Colder Months And COVID Fatigue: Idaho Doctor On How To Fight The Virus This Fall

Oct 14, 2020

Idaho is continuing to move in the wrong direction when it comes to new COVID-19 cases. At the same time, folks are headed indoors as the colder weather sets in and flu season gets underway. What does Idaho need to do to stay diligent eight months into the pandemic, and why is the indoors so dangerous when it comes to virus transmission? 

In this special podcast version of our Idaho Matters doctor roundtable, we check-in with Dr. David Pate. He's the former CEO of St. Luke's Health system and a current member of the Idaho Coronavirus Task Force. Pate shares his perspective on recent health and school board decisions, why the first known U.S. case of reinfection of the coronavirus matters when it comes to the theory of herd immunity, and more. 

Have a question for our Oct. 21 week's doctor roundtable? Email us: idahomatters@boisestate.edu.

Read the full transcript here: 

GAUDETTE: This is a special podcast edition of Idaho Matters on this Wednesday. Joining me today is Dr. David Pate, former CEO of St. Luke's Health System and the current member of the Idaho Coronavirus Task Force. 

We are doing a special podcast because right now we have the SCOTUS nomination hearings going on in Capitol Hill and that is taking precedence over our show, but wanted to bring Dr. Pate in today because Dr. Pate, you know, I feel like we can't let a week go without, you know, without talking about where we are with this pandemic. And in particular, Dr. Pate, we're setting records again. And these are not records that we wanted to see. And I believe on Tuesday, if I have this right, saw more than 790 cases. We hadn't seen that before.

PATE: No, you're right, Gemma. These are not good records, and if you look at where our state is, so we had our first spike back in March and April. And of course, everybody remembers the governor took swift and decisive action. We had to stay in place order. And what happened is our numbers came way, way, way down. And so we got kind of over that spike. But then, of course, it seems that people have little endurance for these kinds of things. So we saw another spike come in July and August. That was our second one.

The difference is now, as we are into our third spike, is we never came down from the second spike. In fact, even at the low point on the return from the second spike, we were above where we were with the peak of the first spike.

So what we're seeing is higher numbers of cases, as you just pointed out. But what really concerns me is, you and I know that hospitalizations lag behind when we see the cases go up by usually two or three weeks. What happened here is as we were coming off the second spike, we had still lots of people in the hospital that were lagging that two to three week period from the onset of the second spike. So they're all in the hospital and now we're having our third spike. And we're going to be adding to those hospitalizations, which is going to put a lot of pressure on our health care. And that's not even to mention that we are bracing for influenza season to start soon, probably in the next month. And we'll see hospitalizations from that. So we're not in a pretty place.

GAUDETTE: And Dr. Pate, I mean, months ago when we first started having these conversations, you and I talked about urban areas versus rural areas. And if we look at even when this virus first hit the United States, it hit New York City extremely hard. You know, dense population, people living in condos and apartments, high rises, things like that. And, you know, you had said that if we do not get this under control, this won't stop in the urban areas. And if it gets to rural locations, this could be devastating, the reason being, and I want you to talk about this, is that we know full well that there is a lack of health care when you are in rural parts of the United States and Idaho is a rural state. It doesn't matter that Boise is the epicenter of the population. We are a rural state.

PATE: Well, you're exactly right, Gemma. And as you were saying, we've been discussing this and we were seeing this huge spike in New York and the surrounding areas. And if you recall at the time, Florida was kind of celebrating about, hey, we've dodged this bullet. Look, we're doing fine. This is really a problem for New York. And, of course, fast forward and we saw Florida got hit extremely hard. It was just a matter of time. And when that was happening, you and I were talking and saying, you know, the same thing goes for Idaho. We shouldn't be celebrating that we're over that first spike and it's all going to be good because it's coming. And of course, it did. And I said the same thing as you just pointed out. Those rural states that were kind of last in line ought to be bracing themselves. And so look where we are today. We looked at Montana and said, you know, they're probably the great example of how you manage this. I was extremely skeptical. And now they're one of the top hot spots in the country. Same thing you can talk about the Dakotas. And so to think that there's any place in the United States where you're going to escape this is mistaken because people travel, people visit places, people visit family, people go to places for vacations. They're going to take the virus with them. And that's exactly what they're doing.

