thinking about it, no causative organism by extensive testing, usually these patients present with true pneumonia in clinical picture, so have a real fever, have real evidence radiographically of pneumonia.
00:22:02
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I think that also important to mention, Raquel, is that they usually have either low lymphocytes, normal or low white count,
00:22:11
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and don't respond to usual treatments with antibiotics, right?
00:22:14
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So these are all things that when you see this together, you should start thinking, could this be some viral pneumonia?
00:22:20
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Could this be something that is novel?
00:22:23
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Correct.
00:22:24
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And I guess- But the term has been applied, I'm sorry, the term has been applied for cases where, like let's say strep pneumonia was, end up being identified as the organism.
00:22:36
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But when you did the culture and extensive workup, you couldn't find an etiology.
00:22:40
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Just to put things into concept that, yes, you do need to have the fever, the pneumonia, and the findings of pneumonia and extensive workup that did not show a specific virus or a specific organism etiology.
00:22:54
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Okay.
00:22:55
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And I guess the other side of that coin or the extreme in this particular outbreak, just to share the term, is the idea of the
00:23:06
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NCIP or novel coronavirus infected pneumonia, which is, I think is patients who present with severe pneumonia who now have a confirmed coronavirus diagnosis, right?
00:23:17
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That's the syndrome that we're going to talk about today.
00:23:19
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Okay, excellent.
00:23:21
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So let's dive into the novel coronavirus infected pneumonia and how this might be of relevance to our listeners and our clinicians in the ICU.
00:23:32
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And maybe we can start by telling us
00:23:34
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Who are we seeing right now in hospitals?
00:23:37
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Who's getting sick?
00:23:38
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And you did mention something about kids not being part of that cohort, but maybe you can just tell us what are we seeing in terms of patients presenting at least for care and in the hospital?
00:23:48
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All right.
00:23:49
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So all we know for this current outbreak is what we have pulled from the different papers published in New England, Lancet, and most recently JAMA.
00:24:03
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And what we know about those patients who present is that by the time they present to a hospital, they were pretty sick.
00:24:11
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They had a very high percentage of them presented with fever, which seems to be a common denominator.
00:24:19
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They also have fatigue, dry cough.
00:24:25
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all two things that you would expect a viral illness would give those patients, an individual.
00:24:33
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Diarrhea seems to be present in a good percentage of those patients, as well as the abdominal pain to a lesser extent.
00:24:44
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So most of the patients, what seems to be a constant denominator is the fever.
00:24:51
Speaker
Of the 138 patients presented in the
00:24:54
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JAMA paper published on February 7, 2020, was that 136 out of the 138 patients had fever.
00:25:06
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And then the next common one would be fatigue, which is 96% of those patients having fatigue, followed by a dry cough.
00:25:14
Speaker
So those seem to be a common presenting illness or presentation for those patients.
00:25:20
Speaker
It's
00:25:22
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Is there a particular predilection for certain ages or for patients who have certain comorbidities?
00:25:28
Speaker
So again, the ones who are presenting to the hospital, so this would be the tip of your iceberg, the ones who are the sickest, they tend to be male.
00:25:40
Speaker
I think part of the bias with the male is because where the outbreak started, it was in a market where there was a predominance of male workers.
00:25:52
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And most of them had some kind of cardiovascular risk factors as part of their comorbidities.
00:26:02
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So of the 138 patients who presented to the hospital,
00:26:09
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43% had hypertension, 20% had cardiovascular disease, and 14% had diabetes.
00:26:23
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So there is some kind of predisposition there.
00:26:26
Speaker
Again, the outbreak is still too early to make a linkage, to make it, you know, those people are sicker.
Mortality and Transmission Dynamics
00:26:34
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than others, but those are the ones who are presenting to a hospital.
00:26:39
Speaker
And as you said, I mean, this is a very fluid situation, and a lot of the information that we have is based on the patients who have seeked medical care and who have been hospitalized.
00:26:50
Speaker
And among those that we know, I mean, that have been confirmed, what's the current mortality, and how does this compare to maybe some of the other outbreaks that you discussed earlier?
00:27:00
Speaker
Right.
00:27:00
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So as of now, the mortality for SARS is around between 2.2 to 2.4%.
00:27:08
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If you compare that to your influenza, for instance, every year influenza will have a mortality of 0.1%.
00:27:18
Speaker
But if you put things into perspective, influenza tends to infect more people.
00:27:25
Speaker
So to give you an idea, as of now, we have
00:27:29
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15 million Americans infected with influenza.
00:27:33
Speaker
So we do have a higher number of influenza cases and the mortality tends to be in the 30,000 a year, bringing down your mortality with seasonal flu to be around 0.1%.
00:27:50
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And I think that, so we're talking about a mortality of 2.2%, but obviously a very
00:27:55
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dynamic situation with the epidemic.
00:27:58
Speaker
So we still don't know, but it's significantly higher than percent wise than influenza.
00:28:03
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And I think that ultimately what I would say is we should take all of these viruses, including influenza, very seriously, because if we don't put in place the proper interventions, it's when things really can spread and get out of context.
00:28:18
Speaker
So Raquel, tell me a little bit more about the natural history.
00:28:23
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So we talked about how these patients present
00:28:25
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with the fever, the cough.
00:28:27
Speaker
But it seems, I mean, when you look at these natural history of these patients, there seems to be a period since the first symptoms to when they really start getting sicker and when they might develop worsening respiratory failure that would lead them to an ICU.
00:28:44
Speaker
If you could share with us a little bit of what we know so far, understanding that it's limited on small case numbers of those 130 plus patients, et cetera.
