Lori Walsh: As COVID-19 cases surge nationwide, South Dakotans ask questions about whether or not SARS-CoV-2 can be spread by asymptomatic people and how sure we are about the efficacy of wearing masks to slow the spread of the disease. The pandemic provides even more opportunities to search for clarity. So today, we welcome back Dr. Wendell Hoffman. He is an infectious disease doctor with Sanford Health. Dr. Hoffman, welcome back. Thanks for being here.
Dr. Wendell Hoffman: Thanks for having me, Lori. Pleasure to be with you.
Lori Walsh: I want to start with some recent questions that have been coming up in South Dakota, and one of them is about this difference between presymptomatic and asymptomatic people and who can spread the disease because people are still confused about this. Can you help clarify first the difference between presymptomatic and asymptomatic?
Dr. Wendell Hoffman: So this is an illustration of what we might call a flashpoint. And if I might, just for a minute, just kind of take a step back and just kind of look at the breathtaking nature of this pandemic, which has really been devastating in its wake, and in many ways, it seems like we're living in more like an alternative universe, kind of like a fairytale called Once Upon a Plague. But as we see, as you're pointing out, the surge of cases, and particularly in the South, but really in the West and in other places in the country, we see how strongly linked to human activity is to the waxing and waning, if you will, of this pandemic.
Literally though, it just is really quite amazing. COVID-19 is not a dream, but a dread. And as I've said, hearing hoofbeats, the horses are zebras and the patient is COVID. And in this kind of fragment of a century, blink of the eye, really, everything has changed.
So to your point, I mean, we are grappling, physicians are grappling with how to proceed because we're confronting these kinds of flashpoints which you've raised, which demand our obligation, and they include the demand to help while doing no harm in the individual COVID patient, the demand to protect public health while delaying care in the non COVID-19 population, and the eventual flashpoint, which we can anticipate as the demand for reform in American medicine overall because of all these health disparities, which are further emerging.
So to get to your question, it is clear that the virus, I believe, and I have not ever heard an infectious disease physician say to the contrary, or an epidemiologist say otherwise, that this virus is asymptomatically spread. There's simply no other way to explain the rapid progression of this pandemic around the globe.
In a recent review of this subject in the Annals of Internal Medicine, which looked at, I believe it was 16 different examples, the level of patients who are infected with the virus who are asymptomatic may be as high as 40%. And it is just simply amazing, and it just goes to the point of how this pandemic illustrates what we're trying to help the public to understand as emerging science versus settled science. And also in this pandemic, it's kind of like we're in the second chapter of what might be a long read such as War and Peace. It's an apples and oranges situation.
So early on, we really didn't know what the prevalence of the asymptomatic rate was. Now I think we have a much better understanding. And so it is a little bit like apples and oranges and we're in this kind of, arguably, maybe new phase of the pandemic where our understanding is that this can be transmitted asymptomatically. I think there's fairly strong data that suggests that people begin to shed virus several days before they develop symptoms. And then for several days thereafter, they will kind of peak and then come down. And by about day 9 or 10, viable viruses likely stops.
And of course, this has to be a flashpoint, right? We have to have the commentary of, "Well, we don't think that asymptomatic carriage or infection is a source of infection," and I think we would have to strongly disagree with that. Part of the reason is that there is now increasing the possibility of the aerosolization of this virus.
Just published this month in Clinical Infectious Diseases, which is the journal of my society, some 239 scientists made an appeal to the World Health Organization that what they said beyond any reasonable doubt that this virus released in microdroplets small enough to remain even aloft in the air, this has been true for other viruses, such as RSV, MERS, and influenza, and so what they called for there was, even to begin to consider in how we approach this, is even looking at our ventilation systems, with high efficiency air filtration, UV light, of course avoiding overcrowding, and those kinds of things.
Now the World Health Organization has kind of pushed back a little bit, but one can see that, as we gain understanding, the asymptomatic spread and the potential, at least, for some aerosolization, although we do still believe that it is the shorter distance, large droplet spread that is most important. And so the six foot rule still definitely applies. And therefore, because of all of that, masks make complete and total sense.
Lori Walsh: I want to clarify something that some people were asking me over the weekend, and that is, if I never have symptoms and someone who I have been in close contact with gets sick, could I have given it to them without knowing it? So that gets back to the difference between presymptomatic and asymptomatic. And this is more of a curiosity thing. Could I have made that person sick? Because right now, we still don't have the amount of testing or the amount of antibody testing that we would want to answer some of those questions. So people are still guessing, "Could that have been me who spread it, even though I never had any symptoms?" So if I never have any symptoms at all, and really don't even know that I would have tested positive at a certain point in the last week or so, could I have spread it to other people?
Dr. Wendell Hoffman: And the answer to that is, I think the emerging science of this would resoundly say yes. It is clearly possible that an asymptomatic person can spread it to another person, and that person to another person, and that person to another person. And pretty soon, it winds up in grandma's lap, and suddenly, it lands in a place where it really gets to be serious. And that's why everybody has to take this very seriously and see the role, the important role that they play in the community, like this big team that we've talked about, doing the blocking and tackling. The blocking is the social distancing and the wearing of masks, particularly indoor. The tackling is the hand hygiene and the environmental cleaning, which kind of take the virus out of the play. Until we have the ultimate blocker, which would be a vaccine, and the ultimate tackler, which would be a good antibiotic drug, it's up to us.
