This conversation originally aired on Wednesday March 11. Listen to it in its entirety here:
Lori Walsh: The South Dakota Department of Health has announced its first a confirmed case of COVID-19 in South Dakota and though most South Dakotans were not surprised by the announcement, now is the time to remind you about basic preparedness. Dr. Wendell Hoffman is an infectious disease doctor with Sanford Health and he joins us today to talk about the virus, the confirmed cases in the state, when to call your doctor and those precautions that help the most vulnerable among us. Dr. Hoffman, welcome. Thanks for being here.
Wendell Hoffman: Well, thank you very much. Good to be with you.
Lori Walsh: These positive cases were not unexpected. We've had at least seven weeks to prepare since the first case was discovered in the United States. Are we ready? Have we been preparing as much as possible as we can for something like this in the state of South Dakota?
Wendell Hoffman: In many ways we have been preparing for years. All the preparation that was accomplished through the 2009, 2010 pandemic H1N1 has helped us out significantly because coronavirus in many ways acts like influenza. Although there are some fairly distinct differences. The Ebola preparations that we underwent several years ago also has helped us enormously. The answer to your question is, I think we are well prepared, although there are going to be some challenges that we all face because we're trying to take this very seriously and yet we're trying to say to the public, "Please do not panic." This virus in the United States is going to be different than this virus anywhere else, just simply because of the amazing performance overall of our public health system, the quality of our hospital care and outpatient cares and so on and so forth.
Lori Walsh: Let's talk a little bit about that infrastructure and what that looks like from a testing standpoint. How are we ready to test people?
Wendell Hoffman: Well, that's a great question. And actually there are many layers to that kind of obvious question. It's one one that is on everybody's mind right now. The question is, first of all, who should be tested and and the CDC is still maintaining kind of the classic definition that we've seen fever, cough and shortness of breath, but we know that this virus has a spectrum of presentation. From the China outbreak, we learned that about 15% of that group in a huge epidemiologic report had a what is called severe disease, which by definition means disease severe enough to be hospitalized. Within that is then the sort of critical group of patients who actually need intensive care unit and potential ventilatory support because the primary issue here is a viral pneumonia and they can easily overwhelm patients who have preexisting conditions.
The question comes back then as far as who is we test, I think that's it's a little bit of a moving target right now. The other thing that influences that is that we know that patients with COVID-19 are presenting with the symptoms of a common cold and the frustration for both the public and frankly for all of us who want to know as much as we can, is that the spectrum of illness in that mild category has yet to be completely understood. But right now, the who should be tested is going to be made rather on a case by case basis. And we are trying to, with the best of our ability to determine if it's more likely than not, that that patient might have COVID-19 as opposed to other other viruses.
Of course, when patients come in and they present to our various different acute cares, urgent cares and hospitals, they can be tested for other viral pathogens that could help again, more likely than not, exclude COVID as a cause of their symptoms. In terms of who is tested, it is in, I would say it's in flux and we certainly want to know as much as we can. And that leads to the second aspect of your question is, are we going to have the testing capabilities necessary? And right now, we're being told that there is an active process in engaging multiple different laboratories who are developing their own tests. We have the CDC sort of official test that's been distributed with these testing kits. We have, I'm not sure what the number is right now, but in the hundreds, I heard 800 or so at the South Dakota lab.
But you can see that with overwhelming numbers of people who want to be tested, but that potentially could be overwhelmed. We want to use discretion and wisdom in terms of deciding who we test. Because again, the majority of people are going to have mild illness and they can stay at home, they can self quarantine, so to speak, if they're ill because we don't want as much as feasible, we don't want patients who have any respiratory symptoms to be going out especially in social settings like going to see grandma and so forth and so on when you even have a cold. And so that's the message. And the testing thing will, I think sort itself out. There was a glitch with the CDC. They have owned up to it. And rather than blame people, we need to learn from this and continue to move forward getting these tests as rapidly available as possible.
Lori Walsh: For people who do have underlying health concerns, and one of their big questions is about that intensive care, the capacity for that. And again that infrastructure. What can you tell people to reassure them that if this becomes more widespread in this state that they'll be able to get the emergency care that they need, the intensive care that they need? Or is that at risk of being overwhelmed?
Wendell Hoffman: What I think the public needs to know is that it's not like you're going to have a 100,000 cases of COVID-19 present at one time. This is a rolling process of cases that are beginning to appear and our healthcare systems are extraordinarily sophisticated. We have detailed triaged planning for being able to handle a lot of patients if they were to present it once, but it's not like a big mass casualty where you have, a 100 people presenting to your ER with the same thing that demands the same approach. We will continue to see this go forward and I think the public can be very confident that the health systems in South Dakota are very much prepared to handle the very sick and ill patients.
Lori Walsh: You mentioned this is somewhat different from the flu, and as we sort of dispel some of those myths, one of the things that people who are less worried and are not necessarily inclined to change any behavior will say, "It's just like the flu." Tell us a little bit, break down how this is different from the flu so for people who think, this is sort of hysterics. Why is this different? Why are we so concerned about coronavirus versus influenza?