00:28:53
Speaker
Yes.
00:28:54
Speaker
So, um,
00:28:55
Speaker
What we know so far is, as you said, very fluid, but for the patients who tend to present to the hospital, we know that by the time they present, they have, from time of infection to presentation is usually about seven days.
00:29:12
Speaker
We also know that from time of presentation to ICU admission is around eight days.
00:29:21
Speaker
And I think that has been very nicely delineated in this study.
00:29:25
Speaker
recent JAMA paper that I just quoted.
00:29:28
Speaker
If the patient will end up in the ICU, usually the time of hospital admission to ICU admission is usually one day.
00:29:37
Speaker
So they tend to deteriorate, as you can see, pretty rapidly.
00:29:42
Speaker
And the
00:29:44
Speaker
just to give you an idea about, you know, to compare to others, infections or other progression, like your white counts tend also to start drifting down within three or five days of admission with an increase in your renal dysfunction starts to be seen around day nine of admission, where you see the people who tend to be
00:30:11
Speaker
the non-survivors or the ones who are more likely to die, you start seeing them going into an AKI.
00:30:20
Speaker
So this is just a few trends that, you know, to bring to the attention.
00:30:25
Speaker
Again, by the time they present, it's usually seven days of infection.
00:30:28
Speaker
Okay.
00:30:30
Speaker
And in terms of before we start diving more into the specific clinical behavior or therapeutics and diagnosis,
00:30:41
Speaker
Can you just tell us what we know so far about how this is spreading and being transmitted right now?
00:30:47
Speaker
Because I think that we are probably getting to a point where just asking if you were in Hunan in China is not going to be enough.
00:30:55
Speaker
I mean, there's other ways people now can be infected.
00:30:58
Speaker
So just understanding how it's transmitted, I think, is important, but also in terms of protection for health care providers.
00:31:06
Speaker
Right.
00:31:06
Speaker
So the transmissibility, again, this is, as you said, is very full, but as we know now, it's droplet.
00:31:12
Speaker
Droplet transmission with possible fecal-oral transmission.
00:31:19
Speaker
So that will put you into, if you want to think of it as, you know, what kind of PPE I'm going to put on.
00:31:26
Speaker
For droplet, you usually wear a surgical mask.
00:31:31
Speaker
For droplet,
00:31:33
Speaker
contact, you usually put a gown.
00:31:35
Speaker
Having said that, at this point in time, because of the novelty of the virus and because of the way the epidemic is behaving, we still are required to put in a N95 mask with goggles for eye protection along with your gown and your gloves.
00:32:00
Speaker
And I have to say that hand hygiene is
00:32:03
Speaker
is one of the most important measures we can implement dealing with this kind of outbreaks.
00:32:11
Speaker
I can't emphasize that enough.
00:32:14
Speaker
So an alcohol-based hand hygiene product that has at least 60% alcohol is what the CDC is recommending.
00:32:22
Speaker
Excellent.
00:32:23
Speaker
That I think is very important.
00:32:24
Speaker
We did talk about a little bit at the beginning, you did allude to the super spreading events.
00:32:30
Speaker
And can you talk about that and how it impacts healthcare workers and what we know so far?
00:32:36
Speaker
Yeah.
00:32:37
Speaker
So super spreaders were first described with the SARS outbreak.
00:32:45
Speaker
And part of the thing is that, if you'll recall at that time, patients were admitted with SARS and with SARS,
00:32:58
Speaker
the contact person being somebody who was in the hotel or who didn't have direct contact with them.
00:33:06
Speaker
And the thought was that the transmission happened through either a convection system in some of the facilities.
Healthcare Precautions and Safety Measures
00:33:18
Speaker
The other way that you can think of it is when the patients have been going from the Canadian group, when the patient traveled, I think it was from Hong Kong,
00:33:27
Speaker
and went to Canada and then infected in that institution around 44 other people.
00:33:34
Speaker
At that time, it was felt that most of the transmission that happened in our healthcare workers were related to high-risk, what we call high-risk behaviors that will predispose the healthcare workers to specific infections.
00:33:51
Speaker
And just to go over those high-risk behaviors, I'm just going to
00:33:55
Speaker
I want to cite a few because I think there is importance in our line of practice.
00:34:02
Speaker
For instance, non-invasive ventilation, putting the patient with a face mask or a vapotherm, anything above six liters per minute has been associated with the super spreading effect.
00:34:16
Speaker
Staff working whilst experiencing symptoms.
00:34:19
Speaker
So if you come to work and we all think guilty of that,
00:34:22
Speaker
and you have a slight fever or a slight cough, you just suck it up and do it, has been associated with a super spreading effect.
00:34:30
Speaker
Doing CPR or resuscitation during colds, you can imagine how chaotic that can be, has been a risk factor.
00:34:39
Speaker
And then moving from there, if you, let's say you have what we call like a common changing area for the staff, those places that have those kinds of facilities or facilities,
00:34:52
Speaker
has been associated with spreading.
00:34:54
Speaker
And again, for the patients, like, you know, from staff to patient or patient to patient, it was found that rooms that had core share, like if you're not single-roomed or your room was more than one person, if the distance between one bed and the other is less than one meter, it seems to have significantly associated with spread from patient to patient.
00:35:17
Speaker
As for procedures that has been associated with increased transmission to healthcare workers,
00:35:22
Speaker
I want to cite tracheal intubation.
00:35:25
Speaker
I mentioned already non-invasive ventilation.
00:35:28
Speaker
Doing a tracheostomy and manual ventilation of the patient before intubating.
