As Idaho Extends Stay-At-Home Order, Doctors Answer Your Coronavirus Questions

Apr 15, 2020

 

We’re back again this week to answer more of your COVID-19 questions. Every Wednesday during at least the month of April, we will bring on a panel of doctors and health professionals to get us updated and to answer your questions. 

Joining Idaho Matters this week to share their expertise are:

  • Dr. David Pate, part of the governor’s Coronavirus Task Force, and former CEO of St. Luke’s 
  • Dr. Ryan Heyborne, Chief Medical Officer at St. Alphonsus Regional Medical Center
  • Dr. Sky Blue, board certified in Infectious Diseases with Sawtooth Epidemiology and Infectious Disease

If you have questions for next week’s show, please leave us a voicemail at: 208-426-3625. We might use your message on the show next week. 

 

 

Read the full interview here:

GEMMA GAUDETTE: This is Idaho Matters. I'm Gemma Gaudette. As we continue to cover the coronavirus pandemic, we know so many of you have questions and concerns. And here at Idaho Matters, we do want to answer those questions with facts. We believe the best way to do that is to bring in medical experts from around Idaho. So every Wednesday, we will bring in a panel of doctors and other health professionals to get us updated and to answer your questions. Now, if you're a regular listener, kind of think of this as a doctor's version of our reporter roundtable. Joining us live today, are Dr. David Pate, former CEO of St. Luke's Health System and a current member of the Idaho Coronavirus Task Force. Dr. Ryan Heyborne, chief medical officer at St. Alphonsus Regional Medical Center, and Dr. Sky Blue, who is board certified in infectious diseases with Sawtooth Epidemiology and Infectious Disease. I want to thank all of you for joining us today.

ALL: Thank you.

GAUDETTE: And a quick and a quick note. We should say that Idaho Governor Brad Little, just about one hour ago at 11:00 a.m. this morning, extended our statewide stay-at-home water with some exemptions until April 30th. And now there are some changes that will allow nonessential businesses to reopen. Those changes include businesses reopening, will need to maintain social distancing, provide proper sanitation and only offer curbside delivery. The governor cited places like garden shops and jewelry stores and peg roaming as examples. Plus, anyone coming into the state of Idaho will need to self-quarantine for 14 days. Little's goal is to open more businesses by the end of the month. But he does say some preventive measures will be needed until a vaccine is found. And he is pushing for more testing throughout the state. And he is urging everyone to wear a mask while in public places. So with that, Dr. Pate, I want to start with you, with you being on the Coronavirus Task Force. These sound like similar recommendations that were that we're hearing from from other states, yet people have questions about, well, why do we need to continue if we're continuing to see the number of cases going down in Idaho?

DR. DAVID PATE: Well that's a great question, and the reason is, is that, the reason that cases are going down is it shows that these measures are working. This is unlike other kinds of epidemics that people might be used to, where we have an outbreak of a bacterial infection in a food restaurant or a store, things like that, that kind of have a short beginning -- or a beginning and a short end. This is different. This is a novel virus that no one in this country had immunity to before it started. The only people likely to have immunity at this point are those that have actually been infected. Therefore, the way to keep this virus under control is to decrease its transmission. If we were to all of a sudden give up on all these restrictions, then everyone would anticipate we would very soon see a rapid increase again in a number of cases, number of hospitalizations, number of people on ventilators and deaths. And it could be such that it would overwhelm the health care delivery system. So what we've done has worked. That's why I think the governor is making a well-reasoned decision that we can loosen it a little bit, but we can not take this for granted. We have it better controlled. But it is not eliminated. It is not the fact that this is no longer a threat.

GAUDETTE: And Dr. Blue, I'd love to bring you into the conversation with you being an epitaph, with you being an infectious disease specialist. Let's talk about the value of testing, because we've got a test to to see if you have COVID-19. But then there's also this antibody testing that everyone is is talking about. Can you talk about the value and the challenges, though, of both of these tests?

