Lori Walsh: Each week we check in with health care providers across the state for an update and what we now know about the novel coronavirus and the treatment of COVID-19. Earlier today, Governor Kristi Noem announced the first ever statewide clinical trial, as researchers launch a registry trial and a randomized clinical trial to study the impact of hydroxychloroquine on COVID-19. Patients wanting to participate in that, if you have been diagnosed with COVID-19, talk to your individual healthcare providers. We're joined now by Dr. Shankar Kurra. He is Vice President of Medical Affairs at Monument Health, which is participating in the statewide clinical trial. Dr. Kurra, welcome back. Thanks for being here.
Dr. Shankar Kurra: Good morning, Lori. Pleasure.
Lori Walsh: One of the things that we heard Dr. Allison Suttle from Stanford say at this morning's press conference was that how unprecedented it is for physicians to be treating patients when we have no known treatments and know almost nothing about the disease that we're dealing with, and you've been part of this as we've had these ongoing conversations about what we're learning. Let's start with the basics. What are some of the things that you think we know about this virus now that we didn't know even as early as last week?
Dr. Shankar Kurra: Yeah, a great place to start, Lori. The virus, we have learned a lot in the short time since January of this year when it broke, we are really living in a good age in that sense, there's rapid genomic sequencing, open access data, all these advanced technologies are helping us to understand the pathogen itself and the host immune response. As you well know, the excitement is about getting those serology tests to look for antibodies and understand that. We are closer to it than before. I think the most dramatic change has been in the last two weeks over serology testing and it's some, still some weeks away, but we have learned a lot from that. We understand this virus more than we ever did.
Lori Walsh: I like to say it's a really fascinating thing to study and a fascinating, interesting time to be alive if you weren't also living through it, and if so many people weren't suffering. It'd be a great academic textbook thing someday for other people to look back on. What have been some of the frustrations and concerns that medical professionals have had as we go forward? Specifically, I'm wondering if information is being shared quickly, if you're getting good information or if you're just getting anecdotal information? How hard is it for doctors to sort through what is true and what is just a speculation?
Dr. Shankar Kurra: Very good point. We have grand rounds every Friday mornings for the entire health system, usually attended close to 200 to over that number of clinicians. We bring to that grand rounds our own internal experts who then review the current data, the reports, the scientific studies published and give a summary of those. A lot of the misinformation is unfortunately brought on by folks who are trying to help disseminate information, but sometimes misunderstand, misinterpret studies. To give you an example, most of the confusion surrounding the transmission of this virus, which is so fundamental, is based on those kinds of reports.
This virus we well know is spread mainly, predominantly through droplets and contact. Those are our reasons why we say keep the six foot distance, observe hand hygiene, observe respiratory hygiene, cover your cough, and more importantly social distance. This virus is going to continue to transmit as long as it has social, human to human contact. The confusion arising around aerosols and the fact that it can stay in the air or on surfaces based on studies is not directly linked. The missing link for the public is there is scientific, physical evidence and then there's epidemiological. Does it spread? Those two disconnects cause a lot of anxiety and confusion.
Lori Walsh: Yeah. Clear that up for us. What do we know right now about that six feet? I mean, can you get it just walking past somebody on a trail?
Dr. Shankar Kurra: No.
Lori Walsh: How, no, say more about that.
Dr. Shankar Kurra: Yeah, let's clarify that. A lot of the studies done during this, transmission of this virus and the one in 2003, with the original SARS, which is very genetically similar to the SARS COVID-2, are kind of similar. The most recent study published in Annals of Internal Medicine, was a study done by the lead author in Singapore. They had cases and one of the cases that they took care of had pneumonia, did not suspect was COVID, and only found out what eight days later after admission. This patient was obviously, once identified, the 41 caregivers were sent home, tested on day one and day 14 for COVID, using the most sensitive PCR Assay, and found to have no transmission of the disease. Then they went back to see what kind of precautions they observed and it was interesting; 85% of this small cohort of 41 care providers were just wearing, were wearing a simple surgical mask, not the N95 respirator, and 15 persons were wearing the N95 respirator.