00:35:35
Speaker
Think of it.
00:35:36
Speaker
Once you intubate the patient, you are in a closed system and you are less likely to transmit the infection.
00:35:42
Speaker
As long as you are in an open system of non-invasive ventilation or bagging of the patient, that tends to aerosolize the
00:35:52
Speaker
the organism or the virus and contribute to the super spreading effect.
00:35:58
Speaker
So before we move on, in terms of precautions, these patients, if we have a suspected or confirmed case, should be placed in droplet precautions.
00:36:09
Speaker
If you have negative isolation rooms, is that something that you recommend for these patients, Raquel, in the ICU?
00:36:15
Speaker
So at this
00:36:15
Speaker
Yes.
00:36:16
Speaker
At this point in time, in ICU euphoric, if you admit to a patient, you should put them in airborne precautions.
00:36:22
Speaker
So it would be a negative pressured room.
00:36:25
Speaker
You will wear an N95 mask and you will put a goggle.
00:36:30
Speaker
And then what we usually don't do for tuberculosis is we put on a gown and gloves.
00:36:39
Speaker
Do you cover your head?
00:36:41
Speaker
you don't have to cover your hair, even though the media portrays that you're covering your hair and your shoes.
00:36:46
Speaker
This is not yet recommended by the CDC.
00:36:48
Speaker
Okay.
00:36:50
Speaker
And that is obviously very important.
00:36:51
Speaker
I think that especially, like you said, in emergency situations, high risk procedures for us would be manipulating the airway before intubation, which I think is something that we obviously in a lot of these patients, if they get really sick, might have to do.
00:37:07
Speaker
So I think these are very, very, very important.
00:37:10
Speaker
Now,
00:37:11
Speaker
Talk a little bit about the 14-day quarantine and where that information came from.
00:37:17
Speaker
You did mention earlier, Raquel, that I could be asymptomatic and be contagious, right?
00:37:22
Speaker
So the idea is that in 14 days, either you're not contagious anymore or you've declared yourself.
00:37:28
Speaker
Is that the thought process?
00:37:29
Speaker
Well, that remains an answer.
00:37:31
Speaker
So what we think is if you got the virus, you will show some kind of symptoms within 14 days.
00:37:38
Speaker
That seems to be the incubation period for
00:37:41
Speaker
the virus from what we saw early on in the outbreak.
00:37:44
Speaker
So patients who have been exposed often, like for instance, looking at the closure of the market, the market was closed on the 31st or the first, the last case seen with the connection with the market was on the 13th of January.
00:37:59
Speaker
So that puts into perspective that probably the incubation period is 14 days.
00:38:05
Speaker
What we don't have data so far is, are you shedding the virus after
00:38:13
Speaker
after you recover.
00:38:15
Speaker
We don't have an answer for that.
00:38:17
Speaker
So what places have been done, for instance, is recommending to check a PCR at the end when you're done with the illness twice.
00:38:29
Speaker
And if you're twice negative, you can say, well, probably you're not infective anymore.
00:38:34
Speaker
We don't have a lot of data there.
00:38:37
Speaker
As for transmissibility, if you are not
00:38:41
Speaker
like if you're not showing signs.
00:38:43
Speaker
That first came to light with the German case, and I'm going to go briefly over that.
00:38:49
Speaker
So the first cases in Germany happened after an automobile meeting that involved a person from Shanghai.
00:39:00
Speaker
That person from Shanghai had hosted her parents' tour from Hubei in her home in Shanghai before she traveled to Germany.
00:39:12
Speaker
the parents reportedly were okay, did not show signs and symptoms when she was there.
00:39:16
Speaker
They started to be symptomatic after she left.
00:39:20
Speaker
She was okay during her meeting.
00:39:22
Speaker
And then it's only on her way back to Shanghai in the airplane that she started to show signs and symptoms of being infected.
00:39:31
Speaker
One of the co-workers that were working with her got her infections.
00:39:38
Speaker
the coronavirus.
00:39:39
Speaker
And that constituted the first case of coronavirus in Germany and kind of pointed to us that you do have asymptomatic transmission.
00:39:50
Speaker
However, we do know, for instance, for SARS, that one of the theories that we have this super spreading effect is that you have peak viremia around day 14 of sickness
00:40:04
Speaker
usually those patients are in the hospital at that point.
00:40:07
Speaker
So they are bound to be shedding more.
00:40:09
Speaker
So that could explain a little bit of the super spreading effect.
00:40:13
Speaker
With this virus, we don't have this kind of information.
00:40:16
Speaker
We also have a bias in the case definition.
00:40:20
Speaker
As I mentioned before, for instance, in the U.S. and most of the world, you're only testing people who present with fever and or shortness of breath and or
00:40:32
Speaker
travel to China or contact with somebody who had the coronavirus.
00:40:37
Speaker
So the person who presents with a slight cough and no fever and no contact with somebody who has the coronavirus will not be checked.
00:40:45
Speaker
Doesn't mean he doesn't have it.
00:40:47
Speaker
He won't be checked.
00:40:48
Speaker
So that creates a bias in detection.
00:40:51
Speaker
And that's what I call a bias of the case definition.
00:40:56
Speaker
The other group of people is children.
00:40:58
Speaker
who usually are asymptomatic or have very little signs of infection.
00:41:02
Speaker
And those have, you know, also will contribute to transmissibility of the virus.
00:41:12
Speaker
And I think it's important because what we don't know yet here is like those non-very sick patients, how many are they, where are they?