DR. SKY BLUE: Sure. Great question. And certainly one I've been getting quite a bit these days. And so I think we need to understand what those tests are and then what the value is in each of those settings. The first one that we've had for a while now is called the PCR test that's able to identify small areas of the genome of the virus. It does not actually measure infectious virus, but these small chunks of RNA that... Each test has a specific target that it's looking for. And so those are kind of akin to our culture in bacterial diseases. So when we use a swab to obtain a sample and we run it through a PCR machine, it will tell us whether or not you have any RNA from the coronavirus at that time. So really, it's almost -- its value is in real time what's going on right now. It doesn't say if somebody has been exposed. It really doesn't even say if you've had an infection in the past, if you don't have enough of that RNA around to turn positive. So the real value of that test has been to identify a symptomatic individual to tell them what's going on. And so if they test positive by that PCR that this disease is likely the coronavirus so that they'll diagnose a patient and get them on the right therapy. That's the probably the biggest thing. You know, it helps in the hospital because we identify individuals who we need to take special precautions to make sure they don't spread it to other health care workers or patients around them. And then you the other real value for that is the isolation and contact tracing for individuals who are positive by PCR out in the community. You may not need to be hospitalized and they may not need to be on any therapy, but understanding who those individuals are, getting them to self isolate and then find individuals in their close circle that may have been exposed and if they develop symptoms, get them tested as well. So that's the true value of that PCR. It's really an instantaneous sort of thing. What we're talking about with the antibody tests, those are also called serologies. We're looking for evidence that somebody has had an infection by a protein that the body makes in response to an infection. So influenza, other infections that we get, we develop antibodies and it helps us clear that infection. And now everybody's rushing to produce tests that will tell, by these antibodies, if you've recently or in the past been infected with this virus. And so we certainly think there's going to be a value to that. It may say who may have some immunity, although we have not, as you heard, been able to connect that unity to to protection from new infections. Most experts think we will have some immunity. We don't know how long it will last and whether we'll be completely protective. But that's what the value of that hopes to be. However, you know, in our rush to innovate, we probably have 70 to 80 of these rapid antibody tests that are out there now. And so the performance of those tests or what we call the accuracy, which is a combination of sensitivity and specificity, varies quite a bit. The best of these tests out there right now states that they probably have accuracy, insensitivity and specificity into the mid 90s. 93, 95%. And although that sounds really, really good as far as what these tests show, if we were to test, say, a million people in Idaho with that test, with that accuracy, and we think that even up to 5 percent right now may have had this infection, now would be fifty thousand individuals roughly who would have a positive antibody test. But with that degree of accuracy, you would also identify another twenty five hundred that you can say you were negative but truly had the disease. But another fifty thousand who you will tell that are positive, who never did have this disease. So almost as many false positives as true positives when you use it on a wide scale like that. So they say antibody tests will be very valuable. We just have to get to the ones that are going to be accurate enough to tell us where we want to know.

GAUDETTE: So that in your opinion, Dr. Blue, who should be tested? I mean, especially when we get that antibody test that's the most accurate, correct? I mean, should the entire population be tested? I mean, is that is that our best bet?

DR. BLUE: So whenever, you know, doctors order a test, the question is what are you going to do with the results? So if we tested a large population like that, we'll get some very valuable information. We'll know how many individuals might have had this and had never been diagnosed or maybe even realize it themselves. So that is valuable information. And I think a lot of institutions, CDC, NIH are looking at ways to do that, because that's something we don't know. Whether or not each of those individuals tested will get any value of that data or that answer is really unknown at this setting. We said they were looking for a more accurate antibody test. But again, we don't know exactly what to do with those results when we get down. I think using them in combination with our rapid PCR tests are going to be helpful in various situations.

GAUDETTE: And then Dr. Heyborne, now I'd like to have you join the conversation as well, because we're we're starting to see here in Idaho people who've been hospitalized, recovering. I mean, unfortunately, we have seen deaths as well. But at St. Alphonsus, what is the latest with with with what's going on with the virus? Are you starting to see some patients recovering?

DR. RYAN HEYBORNE: Yes. Thank you. Absolutely. As we know, the vast majority of people that contract this virus do very well with it, they don't become critically ill. Obviously, those that get admitted to the hospital are going to to be sick to the point where they need more advanced care. We have treated patients in our E.R., in the hospital, in the regular units, as well as in the intensive care units. And as is being seen throughout the state, some people are getting very ill with this. As you commented, there have been some deaths. Most of the people that we've had in the hospital had in the E.R. and so forth have recovered and are recovering. And so we're glad to be able to participate in that.

GAUDETTE: We're going to take a quick break, when we come back, I want to get to some of our listener questions because they have some concerns. We want to make sure we get to those. You're listening to Idaho Matters. We're going to return with our medical expert panel right after this.

GAUDETTE: You're listening to Idaho Matters, I'm Gemma Gaudette. We are continuing with our medical experts today, our panel, former CEO of St. Luke's Health System and a current member of the Idaho Coronavirus Task Force, Dr. David Pate. Dr. Ryan Heyborne, Chief Medical Officer at St. Alphonsus Regional Medical Center. And Dr. Sky Blue, Board-Certified Infectious Diseases with Sawtooth Epidemiology and Infectious Disease. And I want to jump back in and get to our listener questions. So the first one comes from Erica. She sent us an email and she says, "I have every symptom of the virus, but because I am not on my deathbed, they won't test me. The person I talked to said I most likely don't have it, although I have every symptom. She said if I am not coughing, which I am, I should go ahead and go to work. So can we talk about the criteria for testing?" And who would like to take that? Maybe Dr. Heyborne and Dr. Pate.