Now, to your point about why we should be especially concerned about coronavirus getting into our rural areas as it is, is that as we've seen all along, our health care workers are part of the community. And so we actually believe that the majority of health care workers that get infected today, it's not from the hospital because we've got really good precautions in place there, it's from them being part of the community. If you're talking about a rural hospital and you get a significant number of infections and now you have the staff of those hospitals either out isolating because they're sick or in quarantine because they've been exposed, you can bring that hospital to a shutdown, which is basically what happened when we had our outbreak in Blaine County with the St. Luke's Wood River Hospital there. We had so many staff affected, you couldn't basically couldn't run the hospital. And so this is a big deal. And not only that, but if you get really sick with COVID, these rural hospitals do not have the specialists and resources needed to treat the sickest patients. So it means that we're going to have to transfer you. And that's going to mean oftentimes a helicopter is going to add a lot of cost and it's going to be further delay until we can get you the care that you need. So it's just not a good thing.

GAUDETTE: And Dr. Pate, as we're seeing the numbers spike, as you mentioned, we are heading into the winter months. And, you know, you mentioned Florida a moment ago, them thinking, oh, we're off the hook. Well, a lot can be said for the fact that, you know, everyone was outside in Florida when New York got hit. Right. That's the time of year that everyone is outside in Florida. But when it gets hot and it gets humid, everybody heads inside in Florida. And that is where when they saw the numbers go up and they saw those numbers spike. Guess what? In Idaho, everybody goes inside in November.

PATE: Yes, yes, well, you're actually absolutely right, Gemma. And, you can look at Europe and they had their initial outbreaks. Many of those countries got their disease under control. We started hearing some people advocating for the theory that, well, they're doing better now because they've reached herd immunity. That theory is ridiculous. That is not likely at all. And in fact, it's being disproven right now because if you look at these same countries that had their initial big spike and then got it under control and you look at them right now, they're having another one and in some places really bad, even though they got hit really bad the first time like the U.K. So you're right, there are so many factors to this transmission. But to believe that someone got hit and now it's gone is very wishful thinking. And in fact, look at New York City. They are now having another recurrence. So we need to stop this discussion about herd immunity until we have a vaccine. It's not happening. It's not happening anywhere. And yes, some countries are being impacted more than others, but it's more often these various factors that you've mentioned: What are the behaviors and actions of the people? That's what really drives the disease activity.

GAUDETTE: So with that being said, as we start moving indoors more when it starts to get cold here in our state, you know, it's getting a flu shot. It is also this idea of as we head into the holidays, Dr. Pate, needing to limit exposure to people that don't live in our own homes. And I know that that is devastating. That is hard. You know, there are people that haven't seen family members in months. But, you know, these are things that we need to be doing to get these numbers down according to what all the science has been showing.

PATE: Well, you're absolutely right, Gemma, and I think we need to make sure that everybody understands that there are two major ways that this virus is transmitted. There's more than that. But there's two major ways. 

We believe the most common way is the droplet transmission, that is the virus coming out of somebody's mouth or nose in a little ball of secretions that can travel under normal circumstances up to about six feet. That's where our rule about distancing six feet comes. That's why we recommend wear masks, because the mask will catch these droplets as they come out of your nose and mouth to a high degree. And so that's why we say keep a distance of six feet and when you can't wear a mask.

But we've also said anything you're going to do is safer outside. And that's because of the other mode of transmission, which is called airborne. Airborne is much smaller than the droplets. So I liken it to if you were to get a can of hairspray or deodorant and spray that, what you're getting is an aerosol and these are smaller than the droplets. And the difference is they travel on air streams. So when you're outside, Airstreams rapidly dissipate this virus. However, when you're indoors, like you're pointing out, and which is the concern as the weather gets colder and we move inside, they can move on the air streams, which are typically dictated by your air conditioning system and how efficient it is and where the air is being directed to the the returns.