Diagnosis Process
00:41:20
Speaker
And we're talking like a 2.2% mortality is based on people who have been tested in the hospital, which by definition,
00:41:28
Speaker
has preselected to those who have more symptoms or worse symptoms to present for care, right?
00:41:34
Speaker
Right.
00:41:35
Speaker
So in the hospital, I want to clarify, in the hospital or outside of the hospital.
00:41:38
Speaker
So if the patients are not sick enough to be admitted, there have been recommendations to implement care outside of the hospital and just keep on observing because at that point in time, it's still all supportive treatment.
00:41:51
Speaker
And until we have zero surveys done for the first wave of this epidemic,
00:41:57
Speaker
we won't really know how transmissibility happens.
00:41:59
Speaker
So I think there is more to come in a few months when we start doing more testing and surveillance, you know, serology surveillance, so on and so forth to identify the extent of this epidemic.
00:42:13
Speaker
So let's dive into a little bit more detail about what potentially could be the type of patients that listeners of the podcast might encounter.
00:42:24
Speaker
And I think, like you mentioned earlier, Raquel,
00:42:27
Speaker
It really starts with these patients usually will seek hospital care or be admitted to the hospital seven days after starting with symptoms.
00:42:35
Speaker
And once they get admitted, the ones who end up being very sick and will probably have the more severe forms of the novel coronavirus infected pneumonia are coming to the ICU within 24 hours of admission, developing ARDS, requiring higher levels of support in day nine,
00:42:58
Speaker
10, 11, and forward.
00:43:00
Speaker
So let's start by, we talked about obviously some of the things that would make you think about these patients in terms of the pneumonia of unknown etiology or people who have the right travel history or contact history.
00:43:16
Speaker
But in terms of those patients that we see and we suspect may have a normal coronavirus associated pneumonia, we talked about how we should isolate them.
00:43:25
Speaker
How do we confirm the diagnosis?
00:43:28
Speaker
So the diagnosis at this point in time is done through the CDC in the U.S. And you will need a specimen.
00:43:37
Speaker
You will need to collect specimens from lower respiratory tract, upper respiratory tract, and serum specimens.
00:43:45
Speaker
This is an active discussion with the CDC and your local DOH, you know, because first the patient has to meet criteria of person under investigation or PUI.
00:43:56
Speaker
And once this criteria is met, those are the specimens that need to be sent.
00:44:00
Speaker
Your lab will collaborate with those institutions so they can send those specimens.
00:44:06
Speaker
Then additional specimens will be taken, and those include the stool, urine.
00:44:11
Speaker
They might be collected and stored or collected and sent.
00:44:14
Speaker
This is the prerogative of the CDC.
00:44:17
Speaker
The CDC will, yes.
00:44:19
Speaker
Yeah, and I was going to ask, and the diagnosis in the CDC is confirmed by a real-time test
00:44:26
Speaker
reverse transfer states PCR, right?
00:44:28
Speaker
That's the way we're diagnosing this.
00:44:30
Speaker
That's how we're diagnosing it.
00:44:32
Speaker
So, Artie.
00:44:33
Speaker
So, I think on February 2nd, if I'm not mistaken, the FDA released approval for local, for state, at the state level, you can have testing done.
00:44:44
Speaker
So, the CDC shipped a whole lot of kits that will allow the test to be done at the state level.
00:44:49
Speaker
So, not yet commercial, but we're getting there, I think.
00:44:53
Speaker
And I think that we can...
00:44:56
Speaker
review, I think, for our listeners, some of the characteristics that would make a patient a likely suspect as opposed to a false alarm.
00:45:06
Speaker
I think that obviously with all the press, some people might feel that, oh my God, this person has, maybe has coronavirus.
00:45:14
Speaker
And really, when you really ask about the travel history, it's not present.
00:45:17
Speaker
But more importantly, clinically, it sounds that, like you mentioned, real documented fever is important.
00:45:24
Speaker
symptoms of a respiratory infection with cough that is usually dry are very important.
00:45:30
Speaker
Clearly these patients, from what I have seen, Raquel, please correct me if I'm wrong, but consistently the ones that are hospitalized and especially those who are sicker have objective evidence of pneumonia, usually by bilateral on radiographic, either x-ray or CT, which I think is important, right?
00:45:48
Speaker
I mean, this is something that is very important in terms of qualifying
00:45:53
Speaker
And then I think the last ones would be that these patients usually have either low white counts or lymphopenia, and they really have no other source of infection.
00:46:03
Speaker
So if you are seeing a bacterial pneumonia, it's not necessarily due to a novel coronavirus, right?
00:46:10
Speaker
I think it's very important also in terms of thinking about these patients.
00:46:13
Speaker
That's correct.
00:46:14
Speaker
Not to say that they cannot develop a nosocomial bacterial infection.
00:46:18
Speaker
So that can happen down the line, like we've seen with influenza or
00:46:23
Speaker
even not nosocomial, you know, having the viral infection and presenting later on with the bacterial pneumonia.
Complications and Pathophysiology
00:46:29
Speaker
But for now, the person under investigation criteria is very well defined by the CDC.
00:46:35
Speaker
And as you said, you have to have fever or assigned symptoms of low respiratory illness, like a cough or shortness of breath.
00:46:43
Speaker
And you have to have contact with a person who
00:46:47
Speaker
who has either close contact with a lab-confirmed coronavirus infection within the past 14 days, or a travel history to Hubei province in China.
00:47:01
Speaker
Now, if you travel to mainland China within the past 14 days and have fevers and signs and symptoms of lower respiratory tract infection,
00:47:13
Speaker
that will require you to be hospitalized.