DR. HEYBORNE: Just as you know, seeing what we're doing and it's really fairly consistent with what's happening in the community, what we're doing here at St. Alphonsus and I still see patients in a clinic myself. And so this is a topic... And this is, as Dr. Blue very aptly stated, there are pros and cons to testing how testing is utilized, as well as the fact that testing availability is constantly evolving. Just this morning I was talking about the number of tests we have, what we're able to do through the state and so forth. And every health system is building internal testing, utilizing state, utilizing external labs where appropriate. And so that criteria is somewhat changing. We are to the point generally as a community where there is enough access to the nasal swabs at least. And Dr. Blue and Dr. Pate can comment on this as well, that we've gotten to the point where we are planning on testing and we have a tent sites, drive-thrus. I know that St. Luke's primary health benefits have a similar approach, the V.A.... We're expanding that to include individuals with one or more symptoms. The risk profile has been lowered to get that threshold of testing. And so if an individual is having concerns, is still having symptoms and wanting to be tested. I might encourage them to revisit that at one of our tent sites, whether it's ours, Luke's, V.A., primary health. 

GAUDETTE: And then Dr. Pate, maybe you can answer this one. Rick has sent us a question saying, "when are we going to start testing anyone and everyone, not just for COVID-19, but also for antibodies. He goes on to say, If I were an employer, I would want everyone at work to either have a test result saying they're negative or a report saying that they know they have the antibodies. I mean, is that even possible to test everyone?"

DR. PATE: Not today. You know, we may get to something like that in the future, but it's still a far ways off, you know. I want to go back to what Dr. Blue said, because he he made some really good points with respect to the testing were in general talking about two different tests. He talked about the nasal swab tests, that's the one to see: 'Do you have identifiable parts of the virus now,' which would suggest that you may have the infection and you may be contagious? And I've heard people ask about, you know, hey, we just ought to be testing everybody and so forth. No, because a negative test today just means negative today doesn't mean you couldn't be infected tomorrow. So we still have to be guided by symptoms with that testing. The antibody testing, which I think he's really getting to: I think Dr. Blue gave a really good explanation. First of all, that was just approved under an emergency use authorization like a week ago. We don't even really understand it yet. How accurate it is, what a positive test means. Does that mean you're immune? And depending on when you do that testing, you could get a false negative. And so we're not at that point. I do think in the future, once we can test these antibody tests and understand this better and have those answers, it may very well be very helpful to us in figuring out who can get back to work the soonest, who can be in situations where they have to be in close proximity with these infected persons like health care workers. But we're not there and we won't be there for a good while still.

GAUDETTE: And then, Dr. Blue, I'm hoping you could answer this. Paul sent us a question. And he says, "if a test shows antibodies, does that mean a person is immune? Or could that mean they are in the early stages of having COVID-19?"

DR. BLUE: Sure. Excellent question as well. I really love how these days you everybody is getting into the science of this. Everybody is an epidemiologist. It's great. Been doing this for twenty five years and nobody would listen to me. And now all of a sudden, you know...

GAUDETTE: Everybody wants to do! 

DR. BLUE: Yeah, everybody's a virologist and an epidemiologist. So it has to get back to... It depends. So there's two types of antibodies. The first is one called IgM. It's produced pretty early in an infection. And so sometimes it can be used to identify an acute infection. The trouble is, is the IgM pushed out by the body quickly is probably the least efficient at binding whatever it set out to. So we say that has a low affinity. And so it happens that because IgMs in general have a low affinity, they're more likely to bind to all sorts of things. And so you can really get tied up in false positives in that setting. We don't even really know if the coronavirus that circulates every year as a cold or flu in Idaho can give you IgM antibodies from this last season that could still be detected in some of these new tests. So, yes, it may, depending on the accuracy of the test. Over the last few hours, I've actually had two calls from physicians who had false positive IgM tests from the antibodies and they've been out of work and trying to get tested again to make sure that things are safe to get back to work with absolutely no symptoms at all. The other side of that is IgG antibodies. Again, we still have the difficulties with false positives and false negatives, but the IgGs tend to have better affinity, so they're less likely to cross react. But the idea is we don't know if it does make us immune or not. A lot of experts are thinking that there must be some immunity because of what we're seeing around the world and in the ebbs in our epidemics. We've studied it in macaque monkeys, which seems to show that we are protected or they are protected from re-infection. But we know we get vaccinated for influenza every year. We make antibodies to it, but it doesn't keep us from getting the infection. We hope it makes it less severe, but it doesn't even mean that we can't spread it. So we don't technically know what those IgG antibodies tell us if and when we get the accurate measurement of them, so we even know that what the test is showing us is accurate.