So this is why, for example, when I go to schools, I look to see where are those air returns? And what you don't want to have is a vulnerable student or the teacher sitting right under air return, because that just means all those aerosols are directed to that person's direction. And the thing about these is they can travel further than six feet and they can stay suspended in air for hours. So you're right, if we move indoors, we have to now be concerned about the airborne transmission, which really wasn't as big an issue outdoors. But if you have people who you don't live with and you're indoors, if somebody is infected and doesn't know it, you're going to have a much greater risk of being exposed.

And that is, to your point, what we're very worried about is the upcoming holidays. Here we are. We're already having a spike. When you're having more community transmission, that means whoever you interact with is statistically more likely to potentially be infected. And now, as these people who don't live together come together in indoor settings, we could be in for a real problem.

GAUDETTE: Dr. Pate, yesterday, the Central District Health had a meeting and moved Ada County's Schools shifted them back into Category 3, which is the red category. So they did not say that schools must close in Category 3. They did say that there are certain recommendations to pause certain activities until a return to Category 2. I'm curious what your thoughts are on that. I mean, I realize the Ada County numbers we've we've seen increases, but definitely not to the extent that we have seen in other rural areas. With that being said, though Central District Health is not just governing Ada County.

PATE: Well, that's right, I have to say, I was surprised by Central District Health's guidance, the change in guidance, and so I called and talked to them and I understand their position better. I think that when we talk about schools, we do need to distinguish colleges and universities from K-12. They really are quite different and pose quite different risks. And I think we're all in agreement that colleges and universities are a problem and they are contributing to the the case counts in a meaningful way and therefore probably also to community spread. What Central District Health's point is, they're not seeing a lot of evidence that the K-12 is contributing to community spread. And certainly I get what they're saying.

But I will tell you, I'm a bit skeptical. They they certainly may be right, but I'm not convinced. And the reason is when I look to try to figure out what is our situation, I don't look at any one thing because there's limitations to the data of everything. And of course, I think all of us are a little skeptical if we're really getting all the accurate information about cases in schools. There's not been a very good degree of transparency and there's just a lot of reasons to wonder if we're not underestimating that.

The second thing is, even among the schools, there's a lot of variation because they all have different operating plans and some are better than others. And we certainly have seen isolated problems at isolated schools. But what concerns me is if I try to look at the big picture, so I talk to teachers and principals -- and God bless these people because they're really do an amazing job under just incredibly difficult circumstances, and I'm so impressed -- But yet they will tell me, yes, there are certain times and certain activities, we're doing a pretty good job of distancing, but we're not able to keep it up and we're not able to do it at all times. So one has to be skeptical as to whether these plans are going to work in the long term. You might get away with it for a while, but it's going to catch up to us. The other thing is, when I really pressed them about masks, what I find out in almost every case is there are examples of people wearing face shields when it's inappropriate and believing that that's going to protect the person wearing the face shield and those that are interacting with the person with the face shield. And that's just not true. And there are instances of things where people, not intentionally, they just don't know better, but for example, I have heard on more than one occasion of teachers giving children a mask break in the classroom. That is a recipe for disaster. And that is not how we should do mask breaks. I've also seen examples where some children are getting mask exemptions. And from a medical standpoint, that should be exceedingly rare. And probably if you need a mask exemption, you should be in remote learning. So we've got a lot of vulnerability. So that concerns me and I ask, why are we doing as well as we're doing if all these breakdowns are happening? And I haven't even mentioned things like school busses, which have been a problem and I haven't mentioned sports, which have been a problem.

On top of that, if you look at our state numbers-- so as I mentioned at the beginning of the show, we're on our third spike and that third spike is temporarily associated with school reopenings. Now, I'm quick to admit that a temporal association does not mean causation, but if it's not the school's driving that, what is driving that spike? And then one thing I was told is, well, maybe this accounts for it, is that, for example, Boise State is doing more testing and they're finding more cases because they're testing more people. Well, that certainly could be an explanation. But if that were the case, then our testing percentage positivity should come down and it's going up. So I just have to tell you, there's enough other data that is making me suspicious that what we're seeing is not what we can expect in the future.