00:47:15
Speaker
Like if you present to the hospital with those symptoms and you have a history of being in China, then within the past 14 days, then you will qualify to be tested for the 2019 coronavirus.
00:47:29
Speaker
Again, fever is very subjective, right?
00:47:32
Speaker
So if you take Tylenol or Motrin, you might mask a fever.
00:47:35
Speaker
So those are all relevant questions to ask your patient to see if they have any other condition that will mask the fever.
00:47:43
Speaker
And that's why they might not be mounting a fever.
00:47:47
Speaker
And we still have small data sets in terms of knowing what happens to the sicker patients.
00:47:53
Speaker
But before we dive into a little bit more of the treatment,
00:47:57
Speaker
There's two questions I wanted to ask you, Raquel.
00:48:00
Speaker
One is, do we know what the pathophysiology is and why it's mostly respiratory?
00:48:05
Speaker
And number two is, what other non-restrict complications have been described in the sicker patients?
00:48:13
Speaker
Those are very good questions.
00:48:15
Speaker
So the short answer is we don't really know the pathophysiology.
00:48:20
Speaker
However, the longer answer is we can extrapolate from what we know from SARS-CoV-2.
00:48:27
Speaker
And the thought is that the pathogenesis of SARS, for instance, seems to be related to a receptor in your lung tissues.
00:48:47
Speaker
And that receptor is an ACE2, ACE angiotensin-converting enzyme 2.
00:48:54
Speaker
which is a metallopeptidase that is expressed mostly in human organs.
00:48:59
Speaker
And once the virus enters the cell through this receptor, it tends to bring in or pull in all kinds of fluid giving you into the alveolar space, causing this kind of dysregulation.
00:49:17
Speaker
that we see enhanced progression to ARDS or SARS, because this is what has been described with SARS.
00:49:27
Speaker
Coronavirus preliminary analysis showed that the 2019 new cause coronavirus has some of the amino acids homology similar to the SARS coronavirus.
00:49:42
Speaker
And that's how we think it might be the same pathophysiology.
Treatments and Trials
00:49:47
Speaker
We carry this receptor in many organs.
00:49:51
Speaker
We have respiratory, intestinal mucosal, venal tubes, neurons, and lymphoid slash reticolendothelial system.
00:50:00
Speaker
And when you think of it, the way the virus is presenting, if you let me just for one second go over that, for instance, the leukopenia, that will explain that.
00:50:09
Speaker
The fact that you have some patients presenting with diarrhea and GI discomfort,
00:50:15
Speaker
That also will explain that.
00:50:18
Speaker
If you look at the, even though patients tend to develop severe AKI requiring potentially renal replacement therapy later on in the course of on day nine, upon presentation, quoting the JAMA paper, their creatinine was slightly, was
00:50:42
Speaker
was slightly above normal.
00:50:46
Speaker
So that makes you think that there might be a component where you have a, where those receptors are being affected.
00:51:00
Speaker
Interesting.
00:51:00
Speaker
And like you said, I mean, this is extrapolating from what we know of the previous coronavirus severe infections.
00:51:07
Speaker
And in terms of, you did mention some of the
00:51:11
Speaker
the systems that might be affected.
00:51:13
Speaker
Are there other findings that are non-respiratory complications that are of significance?
00:51:20
Speaker
Yeah.
00:51:20
Speaker
So most of the patients, the complication-wise was related to arrhythmias.
00:51:27
Speaker
So it was respiratory, then arrhythmias.
00:51:29
Speaker
And then some of them, I think, developed shock.
00:51:34
Speaker
Okay.
00:51:35
Speaker
So just, I mean, things to have in mind.
00:51:37
Speaker
Let's talk about treatment now.
00:51:39
Speaker
We did talk about
00:51:40
Speaker
the isolation precautions and the proper protective gear that a clinician should use.
00:51:48
Speaker
We talked about what constitutes a suspected case and how we should obviously engage our local health authorities, but also CDC to confirm the diagnosis.
00:51:58
Speaker
Now let's assume that we have a patient who is admitted to our ICU who we've confirmed has coronavirus.
00:52:05
Speaker
How do we treat that patient based on what we know today, Raquel?
00:52:09
Speaker
So most of the literature, so supportive care is what we know works.
00:52:16
Speaker
However, from the SARS outbreak, some antiviral concoctions have been tried in the past and have shown some animal data, some in vitro data that it might work.
00:52:29
Speaker
I'm going to go over some of the treatments that you should not try, and that would be ribavirin.
00:52:35
Speaker
And the reason is, even though there's like a good number of papers, I think around 24 papers published on the use of ribavirin, they never used a controlled group to compare.
00:52:48
Speaker
They also saw a high number, like 36% of those patients developed hemolysis, making the risk of using ribavirin kind of high.
00:52:58
Speaker
Those were used mostly in a Toronto outbreak, like what they saw in Toronto.
00:53:04
Speaker
So the data is very inconclusive, and there is a potential for harm.
00:53:10
Speaker
The other one that you might hear about is corticosteroids.
00:53:13
Speaker
Even in the most recent paper published, they did mention corticosteroids used.
00:53:19
Speaker
I will caution against that.
00:53:22
Speaker
The data is very inconclusive.
00:53:23
Speaker
There is some suggestion that it could be harmful for the patient, and it could potentiate further transmission of the virus.
00:53:33
Speaker
So you prolong the viremia, you prolong shedding of the virus.
00:53:38
Speaker
So there is too many.
00:53:42
Speaker
I think at the end, it might be more harmful than useful.
