As New Cases Of COVID-19 Fluctuate, Idaho Doctors Urge Vigilance

Aug 19, 2020

While we've seen a slight downward trend this past week in new coronavirus cases in Idaho, our state is nowhere near past this pandemic. Especially with schools opening back up this week and next, doctors across our state are worried about what the next month will bring. 

Joining Idaho Matters today to answer your coronavirus questions are:

  • Dr. David Pate, former CEO of St. Luke's Health System and a current member of the Idaho Coronavirus Taskforce.
  • Dr. Mark Nassir, President of the Saint Alphonsus Medical Group.
  • Dr. Jim Souza, St. Luke’s Health System Chief Medical Officer.

Read the full transcript here:

GAUDETTE: You're listening to Idaho Matters, I'm Gemma Gaudette. As we continue to cover the coronavirus pandemic, we know so many of you have questions and you have concerns. And so here at Idaho Matters, we want to answer your questions with facts. The best way we believe to do that is to bring in the medical experts. So if you have a question for our Idaho doctor, send us an e-mail right now, idahomatters@boisestate.edu.

Joining us today, Dr. David Pate, former CEO of St. Luke's Health System and a current member of the Idaho Coronavirus Task Force, Dr. Mark Nassir, president of the St. Alphonsus Medical Group, and Dr. Jim Souza, St. Luke's Health System chief medical officer. Thank you all for joining us today.

ALL: Thank you, Gemma, thank you, Gemma. Thanks.

GAUDETTE: So, Doctor Pate, I'd like to start with you. We have seen a slight downward trend in the 14 day model for Idaho. What are your thoughts on that?

PATE: Well, I think you're right, slight, and I don't really trust these until I see a good two weeks of a trend. Certainly I'm glad we're seeing a slight decrease rather than a slight increase. So certainly that makes me pleased. But before I would conclude that that really means things are getting better, I would need to see it over more time, especially with the testing delays that we're currently experiencing. It could be that there's still a lot of tests pending that haven't been reported. There may be situations where people, because of the long testing delays, maybe aren't getting tested. And of course, we're getting ready to shake everything up with opening some schools. So I'm not even sure what the trend is right now makes a whole lot of difference because we are going to make very substantial changes in how we are implementing our infection control measures. So I think what we're seeing today has very little correlation to what we're going to see a month from now.

GAUDETTE: And Dr. Nassir, to continue with that, how are things at St. Alphonsus right now? Are you seeing a downward tick in cases or what are you seeing?

NASSIR: Thank you, Gemma. It's an honor to be with you today. At St. Alphonsus, we are cautiously optimistic and share Dr. Pate's thoughts. We're continuing to see a significant incidence of COVID in our local community and in our hospital, but perhaps a flattening of the rate of climb in the daily cases. So we continue to have a significant number of patients in our hospitals still admitted. Presently today in the 40 range, 40 to 50 in the last week, which approximately twenty five percent are in the intensive care unit. And we're seeing still a high or significant positivity rate in the patients that we're testing at our testing sites. Today, that is in the 17 percent range coming back positive. So there's still a significant amount of positivity in the community, but the day over day climb seems to not be rising as fast. And that gives us a pause for a little bit of optimism, cautiously and carefully.

GAUDETTE: And Dr. Souza, the same question for you. What are you seeing at St. Luke's?

SOUZA: Similar. We we've been on, I'd say, a plateau for probably the last three weeks in terms of inpatient cases. This morning we had, I think 77 in patients with COVID related illness across our health system, and 17 of them were in intensive care units. I share, though, was what Dr. Pate's concern is. I think it was last week the American Academy of Pediatrics tried to put a rough estimate on what are we going to see as schools reopen. And, you know, it's difficult to predict due to the sort of hodgepodge nature of our approach here, meaning, you know, kind of district by district, school by school and so on and so forth. There's not a cohesive way to do it. They estimated a two to three fold increase in community activities where schools open and then therefore as health care providers, we'd we'd anticipate that a percentage of that would then impact the inpatient setting.

GAUDETTE: So, Dr. Pate, to be perfectly, I think, clear about, you know, I think maybe how some of us are feeling is that every time we've heard about, oh, we're seeing a bit of a downtick, we're seeing a stabilization, I'm frankly almost afraid to talk about that because it seems that every time that's been license to stop doing the things that we have been doing to get those numbers down, do you have a similar concern? Because there just seems to be a pattern of that happening.