GAUDETTE: And I wanted to also talk about, Dr. Pate, we know that there have been a handful of Idaho children who came down with --

PATE: MISC.

GAUDETTE: We now know that there is an Idaho teenager, I believe, who was diagnosed with this. They are now in Salt Lake City awaiting a heart transplant.

PATE: Yes. Yes. This is something that has really frustrated me in my many conversations with people that are looking for a way to be dismissive of this SARS-CoV-2 threat. They will often assert that this is no worse than the flu they will often assert, look at the mortality rate, it's very low. They will often assert, hey, we know who's at risk. It's old people and people that are really sick. So let's just keep them locked up. And all of these statements are incorrect and flawed.

And it's very frustrating when people just focus on the deaths because, you know, in comparison to some other things, this virus isn't extraordinarily lethal. But to think of COVID as kind of two potential outcomes, one, mild or asymptomatic disease, you get over it and you're fine or you're old, you might end up in the hospital and you might die is a gross oversimplification. There is so much in the middle. And while MISC, which is the multisystem inflammatory syndrome that children get, while it is rare, it's not particularly common, it is terribly serious in these kids.

And the case you point out: a teenager who was perfectly healthy and now we're making arrangements for a heart transplant should cause some people to wake up a little bit and understand, OK, yes, these children are not likely to die, but they can have some very serious things happen to them. And we certainly end up hospitalizing many children, many young adults. And now, of course, you and I have talked on other shows about long haulers. We've talked about myocarditis. And we're seeing estimates that perhaps somewhere between 10 and 20 percent of people, even those that had relatively mild illness, can have long lasting effects that can be really disabling to these people. So we need to think about this disease differently. I'm not advocating panic. I'm not advocating overreaction, but let's not minimize it either.

GAUDETTE: And I think, Dr. Pate, that's one of the things-- I was literally just having a conversation with someone the other day who said, I know if I get it, I won't die. I don't want to get it, but I know I won't die. And I was like, well, first off, we don't know that, because we don't know how our bodies will react to this. And we have seen otherwise incredibly healthy people, even if it is not fatal, as you mentioned, long haulers, all of the adverse effects that come from COVID. And so, it's having to shift that mindset because you're right, no one should panic. No one should be so scared that they can't have some semblance of a life. But it is knowing that, you know, death doesn't mean that you may fully recover from this.

PATE: Well, that's exactly right, and first of all, you know, when people refer to the mortality rate, it's generally an average mortality rate. In other words, we're including kids and old people in this mortality rate. When you look at mortality by age group, it can be far different. And the mortality rate in children and young adults is not zero. It is very low. It's not zero. And people will often suggest, well, but you can get killed in a car accident. You can get killed with all these other things. Absolutely true. But I don't look for additional ways that I can play the odds of whether my children live or die. I don't think that means we stop taking precautions. We don't get paralyzed by this, but that doesn't mean be reckless.

And what is particularly sad, I remember a young man in a southern state having a COVID party because there was the thought that, OK, we'll get COVID will get over, it will be immune, which is not true. And then more recently, we've heard disturbing stories about people having COVID parties so they can get infected, have the antibodies and then donate their plasma and get paid for it. Look, there are lots better ways to earn money than do that. Please don't do that. But in this one case, we had a young man, healthy, very active in the hospital and now recording [on] social media: My God, I've made a terrible mistake. Please don't do this. And so the point is, yes, if you play the odds, you're going to do OK if you're young. But there are going to be, if enough people get infected, there are going to be some people that die. There are going to be some people that end up hospitalized. And it's not fun.

I have never seen a young person in the hospital getting ready to be intubated, have a tube put down their throat. That wasn't scared as much as they've ever been in their life. It's not fun. And we don't need to go through this. Let's not be reckless. Let's give it respect. Let's not let it paralyze us. Let's not let it cause undue fear. But let's please not disregard it. Let's not be cavalier about it.