00:53:44
Speaker
However, immediately in the SARS period, when they used steroids,
00:53:49
Speaker
They saw resolution of fever, which is expected, and improvement of the lung consolidation.
00:53:57
Speaker
Again, I would caution against the use of corticosteroids.
00:54:03
Speaker
Now, other treatment that have been tried would be interferon alpha.
00:54:11
Speaker
And it's only two studies that have shown that use that.
00:54:13
Speaker
It's very inconclusive.
00:54:16
Speaker
And the
00:54:18
Speaker
They only showed benefit in use of steroids that I already told you not to use.
00:54:23
Speaker
And I think those patients, everything was thrown at them.
00:54:27
Speaker
So it's really hard to say interferon alpha steroids, what made the difference?
00:54:31
Speaker
It was too many interventions at the same time.
00:54:35
Speaker
Convalescent plasma seemed to be promising.
00:54:40
Speaker
However, we don't have enough studies.
00:54:43
Speaker
And those were done...
00:54:46
Speaker
along other treatments.
00:54:49
Speaker
So it's hard to say conclusively that it's made a difference.
00:54:53
Speaker
Two other treatments stand out, and this is the protease inhibitors, so drugs that we are using for HIV.
00:55:01
Speaker
Again, this is SARS.
00:55:02
Speaker
So back then, Kalitra, which is lopinavir, ritonavir, was part of your backbone for treatment of HIV, and they tried that treatment for SARS.
00:55:16
Speaker
The studies were inconclusive in the sense there was too many interventions done at the same time.
00:55:21
Speaker
However, more recently, with this current outbreak, we had reports that in Thailand, they used the combination successfully.
00:55:30
Speaker
And there is currently an ongoing randomized trial where they're using the combination to see if it's helpful.
00:55:40
Speaker
So that would be, for me, one of the reasonable options.
00:55:44
Speaker
In those two trials that used lopinavir and ritonavir, they used 400 milligrams of lopinavir
00:55:51
Speaker
Ritonavir, 100 milligrams, both are oral meds that you give every 12 hours.
00:55:59
Speaker
The death rate from the lopinavir, ritonavir group was 2.3% compared to 15.6%.
00:56:05
Speaker
This is, again, SARS.
00:56:05
Speaker
And if you used it as a rescue, it was 12.9%.
00:56:16
Speaker
in the rescue compared to a control of 14%.
00:56:19
Speaker
So if you use later on in the course.
00:56:22
Speaker
So there is logic.
00:56:23
Speaker
This was a study that was published, that came out of Hong Kong Medical Journal in 2003.
00:56:31
Speaker
And the other one that came from Thorax in 2004 explored the same drugs and the composite outcomes was severe hypoxemia and death.
00:56:43
Speaker
And the lopinavir, ritonavir group,
00:56:46
Speaker
had a better outcome.
00:56:47
Speaker
So I don't think given the tolerability of this drug, that if we are faced with this situation, it wouldn't be a bad idea to try either one.
00:56:58
Speaker
Of course, when, if we do have a case, this is going to be a decision made along with the CDC that will help us with those kinds of decisions.
00:57:07
Speaker
I'm assuming.
00:57:08
Speaker
Absolutely.
00:57:09
Speaker
Given how recent and how novel this is.
00:57:12
Speaker
Now, the other drug I want to mention is because it was used in a patient in Washington, and that's called Remdesivir, or it has a number still, which is GCS5734.
00:57:27
Speaker
And it was obtained as a compassionate use.
00:57:30
Speaker
It was used on day seven of illness.
00:57:32
Speaker
It seems at that point, if you look at the case report, the patient starts to have more respiratory symptoms.
00:57:37
Speaker
I want to point out that this antiviral agent was initially developed for Ebola and Marburg viruses and has been on as an accelerated type of development.
00:57:50
Speaker
And then it turns out that it works against coronavirus.
00:57:53
Speaker
And the way it works against coronavirus is that it inhibits the proofreading mechanism that the virus has once it becomes mutated.
00:58:04
Speaker
Now that the virus is mutated, it has a lower level of resistance towards the drug.
00:58:14
Speaker
So this will impair fitness and virulence of the virus.
00:58:19
Speaker
And the other two questions I was going to ask you before we kind of recap the treatment was I know that in the Chinese series, they've used Tamiflu or Sotamivir in a lot of cases.
00:58:32
Speaker
And then in a lot of cases, people have added antibiotics for presumed or potential superimposed bacterial infections.
00:58:40
Speaker
Any comments on what we know so far about that, Raquel?
00:58:43
Speaker
Even the authors concluded that it doesn't work for the coronavirus.
00:58:47
Speaker
So I don't think the Ose tamivir will work for this virus.
00:58:51
Speaker
Okay.
00:58:53
Speaker
And what about antibiotics?
00:58:54
Speaker
What would be your approach to this?
00:58:56
Speaker
My approach will be like we would do for any, you know, those patients are at risk, not that you have a damaged epithelium, you are at risk of, you know, getting a bacterial pneumonia.
Future Research and Misinformation
00:59:06
Speaker
So if you have BALs or if you have sputum, you know, sputum traps that suggest positive bacterial culture, by all means, treat it.
00:59:15
Speaker
If those patients are not yet in renal failure, we do know that procalcitonin, and not that I'm advocating for using that, but most of the series so far,
00:59:26
Speaker
showed us that the procalcitonin is low in those cases.
00:59:30
Speaker
So an increase in procalcitonin in absence of phenyl failure might be a suggestion that you're dealing with a bacterial superinfection.
00:59:37
Speaker
So I don't think we should just say no antibiotics.