PATE: Yeah, I do, Gemma, and, you know, I think that what we've seen from this is the American public as a whole has very little patience for these things and very little sticktoitiveness for this. Now, with that said, you know, we've certainly demonstrated there's times we can rally. I was very proud of Idahoans back at the time when the governor issued a stay at home order. Frankly, the reason that didn't have to be implemented before it did is that we saw a lot of good behavior. But with time, people get tired, they get impatient. They long to get back to their regular lives. And I understand that. I want things to get back to normal, too. But it's quite ironic that when we start to see these improvements and therefore we let up our guard, what follows is another big spike. And of course, then that just kind of causes us to try to clamp down again. And we really kind of need to get away from this 'yo yo' effect and just realize, look, you know, I hope this doesn't last a very protracted period of time, but I can't imagine that this isn't going to be the case til next summer. So let's just get in the mindset, everybody, that for this school year, we need to be careful. We need to stay home when we can. We need to work from home when we can. If we're sick, we need to stay home. If we're going out, we need to physically distance. And if we can't physically distance, we need to wear masks. And this is not going away any time soon. And that virus stays out there. And this is what we've seen over and over again with states or countries that kind of get things under control, but then loosened up and then you get resurgences.

GAUDETTE: So, you know, you mentioned, you know, things like wearing masks and all of that. But Dr. Pate, I mean, we still there is no mask mandate, as you know, in the state, but we have one in the Central District Health District. But, hey, Canyon County is, you know, less than 20 miles away from from Boise. And, you know, they're in a different health district. We've talked about this -- no mask mandate. The governor is holding a news conference on on Friday. 

Will we see or do you think there is a possibility that we're going to have to implement a statewide mask mandate or should we even stop talking about it because it's not going to happen?

PATE: Well, I don't actually know the answer to that question, Gemma. You know, the governor has been quite clear about a couple of things.

One is he has pointed out that because different parts of Idaho are in very different circumstances, that as opposed to his statewide stay at home order, which was a brave move on his part and the right thing to do early on -- and did get things under control. But then his view was the local leaders need to do their jobs. And, you know, and before all this, we thought we could count on our local public health districts to do the right thing. And some have and some have stepped up in a big way and others, unfortunately, continue to disappoint. So the governor did say he would not say never, that he's not going to do it. Obviously, he's reluctant. But I do think the governor understands the threats that we face. And I think that depending on what we do see with schools opening, it could precipitate that kind of action. But I don't know of any planned action on the governor's part to do that. And I know he's reluctant to do that, but he's not ruling it out.

GAUDETTE: And before we take a quick break and get to listener questions, Dr. Souza, I want to talk a little bit about the first child in Idaho that was diagnosed and hospitalized with what is being called MISC. Now, they've been released from the hospital, but here we are, right. Schools are reopening. And we have the first case of this. For people who may not be familiar, can you tell us what this is? And and also, Dr. Souza, what we should be looking for as parents.

SOUZA: Sure thing. Thanks. MISC, it stands for Multisystem Inflammatories Syndrome in Children, and it's now a recognized complication of COVID-19. Fortunately, it happens relatively rarely. I believe the stats are roughly one in a thousand children who gets infected with COVID we can expect to develop this complication, but it's a big deal. I saw some of the chatter about this last night and was profoundly disappointed by some of the online comments. To be clear, this child was critically ill. Was admitted to an intensive care unit and was in shock. That means that they had a blood pressure that was incompatible with life and needed to be resuscitated. Fortunately, they responded to aggressive treatment and are doing well now. We can expect more of this as we see more pediatric infections. Did I answer your question?

GAUDETTE: You did. And I think that that's the part of it, though, too, is that we're going to see more cases of this now.

SOUZA: Yes, we expect to. We're planning to, in fact, sadly.  

GAUDETTE: So as parents, Dr. Souza, what are some of the signs and symptoms that we should be very highly aware of?

SOUZA: Yeah, you know, fever, rash, red hands. This particular case presented looking like, you know, sort of a potentially a case of strep throat or something like that. But, you know, it's got wide ranging symptoms and can affect multiple different organ systems so that a complete list is quite exhaustive.

GAUDETTE: Dr. Nassir, Jose wrote in wanting to know about the side effects of COVID. He says, In terms of the loss in taste with COVID, is that something that happens gradually or is it sudden from one day to the next?