GAUDETTE: Dr. Pate. I want to talk about some of the vaccine trials that are going on. So I believe earlier this week, Johnson and Johnson paused its coronavirus vaccine trial in the late phases of this because of a sick volunteer. And then we just learned that the Eli Lilly antibody trial is paused because of some potential safety concerns. We know that another, about I think about two months ago, there was another trial that paused for a while because they had a sick volunteer. It has restarted. Can you talk about why frankly, this isn't necessarily a bad thing when these trials are suspended?

PATE: Yeah, it's a great point, Gemma. So first of all, these trials are highly publicized and everybody around the world is watching. We have had clinical trials going on for many decades and it is not unusual for a trial to be paused when we see some things in order to allow the oversight body to determine, is this something that just happened independent of the vaccine or is this caused by the vaccine? So keep in mind, many of these phase three trials that are going on right now and some of the companies you mentioned, they have 30 or 40 thousand people in them. And if you take care of 30 or 40 thousand people, they are going to have things happen to them, whether they're getting a vaccine or not. And so when somebody on a vaccine trial has something happen to them, we have to decide, was this something that they got regardless of the fact they were getting the vaccine or did the vaccine cause it? So the first one that became very public was the AstraZeneca trial. And there was a study participant that if the leaked information is correct, was a UK citizen in the trial who developed a condition called transverse myelitis. And it's probably not important that your listeners understand what that is, but that is a condition that I could probably name about 30 things that could cause it. One of those things would be vaccine. And what it turned out is that this study subject did not disclose, apparently, if the information is correct, that he had multiple sclerosis, which is one of the conditions that can cause this problem. And so they paused the trial. And as you said, I think that's a great sign. That shows that the drug companies that do have a significant financial risk in this being successful were not willing to compromise safety and they stopped it so they could have a look. And in UK and over the European Union, they reviewed it. They said, OK, this is OK, is not due to the vaccines. They restarted the trial. It has not been restarted in the United States yet. It's still under review. But now we have these additional studies that are having things. Most of the time, I think these will not turn out to be anything and the trials will get started up again.

The two takeaways are, number one, these drug companies are being very responsible. So kudos to them. And number two is whenever you hear the pronouncements from the president and others about when the vaccine is going to be available, understand, they are saying if everything goes along perfectly and they seldom do. And so whatever they're telling you, that's the earliest possible it could be. It may very well be delayed by a month, two months, three months because of these kinds of events.

GAUDETTE: And then today, Pfizer came out and said that they've gotten approval from the Food and Drug Administration to include adolescents aged 12 to 15 in their late stage study. And why is it important, Dr. Pate, to make sure that we're starting to include younger people, I mean, children in these studies as well.

PATE: Yeah, it's very important, so my specialty is internal medicine. I specialize in the diagnosis and treatment of disorders of adults. I learned a long time ago that kids are not little adults. They're a complete different species, and you just can't treat them all the same. So when we do vaccine studies, we always start with adults. We don't want to take chances with kids, so we start with adults.

But the good sign about the FDA granting this is it means the FDA is confident enough that these vaccines are reasonably safe, and safe enough that we can now expand it and include some older age children.

And that's good because vaccines don't always work the same in kids as they do adults, especially older adults. So we need to look at as many different populations as possible. This is a good thing. I think before this, the youngest people enrolled have been 15 or 16. So this is good. We'll start decreasing the age. That will happen with more trials and that will lead to us having good information about children sometime next year that we can include them in the vaccinations once we're sure that we're not seeing anything unusual in kids.

GAUDETTE: Another thing that came out today was President Trump working to get emergency approval for Regeneron. This is the antibody treatment that he received when he contracted COVID-19. He said, quote, It made him feel very good, very fast. He also said, and this is a quote, 'they call it a therapeutic. I don't think it was therapeutic. I think it was a cure.'