Wendell Hoffman: Wonderful question. Couple of things. How is it like the flu? Well, it's like the flu in that it can be transmitted prior to the onset of symptoms, which is what makes this so difficult to kind of get our arms around. We have people who are walking around in our communities just like they did in China. The estimate over there in that very large study that I just mentioned is that at least 1% of some 44,000 confirmed cases were asymptomatic. Now, whether it's 1% or a higher percentage, we don't know. But the point is that influenza has, we've known this about influenza, seemingly quote unquote, forever, where the virus begins to be shed out of the nose and upper respiratory tract for at least a day or so prior to the onset of symptoms. Corona is like influenza in that regard.
Now how it is unlike influenza is that the reported mortality rate of influenza is about 0.1%. Now the current mortality estimates vary with corona. And why is that? Because we, I'll use the analogy of the base of the pyramid. If we knew what the base of the pyramid is, in other words, if we knew what the denominator is, which means the total number of people who at any one point in time are infected with the coronavirus, we would be able to then calculate the true mortality. The World Health Organization estimation of 3.4% I think is way high. The closer estimate is probably at least a two plus percent. But more likely even, and we've heard Dr. Anthony Fouchy from the NIH make the statement just recently that the estimates are, maybe it's going to be closer to maybe 1%. But even if it's 1%, it's 10 times the mortality of seasonal influenza.
And like we have been saying, a small percentage of a large number is still a large number. And so we need to take this very seriously. In particular, we need to take it seriously with our vulnerable patients and we need to take every measure possible to prevent them from becoming infected with this. Because if you take simply the age range, and again we rely on the Chinese data, but between ages 80 and 89 the reported mortality over there is around 15%. Between 70 and 80 the reported mortality is somewhere in the 7.5%. And between 60 and 69 strictly on an age basis, it's around 4%. Once you drop below 60 the mortality rate falls off significantly.
It is like the flu and yet it is not like the flu. And so we we need to, and another thing I would add and that is I think most of us feel that coronavirus is here to stay. That this is not just going to be a one off so to speak. It is going to be something that will incorporate itself into the community. A collection of viruses that we deal with. For instance when we order some sophisticated testing now on the upper nasopharyngeal tract, we currently measure four other coronaviruses which cause the common cold. Well this may well be number five that we begin to measure on an ongoing basis. What does that say? It says that just like the flu, we need to make both short term and long term kind of preparations and be armed with the knowledge that from here on out we need to all change our behavior which goes to the what can I do a part of this. And there are certain things that the public, that we all can do that can actually contribute to slowing this virus down.
Lori Walsh: All right. Tell us some of those things before we let you go. What are some of those things that, because one of the things that people are trying to balance is, how serious should our restrictions be right now to give people time to figure things out? But we also know that this is the longterm thing so we're not going to going to do colleges at home learning, for indefinitely. What should we do now? And what should we expect to do longterm?
Wendell Hoffman: Yes. I think the longterm, I think actually looks quite bright because, and I'm very optimistic that we will have a vaccine, but it's going to take time. If you remember the H1N1 pandemic that that we became aware of in April of 2009, and then if you remember when the vaccine for H1N1 became available, which was October 2010, there you have your 18 month timeframe. And literally it takes that long to test the safety, efficacy of these kinds of vaccines because we don't want to be developing and releasing vaccines that we have questions about or that might work. The longterm is good. We have the antiviral therapies that I think are quite promising and that even could be used now under compassionate use protocol.
In the short term however, we have to revert to simple common everyday things, which by the way we should be doing anyway. The first thing is to understand how this virus has spread and that it is easily spread. It appears to be the major mechanism is through large droplet nuclei, which are those secretions, small secretions that fall off when we talk or sneeze or cough about out to three to six feet around us. And so we need to be aware of that. That's why social distancing makes a lot of sense. Particularly again in our vulnerable population. If you've got children and they have a cough or a sneeze, you shouldn't be taken to grandma's house. And we need to maintain social distancing. And if you're not ill, even with a cold, you probably should not be going out into social settings where you could place other people at risk. Social distancing is very important.
Also, we need to understand that the virus, therefore the second thing would be this whole aspect of environmental cleaning. Because if we use the analogy, if we use the example of the respiratory droplets going out from us and landing on external surfaces and there is some evidence I think of that environmental contamination around infected peoples can be picked up on the hands of other individuals, which then are brought to the mouth and then it could be acquired. And so, but the additionally this virus is one of these cool so-called envelope viruses which are enormously susceptible to common everyday cleaning solutions. Things like Lysol, Clorox, the regular kinds of cleaning stuff that we have in our homes should be adequate to completely clean these surfaces. And so I think reasonable environmental cleaning is, I think also something else we can do.
Lastly, washing our hands is so important. As a population, we don't do this very regularly and even when we do, we don't do it correctly. And remember you don't need to have hand sanitizer, that washing with good old fashioned soap and water, even regular old, regular soap that's not necessarily antibacterial. If you moisten your hands first and then you wash for at least 20 seconds, which is what the data show and then dry your hands after, you can be reasonably assured that at that moment at least you're ridding your hands of potential organisms that could be spread.
Lori Walsh: Dr. Wendell Hoffman, infectious disease doctor with Sanford Health. I'm sure we'll be talking to you in the future as the situation develops, but we really appreciate your time today. Thanks so much.
Wendell Hoffman: You're very welcome. Thank you for this opportunity.