NASSIR: Thank you, Gemma. So for Jose, the side effects of COVID or the symptom I believe he's describing with the loss of taste or smell: We've seen it to be for some patients sudden and for others, a little more slower onset. Of interest, we've also in our testing experiences in St. Alphonsus, found that some patients have that as an early presenting symptom. You know, early on, they notice that they lose taste or smell. And just this last week, we were discussing a case of a patient who several days or perhaps even a couple of weeks after the diagnosis, this patient lost the sense of taste and smell. And so, again, we're learning more about this virus every day and how the symptoms present. COVID can present with a wide range of symptoms, most commonly being fever, cough, shortness of breath. But the list is long of possible symptoms that can be COVID related.

GAUDETTE: And then, Dr. Nassir, I want to follow up with that, because Paula wrote in and she says, if the only symptom I have is a sore throat, do I need to stay away from other people?

NASSIR: Thank you, Gemma, a great question, so sore throat is a possible symptom, certainly of COVID-19. If a patient develops a sore throat and it's mild, it perhaps could be something as simple as another viral infection. It could be an early sign of a bacterial infection such as strep, or it might just be an irritant. Right now, there's irritants and allergens in the air that can cause an irritation in the throat. And it could be something related to that.

I would recommend in our current context that all patients that present with a new sore throat watch it closely, if it's significant or severe, associated with other COVID symptoms or with fever, with shortness of breath or a significant symptom that causing difficulty swallowing or breathing, they need immediate attention. If it's very mild, they could watch it briefly and maybe touch base with their primary care provider and consider an evaluation and perhaps testing for strep or COVID, if that's indicated or other such evaluation. So it's a possible symptom and should be monitored carefully. Thank you.

GAUDETTE: Dr. Pate, Penelope has two questions, so I'm going to read her her whole email to give you some context. She says, 'I'm 72 and have a 40 year old relative who I suspected had COVID in late February, early March and thought it was just a very bad upper respiratory sickness. I took care of her for a day. Her five year old daughter was in the house during the sickness and exposed as well. I did not get sick until March 9th through March 19th and thought I had an upper respiratory infection. Question number one, if I got a COVID test now, would antibodies still exist and be any kind of indicator? And then question two, can children be tested for the coronavirus?'

PATE: So let me deal with question two first, because that's the easiest, yes, we test children in much the same way that we do adults. 

Now, the first question is much more complicated. So, first of all, this was not an uncommon scenario. We saw people back in March and April that swore they had COVID because of an illness they have. But if you recall, back in January, February, March, when people were getting sick and then concerned was at COVID, that was also the time that we had many other respiratory viruses and influenza. And so, as a general rule, a lot of these people that thought they might have had COVID came in for testing. In fact, we only found about eight percent of them did. So the chances are she did not have COVID. Now it is possible. The problem is, you know, when you talk about tests, so back in March, we wouldn't be talking about the typical test that we do now, the PCR test. That would obviously not help us. But her point about antibodies might or might not answer the question. The first part is we have found from studies that anywhere from around two to 16 percent of people don't even make antibodies that we can measure when they get infected with COVID. So the most do. And so chances are that she might have, but it's not a certainty. The second thing is we have found that these antibodies wane, and in people that were asymptomatic, about 40 percent of them had such a decline in anybody levels over several months that we had trouble measuring them any more. People that were asymptomatic, which she was, it's about 13 percent of those people had the decline in their antibodies. So if you got an antibody test today, yes, it might be positive, but if it was negative, that still wouldn't tell us that she didn't have COVID, although chances are she didn't. But I would say the flip side is, even if she had a positive test, none of us know what that means because we still don't understand if the antibodies are protective, if that means that she couldn't get it again. So really, it would just be an academic question to try to satisfy our curiosity. I would just advise Penelope. Penelope, you may or may not have had it, but it doesn't matter. Don't change anything you're doing. And unless you just have 100 bucks burning a hole in your pocket, don't get the antibody test. Just go on with life and take all the precautions because we have no reason to at this time to know that you could not be infected again.

GAUDETTE: And Dr. Souza, Cherie wrote us this question and she says, 'I go to the gym and I wear a mask when I work out. However, about 95 percent of my fellow gym goers do not. How risky is this for a healthy person?' She says she's forty four years old.

SOUZA: Well, for first, I think she should switch gyms. You know, that's a great question. I think in answering, I'd say the risk of acquiring infection is very high. And then let's talk about the risk of something bad happening to her. The reason the risk of acquiring infection is so high is because none of her fellow gym mates are helping out. I'm happy to hear that she's wearing a mask. Good on you, Cherie, but exercising indoors is like the poster child for a high transmission event. You got a high heart rate. High minute ventilation. That means you're breathing deep and breathing fast and you're going to generate aerosols. The only thing that would make that worse is if you're shouting like in a basketball game or a volleyball game, shouting would be like singing. And we know that singing is a high risk activity. And there have been some famous now outbreaks associated with that. So your mask is a great idea for protecting everyone else. It probably does, Cherie, provide you with some protection as well. So continue to do that. But this is really high risk to acquire the infection. 