And so what we're seeing down south is kind of literally a result of increasing human activity and involving two particular age groups in the population, the 20s and 30s, and sort of the, I don't know any way else to phrase this, but kind of the lack of discipline in parts of the population that may not realize that this virus is, in fact, asymptomatically spread and that we have to treat it as such. Is this science absolutely perfect? No, but it's very compelling.
And so the mask use, for instance, is compelling from healthcare itself. I mean, we saw in the early China experience that a high percentage of healthcare workers came down with COVID-19, but there was very, very poor personal protective equipment used. Once that was put into place, the rates among healthcare workers plummeted.
And so, we need to see the mask wearing because of the asymptomatic situation. We need to see that as a part of the strategy, along with the other blocking and tackling measures, kind of like a mousetrap. So all of the components of the mousetrap have to be present, it's a simple machine, in order for this thing to catch its prey. You can't simply wash your hands and not be aware that you could be spreading this from person to person through your respiratory secretions.
So in my mind, it's not a matter of whether masks are important, it's a matter of which is the best mask. You've got okay, good, better, and best, and there's just been a study released from Florida Atlantic University. I'd encourage your listeners just to Google, seeing is believing, where they do some really interesting experimental studies where they show the effect of certain kinds of masks. As it turns out, all masks probably have some benefit because of this asymptomatic issue that was posed to you, even bandanas, although the bandanas may be kind of the least effective. But as you go up the chain in terms of okay, good, better, and best, you can effectively block the virus from going to another individual, and that's the whole point.
Lori Walsh: The US Surgeon General, Jerome Adams, said we could turn the nationwide rise in cases around in two to three weeks with a critical mass of people wearing those face coverings, practicing six feet of social distancing, and doing those things that we know are effective. Do you agree with him that if we had a critical mass of people doing these things, we can have that kind of a turnaround?
Dr. Wendell Hoffman: Yes, completely. So I'd just like to tag on to that. You know, now, facial masks are becoming political statements. I mean, and this is nothing but divisive labeling, for while masks are very effective, in order for us to come together, Lori, the covered face cannot be my virtue signal, nor can the open face be my declaration of independence. Obligation without liberty is force, then tyranny, and liberty without obligation is licensed, then anarchy.
We have to see, particularly in a place like South Dakota, where we value our personal rights, we are an open state, but we have to see that our rights living in this country were never intended to be divorced from our obligations. Even if you go back and just go back and look at what a number of the founders of this country said about that whole issue, the whole notion of rights, my right not to wear a mask is also predicated and it rests on my obligation to my fellow neighbor, to my friend, to my family.
And so, I think the Surgeon General was absolutely correct. If we had a critical mass of people doing this because it's the right thing to do, rather than getting into this very divisive situation that we find ourselves in, where we find some states, and there are many of them that are now compelling masks, at least in the indoor setting, wouldn't it be great if South Dakota, that is a much more open state, if we could convince our population that it is clearly the right thing to do, that when you're indoors, particularly a congested indoors, particularly when you're in there for a long period of time, like, let's say, oh, Happy Hour, or let's say a worship service, or let's say a backyard party, or let's say a workplace, all of these situations, the virus doesn't care. The virus is going to do what it's going to do.
And so it would be amazing if we could use persuasion to convince our colleagues, the good South Dakotans, who naturally want to do the right thing... I mean, this is a phenomenal state in terms of people stepping up and doing the right thing. Masks are a pain. I don't like the fact that I have to wear them 8 to 10 hours a day either, but I do it because I believe that it's an effective barrier between me and a patient that I see.
Now, at Sanford, and I think it's a lot of places, we will mask both patient and caregivers. So we actually even get a double benefit. It's highly unlikely that virus is going to be spread under those circumstances.
So I think the answer is not compulsion, although if it gets to that, I can understand why leaders would say, "Hey, we have to keep these numbers down," because the original premise of the lockdown, so to speak, was to protect the healthcare delivery systems. But if we don't do this, if we see a continued rise in cases, then we're going to be faced with another flashpoint, and that is, we have to put then on the burner, on the side, all of the non-COVID-19 healthcare issues, which kind of gets us into the whole school thing. And also, all of the illnesses that people are dealing with, they're sitting at home, they're afraid to come in, they're having their heart attacks and not getting in and taking advantage of that 90 minute door to balloon time, which is optimal to save somebody's life with an acute EMI.
They're not getting screened for their cancers. They're not getting their immunizations. And there's a great deal of mental health suffering, with increasing, soaring, even suicide rates, and all of this that goes with what some people have called the true second wave. In order to avoid that, in order to live alongside this virus, we all need to take this responsibly, and our leaders frankly need to increasingly call for this, especially in a state like South Dakota, where we're a much more open state. That means that the persuasion has to go up concurrently. And whether it is in a church or a small business, or at a political rally or wherever, we need people to begin to believe that the asymptomatic thing is real, and there's a strong rationale for wearing masks in the indoor space.
Lori Walsh: Dr. Wendell Hoffman is an infectious disease doctor with Sanford Health and he has been joining us on this program since the pandemic began, providing clarity and information and the latest scientific research as we all work together to make a difference in saving lives. Dr. Hoffman, we look forward to our next conversation. Thank you for being here with us today.
Dr. Wendell Hoffman: Thanks very much, Lori, and have a great day.