GAUDETTE: And then Diane, she wrote in saying, "In the late 1980s, a doctor cautioned me about a malaria drug. She said the drugs used at the time had serious potential side effects, including blindness. So do the malaria drugs being considered for the coronavirus have serious potential side effects?" And I guess my question would also be to add onto that. Are they still looking at malaria drugs as as a potential drug to help?

DR. BLUE: Sure, I can take that one as well. So the main one that we're seeing at this time is the hydroxy chloroquine that's been on some of the national updates and we're talking about EMA [European Medicines Agency] is just pushing out a lot of doses of that out to various areas. And so it's probably the most widely used and it's a derivative of the malaria drug, chloroquine. And so any medication that we use has potential side effects. And so, you know, you mentioned blindness. And for longer term use, you can have some retinal side effects. The main one in the short doses that we are anticipating using are probably dysrhythmias of the heart, abnormal beats that could be caused by this, especially if there's other medications that the individuals taking that interact with that. You know, the biggest question, though, is does it work? And we don't know. And that's an area of active research. Even today, I saw a pre-print of an article that suggests that it may -- you know, a lot of caveats in there -- may give us slight benefit when used early. So it sure... We always have to decide whether or not the risks that we see with these things are worth the benefits and we are trying to decide that right now.

GAUDETTE: And then there's a question from Petra and maybe Dr. Pate, you could take this. She wants to know if everyone who who dies is tested for COVID-19. And if not, could the death toll be actually higher than is being reported?

DR. PATE: So, no, not everybody in this country is tested for COVID, when they have a death. And keep in mind, most people that are dying in the United States are not dying of COVID. And so sometimes there's some very obvious reasons why somebody died. Yes, it's possible we're missing some deaths that are due to COVID. But certainly in what we've seen so far, the people that die don't tend to just die real suddenly without the onset of symptoms and things that, you know, would make their family or their physician aware that they have some kind of respiratory illness in those cases. I would think across the country they probably are being tested, but not everybody. And I don't think our death count will be off very much, even if we are missing some cases of it.

GAUDETTE: Ok. And then Roger has a question, and I really do want to ask it, because sometimes it's nice to maybe end on a bit of a lighter note. He wants to know, can he get arrested for kissing his girlfriend in public?

DR. PATE: Yes.

GAUDETTE: OK. [laugter.]

DR. PATE: So, I said that for a fact, Let me expand. Technically, yes. Violation of the order of the Department of Health and Welfare by the director is a misdemeanor, which in Idaho can be punished by up to six months imprisonment and/or a fine of up to a thousand dollars. So, yes, he could, but he won't. And so the way our legal system is, is that law enforcement exercised this discretion every day and with every law. And and I think every law enforcement agency in Idaho's come out and said, you know, at this point, what they're trying to do is educate. We're not I don't think they're even writing tickets. But, yeah. He technically could, but it won't happen.

GAUDETTE: And maybe the other question to ask is that it's about that social distancing. And we do know even how the order stands, that it's like you can be with your the people that you live with in your home. I mean, I am out in public with my husband and my kids. Right. I mean, my husband I go on to go on a walk everyday around our neighborhood. We are not social distancing. So, yes, someone could say that we're not following the rules. But I would say Dr. Pate, that we are based on what the social distancing requirements are. I mean, we live in the same home.

DR. PATE: Right. Yeah. I think the I think the point is, obviously, my wife and I, who to the best of my knowledge, both are fine right now. We're not social distancing in our our house. We still come into close contact. But the point is, if you're going to be around other people who are not in your household. First of all, you should try to avoid that if you can. But if you can't avoid it, then maintain the separation. And, you know, I just want to reinforce what the governor said today. We're so proud of Idahoans that we know this has been very tough. But it is clear from that and from our observations that people are observing these guidelines, by and large. And it is really helping. And I hope all of those that have been going to the trouble of complying with this order do understand they likely have been saving lives by doing so. And the other thing is, I'll just say, on behalf of health care workers, thank you for not putting them at more risk than they're already taking by not following these orders and potentially causing many more patients to be at our hospital. And just a special thanks to all of our health care providers. I have just so been inspired by their fantastic work and dedication.

GAUDETTE: And I want to thank all of you for coming in today. I know you have busy schedules. I mean, the pressure that our health care professionals are under right now. So I thank the three of you for making time for us, for answering our listener questions with facts. It is so critically important that we give people the right information. So thank you so very much. We've been talking with Dr. David Pate, former CEO of St. Luke's Health System and current member of the Idaho Coronavirus Taskforce. Dr. Ryan Barn, chief medical officer at St. Alphonsus Regional Medical Center. And Dr. Sky Blue, who is board certified in infectious disease with Sawtooth Epidemiology and Infectious Disease. Thank you so much for your time today. Thank you.

ALL: Thank you. Thank you so much.  

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