In terms of a bad outcome, I think Gemma said she was in her 40s, and so, you know, let's just run through the bad outcomes. What's your risk of dying? In your 40s, assuming you're otherwise healthy, it's probably not higher than one percent, but it could be that high. You know, that's that's a higher risk than jumping out of an airplane with a parachute. Your risk of hospitalization probably in the 10 percent range and your risk of feeling really sick is about 60 percent. And, you know, the problem is that we also just don't know enough about this virus yet. So we don't know if you might be one of these long haulers who has long term symptoms. We don't know the long term cardiac effects. There's emerging data on that and on and on. So keep on your mask can maybe switch gym. Or enjoy our foothills.

GAUDETTE: And Dr. Nassir, that goes into Julia's question and Dr. Souza hit on it a little bit. But she wants to know, 'can you discuss the ongoing and recurring side effects and symptoms that continue after someone has had COVID?' Because as Dr. Sousa said, we know that this is changing and we're learning more and more. But I mean, there is a great concern of I mean, these could be lifetime issues that you're dealing with.

NASSIR: Thanks, Gemma. That question has so much in it that Julie is asking my colleague Dr. Souza really hit the nail on the head, which is we are truly in a learning environment with this virus. It's a new or novel coronavirus, which means, you know, we're every day, every week, we understand more about the virus, how it moves to the community, how it impacts each individual. And I think it's important that as we approach any plan to move forward, that we remember that. So that's such an important point. And so to answer the specific question, for many, the symptoms are none, which we asymptomatic, we call that or mild, very mild symptoms. For others, the list of symptoms that we've been discussing during this talk of fevers, chills, cough, lung symptoms, other sore throat congestion, nausea and vomiting, diarrhea, achiness like the flu, and the loss of taste or smell. And then some patients have some combination of those symptoms that come and go at different levels. And then other patients have lingering variations of those symptoms and they continue to need follow up after the virus has run its course. But they continue to have lingering pulmonary lung related symptoms. We're learning more about late effects on the heart and other organ systems and again, learning more about adults and children. So much more to follow, much more for us to understand and learn with regard to early as well as lingering or late effects of this virus.

GAUDETTE: Dr. Souza, Dolores asks, please set the record straight on hydroxychloroquine.

SOUZA: Wow. OK, answering this I think requires --

GAUDETTE: Patience? It requires patience because there's so many differing ideas about this?

SOUZA: No, I mean, it requires understanding science, I would say. And, you know, so there are small observational studies that are sometimes used to generate a hypothesis and then smaller retrospective studies that look backward in time to sort of test a hypothesis. And then, you know, the grandpappy of them all, are the large prospective randomized controlled trials that attempt to prove a hypothesis. So if you run through the lines of evidence for hydroxy chloroquine, it's just no good. One retrospective study in Detroit showed a slight benefit. Other retrospective studies did not. Randomized controlled trials in the recovery trial did not show benefit. So then, you know, it was tested to see in a randomized controlled trial if maybe it helped prevent getting COVID, it showed no benefit. There were some small uncontrolled studies that added zinc, but then they were poorly done. They compared them to non-identical historical controls. So there is a mountain of evidence that there is probably no benefit. If there's any benefit, it's slight, so slight that trying to prove it would would be cost prohibitive. And moreover, there's actually evidence of harm. So that's why the FDA withdrew the emergency use authorization. The bottom line is that the risk is greater than the benefit of using this drug and it can't be recommended. And I kind of wish we'd stop talking about it because I feel like the more oxygen we give to this topic means we're going to be applying more oxygen in our intensive care units because we're going to have people actually believing that a magic pill is going to protect them from something instead of a simple cloth face mask, which actually will.

GAUDETTE: Right. That's such an incredibly good point.

So, Dr. Nassir, we have had a few emails about this topic, including Sherry, Jim and Janet, all sending in similar questions. So every day we hear of several hundred new cases being discovered in Ada and Canyon in counties. Who are they? Not by name, of course, but are there hot spots within the hot spots like large gatherings, neighborhoods, parks, the Greenbelt, care centers, gyms, grocery stores? Where are they? Or are there just hundreds and hundreds of simply unlucky people?