00:59:41
Speaker
I think you have to take each patient at a time and decide if it fits your current patient presentation or clinical status.
00:59:49
Speaker
But I think that going back to your first point, obviously, as of now,
00:59:53
Speaker
the mainstay of treatment, like in most cases in the ICU is supportive care and executing the best we can, our usual supportive measures in terms of these patients and applying all the things we know work for respiratory failure and supporting them.
01:00:10
Speaker
And as I think cases grow, we'll probably hear or might hear more details on specifics for the ICU.
01:00:18
Speaker
That's correct.
01:00:19
Speaker
I would try those to steer off use of steroids.
01:00:24
Speaker
Excellent.
01:00:25
Speaker
And in terms of other issues or other areas of uncertainty that you think are still very important to be defined, obviously, we talked about this is a very fluid situation, but anything from your perspective, big questions that we're trying to figure out as things move along?
01:00:43
Speaker
So, I mean, I think one thing that needs to be determined will be, you know,
01:00:51
Speaker
Once we identify a treatment, is early therapy something that is beneficial to prevent progression of this disease?
01:00:57
Speaker
We know that works for influenza.
01:01:00
Speaker
So will that have the same impact for this new coronavirus?
01:01:07
Speaker
The other thing is, I think we need more information.
01:01:10
Speaker
I think time will tell us about the extent of
01:01:15
Speaker
of infectivity of this virus and how many folks have been infected by this virus and did not present.
01:01:21
Speaker
So that's some important information.
01:01:22
Speaker
Is this going to be our next, you know, chronic seasonal influenza that we're going to be dealing with for the next years or so?
01:01:30
Speaker
I'm also very curious to know how they're going to name the new virus.
01:01:36
Speaker
Obviously, it's not going to remain novel forever.
01:01:39
Speaker
And I know there is specific criteria put in by the WHO
01:01:43
Speaker
that a group of virologists will get together and come up with a new name for the virus.
01:01:52
Speaker
And that's something I'm curious to see how they're going to come up with that.
01:01:57
Speaker
So those are a few of the things that remain, you know, we don't have an answer for that and will have an impact whether the way we manage those patients and even sometimes economically, if you think of it.
01:02:10
Speaker
You know, when they called swine flu flu,
01:02:13
Speaker
swine flu, Egypt mandated the killing of so many numbers of pigs, even though pigs have nothing related to the transmission of the virus.
01:02:24
Speaker
It's just a perception of how we look at those virus that will affect how we deal with them.
Philosophical and Social Perspectives
01:02:30
Speaker
So I think it's an important part of this definition.
01:02:33
Speaker
And I think that from the perspective of the amount of information that is flowing right now and misinformation is really, I mean, amazing.
01:02:43
Speaker
And
01:02:43
Speaker
for the clinicians involved with caring for patients, I think seeking the right information, understanding what we know and what we don't know and what makes sense and what doesn't make sense, I think based on that information is very important.
01:02:56
Speaker
And I think that Raquel, obviously with all the question marks that still remain, I really appreciate your time in terms of giving us clarity where clarity exists and understanding what we know and what we don't know.
01:03:09
Speaker
So I hope that as we progress, I mean, we might have a chance to talk a little bit more about this and clarify some of those questions.
01:03:17
Speaker
But again, I think there's a lot of great information that is available right now.
01:03:22
Speaker
And I think it'd be a great use for all our clinicians in terms of understanding that.
01:03:27
Speaker
So a tradition at our podcast is to close the podcast with some questions that are unrelated to the topic that we discussed.
01:03:36
Speaker
And I really try to tap into the wisdom of our guest
01:03:39
Speaker
Would that be okay?
01:03:41
Speaker
Of course.
01:03:42
Speaker
So the first question, Raquel, relates to books.
01:03:45
Speaker
And I would like to know if there's a book or books that have influenced you greatly or books that you have gifted to others on a frequent basis.
01:03:54
Speaker
So one book that comes to mind, this is a tough question, by the way.
01:03:58
Speaker
One book that comes to mind, especially in the current situation, is a book I read a while ago.
01:04:04
Speaker
It's called Waiting for Godot.
01:04:07
Speaker
I don't know if you're familiar, it's actually a play.
01:04:10
Speaker
And it's written in the 1940s, end of 1940s.
01:04:15
Speaker
It relates to, literally, they're waiting for somebody who never shows up.
01:04:24
Speaker
So it's two men who are waiting for Godot who never shows up.
01:04:29
Speaker
And every time they get so desperate, they're about to commit suicide.
01:04:33
Speaker
And then
01:04:34
Speaker
A kid shows up and says, well, he's not coming today, maybe tomorrow.
01:04:38
Speaker
And then the scene starts over again.
01:04:39
Speaker
And it feels that many things in life are this way.
01:04:45
Speaker
We work and we do things and we're waiting for something that we don't really know what it is that we're waiting for, but we just do it.
01:04:53
Speaker
And when it doesn't show up, you just keep going.
01:04:58
Speaker
It's an interesting book.
01:04:59
Speaker
If you haven't read it, it's very interesting.
01:05:01
Speaker
I have not, but I definitely will pick it up and I'll definitely link it in the show notes.
01:05:09
Speaker
And I think it also speaks, Raquel, to a lot of what we see with these outbreaks, right?
01:05:14
Speaker
Is that a lot of the anxiety, a lot of the stress in life is what we imagine about things and not what is really happening or what really has happened.
01:05:24
Speaker
And really understanding that in terms of living in the present moment, I think, and what we can control is something that's very powerful.