All these 41 caregivers were closely involved for long durations of time, in aerosol generating procedures, in the care of this patient. The authors conclude that the surgical mask is as good as N95 and also go on to conclude that based on previous studies in 2003 that also showed a similar finding. What is also interesting is the University of Nebraska Medicine Study, which also was done at their biocontainment unit, which was published showing that even though it's present in the air, it only transmits within six foot, the droplets land directly on the mucosa of another individual. Coming back to your question, the myth about getting through a casual contact is extremely low. We're talking probabilities here. The most likely way you're going to get it is through droplets directly landing on your mouth, nose or eyes, which is within six feet. Or by contaminated surfaces. Mostly the high touch surfaces, we're talking about door handles. We're not really talking about just casual touching of things in the grocery store. Really more prolonged contact, like doorways, door knobs and things like that.
Lori Walsh: In theory if you could navigate a grocery store and navigate it six feet apart from people, the risk of contracting it would be very low. The problem with the grocery store is because, it occurs when there are so many people crowded closely together and some of those people are infected; coughing, sneezing and that. Do I understand that correctly? Okay.
Dr. Shankar Kurra: That is correct. The best way, yeah, is social distancing.
Lori Walsh: Yeah, so this begs the question with so many people getting sick, and I'm going to ask it in a funny way, because people are asking it to me in a funny way, are all of us who are getting sick just really bad at washing our hands? Are we really bad at, I mean because it seems like a lot of people who are falling ill have no idea how they got it, is what we're getting at there.
Dr. Shankar Kurra: Yes. I think that's very true. There's a tendency for human beings to touch their face, nose, eyes and mouth, and that's very common for all of us. Ideally, if you can wash your hands and not touch your face at all and wash before you touch it, that alone is, in all the studies we know about this virus, the influenza virus, even the previous SARS, those are the main predominant ways to get this, direct mucosal contact. Of course, if someone sneezes or coughs into your face, that's the other way you get it. That's why hand-washing, respiratory hygiene and staying the distance is very important. Not gathering in large groups is very important, because that increases the chance of the virus. As far as dependence on person to person social contact.
Lori Walsh: Talk a little bit about these, this hydroxychloroquine clinical study that is just a statewide clinical trial. Unprecedented action for unprecedented times is what Stanford's Dr. Allison Suttle said. This is something Monument Health is participating in. Tell me a little bit about what we already know about this medication anecdotally, and how a clinical trial is a huge leap forward in what we will know in the future.
Dr. Shankar Kurra: Lori, good point. We are excited to be part of the trial. Monument Health is delighted to be partnering and like you said, it's unprecedented. These kinds of studies are essential. We don't, like I mentioned earlier, have a cure. If this trial, as it's shown promise from smaller trials, brings forth that promise, that'll be great. I would caution that these kinds of trials, even though they show well in vitro studies and small studies, tend to not always result in a treatment or a cure. What's more exciting right now is the vaccine trials, because those are actually pretty advanced and I think we could see a vaccine in a year or so. That would be a real game changer for the longterm treatment or prevention, actually, of this virus.
Lori Walsh: Yeah. Are there different companies moving, or different vaccine studies across the globe at this point?
Dr. Shankar Kurra: Yes, and I think what's exciting is the paper recently published by the University of Washington in Seattle, they're on trial, phase one trials with an antibody, basically to neutralize the virus. These things are actually being tried, but the trials take time, it takes about a year before they'll actually be safe enough to be administered on a large scale.
Lori Walsh: Yeah, at the right time is moving forward right now a year doesn't seem that far away. Suddenly as we look back and like, "What happened to last week? I don't know." Tell me a little bit about how surge capacity planning is going for Monument Health, because so much of the survival rate of people can depend, we know, on how hospitals are prepared to handle the maximum number of patients. Tell me how that planning is going in the Black Hills area, or in your service area?
Dr. Shankar Kurra: Yeah, it's going very well. We actually took a multidisciplinary team approach to this and have 165 page document called Monument Health System Pandemic Coronavirus Disease Plan, and it has, the plan itself is broken into 11 components. I'll give you some of the headlines; surveillance, communication, education and training, triaging, facility access, occupational health, surge capacities, security, mortuary issues, infection control guidelines and so on and so forth. What's exciting about this plan is it's involving all of our assistance facilities. Each one has a surge plan and then we have an overall plan.