NASSIR: Thank you, Gemma. It's a great question and, you know, for the listeners that want to see the data and understand better about the cases and where they're coming from, I'll just note that the Idaho Division of Public Health has a great website, the Idaho Coronavirus Web page, where the data on cases and case rates, positivity rates, locations and hotspots are all freely available there on that main state web page.

But the cases in the areas of high incidence are all of the above. So we know that when we do formal contact tracing -- so that's when public health experts follow up on positive cases and do the investigation [inaudible] connected with each other and start to trace and test, we can find that some of the areas of transmission were absolutely linked to gatherings -- and that might be gatherings in different venues, sometimes indoors, sometimes outdoors, where there was either a known positive or later it was found out one of the people in that group was positive. And then there was a significant amount of spread to others in that group. And then there's the informal tracing that we find it our testing sites where one member of the family will come in and we find that other other family members or friends associated with them also had illness. Sometimes it's an adult. Sometimes a child will come in with symptoms and will later get symptoms in the parents or other close family members living with them. As far as parks and Greenbelt, less risk and less folks are congregating very close to each other without the protective measures of, you know, wearing a mask or covering the face. And they're not thinking about physical distancing rules, which we all have been encouraging so much and washing hands, of course, as well and not touching the face. And so, you know, casually passing one another, less risk than perhaps, you know, gathering indoors in the setting that was described where you have like a gym scenario, especially a scenario without the protective measures of a mask.

GAUDETTE: Dr. Pate, Healther wants to know what would it take to get home saliva testing strip tests set up in Idaho in order to safely reopen schools, universities and other business. While not FDA approved, could our governor implement a testing strategy of this type?

PATE: Well, that's a great question, and it turns out, actually, Dr. Souza is on our state testing task force, and I just want to thank Dr. Souza, who's already working unbelievable hours for his commitment to helping the state develop our strategy. But let me just make some comments and then maybe Dr. Souza might want to jump in and add to it. But, you know, this listener's bringing up a really important question. And that is really I think most of us believe the way we're going to get a really good handle on this disease is to have very easy to access, inexpensive, rapid testing, preferably in our homes. But we would settle for doctors offices, schools, some of the places that the listener mentioned. Now, the first saliva test did get an emergency use authorization. It's important to understand that's not FDA approval. It's just the FDA saying, OK, you can put that test out while you collect more information about it and submit it to us for our review. So one of the things is, unfortunately, right now, when we do rapid testing, and especially as we try to move it closer and closer to the consumer, we typically lose some sensitivity. In other words, accuracy. Many of your listeners probably heard about the situation with Governor DeWine in Ohio, where he had an antigen test that was positive, which meant he couldn't join the president, but then subsequent testing showed negative. So we certainly can have some errors. However, I think most of us would accept a little bit of lack of accuracy for a rapid, inexpensive option. But this first test that got the approval isn't quite bringing it home. In other words, you can get this test at home and it is good that it is saliva because it is much easier for people to produce a saliva sample than it is for them to stick a tube up their nose. But the problem is you then have to mail that sample back into a specialized lab to do the testing. So you're still talking about days. What I look forward to is when we can get rapid tests that are much like people might be familiar with with home pregnancy tests or with maybe the strep test that you get in the doctor's office, those kinds of things that we could use in our schools. And and so the state testing task force is looking at that. The state is looking at options. We just don't have a great option today. And Dr. Souza, maybe you want to add? 

SOUZA: No, Dr. Pate, That's well said. I don't have anything to add except that I'm aware that the state has a number of different avenues to in [inaudible] on the saliva test.

GAUDETTE: Before we take a quick break, Dr. Nassir, I've got a question for you, and this comes from Beverly, who lives in Sun Valley, and she goes hiking several times a week.And she says 'a lot of people on the trails only put their masks on when they see another hiker. So are we protected wearing a mask for two to five seconds while passing others on a hiking trail? She goes on to say, I think pulling a mask up when passing someone on a hiking trail is of little use and only serves to make those who do not follow this practice feel guilty. To my mind, if you really want to protect yourself and me used to have your mask up for the entire hike.' And she says she's willing to be educated because she wants to help others and herself. So wondering if what you have to say about that.