Dr. Pate, can you talk about that, because there is a difference between a therapeutic and a cure and and also this Regeneron, if I'm remembering correctly, a, does not have FDA approval, but also has only been used, I believe, less than 10 times, at least in the United States.

PATE: Yeah, so, you know, the president often does make our job harder because he sometimes is prone to a bit of exaggeration. So first of all, there's no evidence that, first of all, that he's been cured. And second of all, that if he is over COVID that it was due to the Regeneron treatment, obviously he got a number of treatments. And plus people get over COVID on their own in many circumstances, too. So if somebody does recover, to be able to attribute it to one thing when they've gotten multiple therapies is very difficult. And you can't do that in one person. You need large trials to be able to sort these things out. So I certainly wouldn't put a lot of stock in his words there. And and of course, he doesn't understand that cures are therapeutics. Not all therapeutics are cures. But if you've got a cure, it was a therapeutic. And similarly, his comments about being immune are a bit reckless. First of all, we don't really know at this point. We'll know soon what the marker of immunity is. And as was pointed out, even if he is immune, we don't know how long it lasts. 

But for the Regeneron, let me tell you, I'm a huge supporter. I'm very excited about the prospect. I have been excited about monoclonal antibodies since early on when we understood what the neutralizing antibodies were. We still don't know that neutralizing antibodies are critical to immunity, but we think they are. And if they are, these monoclonal antibodies are extremely promising and very encouraging. However, it would not be the first time that we have thought about something that likely would be extremely exciting and likely to work that doesn't end up working.

So we need the trials. And the point is, is that the reason that the Regeneron treatment doesn't have approval from the FDA yet is the studies aren't far along enough and haven't involved enough people for us to be genuinely persuaded that it's effective. I think it's very promising. I think it's very likely it will be. It certainly -- we have a long history of monoclonal antibodies treating other disorders, and they tend to be very safe treatments. But we need more data before we decide that this is effective.

GAUDETTE: And before I let you go, Dr. Pate, I must say it has been fascinating to watch scientists, to watch doctors, researchers from, when we go all the way back to even January, when you and I started talking about this to where we are today and what we know about this. And it is, even as we are spiking again, even as we are going into the winter months, it seems to me that it might be one of these things where the good news is -- there isn't any great news in the moment as we see the spikes going up. It seems to me, and just my layperson view is that long term, though, there is good news. We are going to have vaccines, we are going to have therapeutics as doctors and researchers and scientists do more, as they learn more, we know more.

Would you agree with that idea of, you know, right now it may not look great, but long term we're going to be able to move through this?

PATE: Yeah, well, Gemma, I couldn't agree more. It may not be obvious to the average person who doesn't pay a whole lot of attention to medical science, but what we, who are in the field, have seen this year is truly staggering and impressive.

You know, there are many things to point fault and blame with: the CDC, the World Health Organization, China, etc. There's many things that didn't go great and we have to learn from and we have to make changes. But on the other hand, let me tell you, those of us in this field were absolutely stunned when Chinese scientists released the genome of this virus on January 7th, that quick. I mean, that is unheard of. That was just a tremendous accomplishment to have that, which allowed us to develop tests to understand the nature of the virus, where it came from, all these kinds of things just truly amazing. And then if you look at the amount of knowledge that we've gained about this virus and still there's many unanswered questions, but all that we've learned in eight, nine months is really staggering. I certainly have been around long enough that I've seen the emergence of many new infections in organisms over my career. Never have we learned this much about the organism this fast. And I think it just shows if there's a sense of urgency, if it's a worldwide focus, if we get scientists working together all over the world, it's just amazing what we can accomplish. It does make me think, what if we all focused on cancer or something? What could we accomplish? But it's truly amazing.

GAUDETTE: I want to thank you so much for your time, it is always such a pleasure to have you on and to get your expertise and advice. So Dr. Pate, as always, thank you so much.

PATE: Thank you, Gemma. 

GAUDETTE: You've been listening to a special edition of Idaho Matters, I'm Gemma Gaudette. 

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