01:05:31
Speaker
So I would definitely look this up because I have not heard about it, but it sounds like a very, very interesting read.
01:05:36
Speaker
A very interesting book.
01:05:38
Speaker
I mean, something to be said about this outbreak that I don't, it's like, even though this is a novel coronavirus, the way we are experiencing the outbreak is very novel.
01:05:48
Speaker
Like if you remember the SARS or MERS, we were not as connected through internet and Twitter and all of those apps as we are right now.
01:05:58
Speaker
And it makes it very interesting to see how this is progressing and the amount of hysteria that you're seeing with it.
01:06:05
Speaker
Yeah.
01:06:05
Speaker
And I think that the term, I mean, that the WHO uses of infodemic is really interesting because there's an abundance of information, but it's not all good information and that it can be problematic also.
01:06:18
Speaker
Yeah.
01:06:19
Speaker
Yes.
01:06:20
Speaker
Yes.
01:06:21
Speaker
So the second question relates to something that you believe to be true in medicine or in life.
01:06:27
Speaker
that many other people or most other people don't believe to be true or don't behave like it's true?
01:06:35
Speaker
So one thing that always comes to mind, and I hope it doesn't come out the wrong way, but one thing that it's hard for us to admit is that not everybody's equal.
01:06:48
Speaker
And that's something that we do not see it or do not admit on a daily basis.
01:06:53
Speaker
And it took for me a while to accept this truth.
01:06:58
Speaker
in the sense that even your patients presenting with the same illness, they never behave the same.
01:07:03
Speaker
And part of it is their physiology, their chronic illnesses, and so on and so forth.
01:07:10
Speaker
And I think this is a touchy subject.
01:07:13
Speaker
So you won't hear people talking about that.
01:07:15
Speaker
But I think we should acknowledge it and understand it so we can provide equal opportunity of treatment because that's something we can control.
01:07:27
Speaker
So we can provide an equal expertise in treatment or equal expertise in or equal education, whatever you want to call equal that we can provide by acknowledging that at the baseline, not everybody's equal, like not everybody's born with the same health or with the same opportunities.
Conclusion and Future Episodes
01:07:46
Speaker
However, we can provide them with something to try to gauge this inequality.
01:07:53
Speaker
Absolutely.
01:07:53
Speaker
And I think that it speaks very highly, I mean, to
01:07:56
Speaker
really the concept of, there's a difference between everybody having equal opportunities to access to certain things versus the uniqueness of people and individuals with their social determinants, their genetic determinants, their history, right?
01:08:15
Speaker
That is very unique and means that they might experience things or present with things in a very different way than somebody else.
01:08:23
Speaker
But I think that you speak to it in terms of
01:08:26
Speaker
equality of opportunity and not necessarily equality of circumstances or presentation, which I think is very powerful.
01:08:33
Speaker
And I agree, these are sometimes hard topics to talk about.
01:08:39
Speaker
The last question, Raquel, is what would you want every intensivist listening to us today to know?
01:08:45
Speaker
It could be a quote, a fact, or something related to what we talked about.
01:08:50
Speaker
So I would like to
01:08:52
Speaker
Something that's been interesting a lot, been interesting to me a lot lately has been relating again to this uniqueness of people is when we talk about pharmacokinetics and the way we should be dosing, mostly antibiotics I'm talking, and not to have a one stamp, you know, one dose treat all for every patient.
01:09:14
Speaker
And just to think about your patient as a unique person, which has its own metabolism that's
01:09:21
Speaker
require maybe a higher dose.
01:09:22
Speaker
So if you have an IV drug user, for instance, you might need a higher dose of a certain antibiotics.
01:09:27
Speaker
So that's something that I've been very interested in the past few years in trying to come up with more data to support that fact and how we can address it.
01:09:38
Speaker
Because even though we can talk about it, it's hard to quantify how much more do I give.
01:09:45
Speaker
So that's one of the things that I've been focused on lately.
01:09:49
Speaker
But I think it also starts with thinking about it, right?
01:09:52
Speaker
Because like you said, I mean, when we think of infections, traditionally, durations of treatments with antibiotics, for example, have been multiples of seven, not because that's what works for everybody, but because that's been convenient for maybe the drug companies in terms of how they think about these things.
01:10:10
Speaker
But we both have the same pneumonia or the same pathogen.
01:10:15
Speaker
I might be fine with seven days of antibiotics and you might need only five.
01:10:19
Speaker
And trying to figure out or more and try to personalize that type of care, I think, as we move forward and get more information is something that I think is very important.
01:10:29
Speaker
I absolutely agree.
01:10:31
Speaker
Absolutely, yes.
01:10:34
Speaker
So, Raquel, it's been a real pleasure talking with you about this very rapidly evolving topic.
01:10:41
Speaker
I'm sure that we will have much more to talk as time comes by.
01:10:46
Speaker
And I think that we will share all the valuable links that you have shared with us at the beginning so that people can actually reach them and see what's going on and read in more detail as we have more information and stay informed with valuable information that can actually help us not only take care of patients, but give people who ask the right advice and make decisions based on data and support them based on data, not based on whatever the latest
01:11:15
Speaker
perception or misconception on this is.
01:11:20
Speaker
So again, thank you for your time and hope to have you back on the podcast soon.
01:11:25
Speaker
Thank you very much.
01:11:26
Speaker
I enjoyed that, Sergio.
01:11:27
Speaker
Thank you.
01:11:29
Speaker
Thank you for listening to Critical Matters, a sound critical care podcast.
01:11:33
Speaker
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01:11:39
Speaker
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01:11:45
Speaker
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