The surge plans are at this point, at least, immediately we could scale up by another 100 beds right away and go all the way up to 200 or even 300 additional beds, not counting what we already have. Our capacity right now is 285, but we could quickly scale up to 530. Going through different phases. Each one is a trigger, so we have eight phases right now. The eighth phase will get us up to 537 total capacity. There's a lot of other details to the plan, but we've taken this approach of not ignoring low probability, high impact scenarios. We've gone through the, let's not take the most rosy picture, but let's assume that we are going to be in real trouble, despite all the social distancing and measures being done locally.
Lori Walsh: Give me an idea, there's so many people who are looking at the numbers in Sioux Falls and looking at the East River numbers and then looking, comparing them to some of those West River or Pennington County, in particular, numbers and seeing that this isn't, as urgent of a problem in the Black Hills as it is right now in, say the community of Sioux Falls. Secretary of the Department of Health for South Dakota, Kim Malsam-Rysdon, said last week during one of the press conferences, "Oh, it will come everywhere, so be prepared and don't sit back and think that you're exempt." However, to what do you attribute the pace of the spread being so much slower in the Black Hills area? Do you think this, because some people were saying, "Well, maybe we haven't tested enough people and it's really here," and other people have different theories. How do you look at that disparity in numbers right now and use it to inform what you know about your community and what's ahead?
Dr. Shankar Kurra: Yeah, I think one of the good news about being in the West River is we are a little more remote than Sioux Falls or the East River side, and at least for now we have not seen a cluster or an outbreak, and that's likely to occur. I think it's just a false sense of security to imply that we have a clear view of future events. The key truth that we cannot ignore is the future always is different than what we anticipate. Thinking that way I'd say, answering your question, we are a little bit remote. I would suspect that could be one, but also all the efforts of the community to do its best to social distance.
I think the only thing that has been shown clearly, if you take for instance, Singapore or Hong Kong, or China even, is social distancing, hand hygiene and basically isolating the population is really no other way to break the chain of spread of this. Unfortunately, this could happen even here. All it takes is an outbreak of a cluster, similar to the one we've seen in the Smithfield plant. All it takes is one infection to start a chain and that is what we are planning for. We hope it never comes to pass, but it's always a likelihood.
Lori Walsh: When Governor Kristi Noem says, if I told everybody to go in their houses and shut the doors for 14 days and let's pretend that inside those houses everybody stayed six feet apart from each other. She said that we would have no more cases, but then you have to go outside and it would start all over again. Explain to us why that's true. If you went through a 14 day cycle or a 24 day cycle, why would it just reappear if people aren't traveling here from other places?
Dr. Shankar Kurra: Correct. The key is how isolated are we from an exogenous spread? There's always endogenous, which basically, in simple terms within our community and outside our community. You're right, if people are not traveling here and if you have no public events that attracts tourists, that's one way. The other concern that is raised by, even after a 14 day lockdown, if you will, is that there can be at least two cycles before you can say truly that there is not someone who just got it on the 14th day and now it's another 14 days out. Typically, in most of these epidemiological scenarios, you're talking if people were to truly stay indoors at least a month and then the total period extends out to three months, because there's always the possibility that you will have someone either come in or bring a source from a hidden area that never knew transmission was occurring. These are kind of the unknowns that most epidemiologists worry about. In reality, a period of at least three months would be a scenario where you could expect no huge spikes.
Lori Walsh: All right. Before we let you go, Dr. Kurra, let's go over the basics, because some people were paying less attention before and now they're paying and they're really keyed into paying attention now. What do people need to know about what their behavior should be to stop the slow of this virus?
Dr. Shankar Kurra: Yeah. Simple advice there is, remember that this virus is unforgiving as far as if it has a susceptible host, it'll infect. The only way to stop this virus is to break the social chain. The important takeaway is social distancing. Stay at home, and stay at home as much as you can. Hand hygiene, don't touch your face. If you do have to touch your face, wash your hands. Then respiratory hygiene and stay at home if you're sick. Always call 9-1-1 if you're developing signs or symptoms of shortness of breath, other than that, stay at home if you're ill and can manage to stay at home.
Lori Walsh: Yeah, and if you have those chronic conditions, be working with your doctor to manage them and stay on top of your medication and stay as healthy as possible, because now is not the time to have to go into the emergency room for another condition as well. Everybody be-
Dr. Shankar Kurra: Absolutely.
Lori Walsh: Be healthy. Dr. Shankar Kurra, thank you so much for joining us today. We'll talk to you next time.
Dr. Shankar Kurra: Thank you, Lori. My pleasure.