NASSIR: Thanks, Gemma. So great question and you know, in a time of this pandemic, I think just as an opening comment, it's so important, I think, for folks to sometimes just get out into Idaho outdoors. I think Dr. Souza I mentioned to enjoy our foothills. And I think that the fact that we're trying to get out and enjoy the outdoors safely is super important. So the mask creates, if you will, safety for others and somewhat for the wearer to reduce the chance of the spread of infection. It almost creates distance. So when people are together and they can keep at it at a safe distance apart, six feet or greater can be 20 feet, it would be very difficult to transmit the virus. So that's what the mask does. If someone's out exercising in the outdoors and not around others, less important, clearly to be wearing a mask. But if gathering or congregating in the outdoors within six feet it becomes much more important. And so that would be the importance of when spending time outdoors to go ahead and bring the mask and use it in situations where folks will be gathering together maybe spending time greater than 10 minutes together in a space where that's where the risk would be increased without the use of a mask.

GAUDETTE: So Dr. Pate, Alex has a question. He says he and his wife both work and they have a four year old son. His daycare was open prior to COVID. He went five days a week. Since COVID in March, they tried to limit him as much as possible. He still goes one to two days a week. He and his wife both work from home part time, but they are required to go to the office a few days a week. So their little boy is starting preschool this month. They are concerned about his safety, about the safety of his grandparents because they visit regularly. The daycare does have teachers wearing masks. Parents are not allowed inside. They've implemented some social distancing and cleaning measures. But could you discuss balancing the need for social and mental development with the risks for both their four year old and the and the family themselves?

PATE: Well, that's a really important question, and it brings out a lot of important points.

First of all, let me compliment your listener for the steps that he and his wife have already been taking. Obviously, they're taking this seriously. And additionally, the extra care that they're exercising because there's grandparents, which obviously are going to fall in the high risk group. So my commendation to them. With a four year old first of all, I'm not a child developmental specialist, so I'm not going to give you specialized expertise on that. I'm not sure the social issues are as significant for that child's development as they might be in an older child. Nevertheless, we always want when it's safe for our children to be having social interactions, learning that way and so forth. I think the real problem, as the listener asks me to balance the risks is, is we don't quite know what the risks of COVID are for children. And so, you know, we've had as as Dr. Souza commented in a previous segment, you know, children, as a rule tend not to get severely ill. There's also some suggestion that they don't tend to get infected as often. And there's one study that suggests that children under the age of 10 don't tend to transmit the infection as well as others. Now, I throw caution here to everybody, because if you think about how we've done these studies, it was right after the disease manifested and most states, our country and other countries actually closed their schools and we had children at home and they haven't had the exposures. Now, there are some countries that did open up their schools and we've seen variable results from them. But no one opened their schools with the kind of disease activity that we have. And so the first point I just make is I don't think we can put confidence in what information we have about children right now. Just in the past month, the cases in children have increased 90 percent. And I think that's because we are starting to have some schools reopening and so forth. And I suspect we're going to see more. Now, the good news for this family that we do think a four year old is going to be at less risk than a 14 year old, both getting symptomatic and spreading it. But we don't know that for a fact. The good news is we have not really seen in Idaho any significant outbreaks in daycare. We have had episodic cases. The most important thing is that daycare is exercising lots of precautions and it sounds like they are. So that's very important. And so what I would say to this parents is, look, what you're doing seems to be working. There is some risk, but you do what you have to do. And if they do have to go into the office and they have to go on the same day and they need to put their child in daycare, then I would as long as I was confident that that daycare was taking this very seriously, exercising all the precautions that they need to.

GAUDETTE: Final question, Dr. Pate, from Shawn. He wants to know who will do the contact tracing for positive cases in schools? Or do we even know that?

PATE: Well, so what happens in Idaho is when somebody has a positive test for COVID, that the laboratories that do this test are required to report it to the state. When the state gets the report of the positive test, then we will have investigators and contact tracers contact the patient. And what we will try to determine is with symptoms. And then we will try to look in the two days preceding those symptoms and find out who did they have significant contact with. And what we consider to be significant is an interaction with people within six feet for 15 minutes or longer. And then the state will contact those people that were close contacts, ask them to isolate themselves, check to see if they have symptoms. But your your listener has a great point. There is a limit to what we can do. And if this disease spreads, continues to spread like wildfire like it is in some of our areas, and particularly, I think you heard Dr. Souza mention some of the projections by the American Academy of Pediatrics -- If we have that kind of skyrocketing cases you can't do contact tracing, it' just not feasible, first of all. And second of all, it becomes almost impossible to tell where is the infection coming from.

GAUDETTE: I want to thank you so much for all of your expertise to all three of our doctors who joined us today. 

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