Transcription:

Colin Ward: The following is a Special Hero Podcast recorded on April 2nd. In the midst of the COVID-19 pandemic, the scientific and medical communities are racing to learn more about how this respiratory disease spreads and what treatment options are viable. Greetings, I'm Colin Ward, the Vice President of Population Health at the University of Maryland, Upper Chesapeake Health. And with me today is Dr. Leo Girio-Herrera, a Board Certified Infectious Disease Physician and the Medical Director of Infection Prevention at Upper Chesapeake Health. Leo, welcome.

Dr. Girio-Herrera: Thank you. Thank you.

Host: Well, so let's talk really quickly at the beginning. Let's go back a couple of months to January. As the news started to trickle out of China, we heard a lot about this novel Coronavirus. Why was it called novel and what does that mean for today?

Dr. Girio-Herrera: Yeah. The main reason for that name title is because we know that there are many types of Coronaviruses out there. If you remember SARS and MERS, they're all Coronaviruses that have caused different types of illness. And so when we had this epidemic start in China, at the time it was a new type of Coronavirus. And so it was novel to the medical community. And then you took about four to six to eight weeks for the novel Coronavirus to become COVID, which we know it's caused by, as it's mentioned, you know, the Coronavirus, SARS Covi two.

Host: So you've been doing a lot of literature review here. And that's important because you're trying to learn as much as you can as quickly as you can. And a lot of this literature is coming from a very compressed time frame or very small populations of patients under studies is that true?

Dr. Girio-Herrera: Yeah, that's correct. I mean, some of them are case studies, some of there are, you know, a small number of participants in the studies, but when you have such a new and novel illness and epidemic that became a pandemic within two to three months, any sort of information in the medical community is of value. Even though they may not be randomized controlled trials, any information sheds light into what we may be able to do and how we may be able to better care for our patients as we see them in our community.

Host: Okay. Well let's jump in then and we'll actually start with the pediatric patients because there's been a lot of question about testing and because test kits are limited, whether or not patients that are less than 18 years old are good candidates for that. What are the symptoms that you're seeing in studies that are being published and as an example, the New England journal?

Dr. Girio-Herrera: Sure. So there was a study that came out in the New England journal March 22nd and it described the presentation of 171 pediatric patients. And essentially what was interesting is that of all of those patients, 15% were asymptomatic. Interestingly, only 20% had URI like symptoms. So you know, we know this virus is a respiratory illness affecting mostly the lower tract, but only 20% had upper respiratory symptoms, 65% so the large majority had a pneumonia, which is interesting. And what is difficult for the pediatric population, when you compare it, for example, with adults, we were basing a lot of our clinical decision making on respiratory distress, which is described as maybe hypoxia. So low oxygen levels. Interestingly, in less than 2% of the pediatric population, there was actual hypoxia with oxygen saturations less than 90%, which means that we really have to have a high index of suspicion with very few severe symptoms. So an pneumonia, a very low amount of uppers per symptoms and hypoxia almost always is not present.

Host: And so the symptoms that are described are consistent with other ailments potentially that a pediatric patient may have. How does that handicap you in trying to diagnose it?

Dr. Girio-Herrera: Yeah, that is, as you mentioned, is a big handicap and I think it comes down to this suspicion of the prevalence of the disease in our community. So if we were making this podcast two to three months ago, our suspicion will be very low. If you are in the middle of an epidemic, like let's say Washington State or New York is having than any sort of respiratory symptom in a pediatric population could really be indicative of COVID.

Host: Okay. Let's skip over then to the characteristics of the adult population of patients. I know there was an article in JAMA that you reviewed.

Dr. Girio-Herrera: Yeah, so JAMA, there was an article that came out also March 22nd and they essentially described 21 critically ill patients. This was from the experience of Washington State went through, you know, they were really at the first State that experienced the outbreak or the epidemic here in the States and they were able to shed some light and knowledge into what happened to some of these critically ill patients. Interestingly, the most common comorbidities were kidney disease, diabetes, and heart failure, as well as COPD. There is an interesting interaction between this Coronavirus and pre-existing cardiovascular conditions, which is causing a lot of the comorbidities. Not only that, 57% of them ended up with ARDS, acute respiratory distress syndrome, which is obviously this is the limited number of individual study, only 21, but it's much greater than the rates described in China. Also, what was interestingly and worrisome is that there was 52% mortality. So if any patient with COVID ends up with ARDS or is critically ill, the mortality is very high, much higher than we had seen again on some of the reports from, from China.

Host: So the challenge there is that, you know, as you get into this older population of patients, you know, it would be less likely that there isn't some other preexisting condition. How do you sort of try and prioritize her and maybe the research isn't there yet, but you know, someone with COPD as opposed to congestive heart failure as a predictor for what kind of impact this disease may have on them.

Dr. Girio-Herrera: Yeah, no, that's another really good question because again, reflecting back some of the data that came from China, it was reported that the co-infection rates were lower, less than five, maybe less than 2%. as we're seeing now from Washington State, from this particular article, they report 14 to 15% co-infection, whether it's flu, RSV, [inaudible] virus, and I know, I think anecdotally some other researchers and clinicians from California have mentioned co-infection rates of maybe up to 20, 22% so I think what this highlights is the importance for us to again, have a high index of suspicion. If we have COVID in our community and they fit the clinical presentation, the fact that they're influenced the A B screen or their BioFire demonstrates another virus, should make us think twice before completely ruling out Coronavirus because there can be co-infection and the rates I think are higher than previously thought.

Host: And so, especially at the outset because testing has been so limited, there's been a lot of question about you have to test for flu first and rule that out. And then if there's, you know, additional testing that you want to do, you want to bang through all these tests as quickly as you can because the capacity was so limited on the COVID testing, has that capacity as of April 2nd opened up for clinicians?

Dr. Girio-Herrera: Yeah. So things have changed, again a month ago our influenced positivity rate in Maryland was 30% I mean in the whole nation was close to 30% as well. So at that point it was much more likely and much more beneficial to, let's say, do flu testing BioFire testing. As the flu season is swindling down, maybe the relevance of flu test is not as important. And maybe at this point we should just be focusing on really addressing COVID-19 positivity. And as you know, in the last week or so, we also had shortages of our BioFire samples and nasal pharyngeal swabs. And so the respiratory BioFire should be at this point ordered. Judiciously, if there is a high suspicion for let's say RSV melanoma virus or the clinical presentation doesn't fit the Coronavirus illness, then you could use that. But for the most part, you know, as of April 2nd, which is today we should be probably going straight for a Coronavirus test, a COVID-19 test.

Host: Okay. Now let's shift from sort of trying to identify if the patient is COVID positive to, what are the options that you have? What are the errors that you have in your quiver here to try and care for these patients? And I know that you looked at two different studies, one in the New England journal and one in the journal of critical care. I'm going to you know, struggle as a non-clinician to try and pronounce some of these medications. So I'm going to leave that to the experts here, Dr. Leo. But what can you tell me about these two studies and what benefits or treatment options there are?

Dr. Girio-Herrera: Yeah, so there are actually several studies ongoing, and I know that we shared the journal of critical care article from March 5th. What's more relevant at this point as of last week, I think March 27th, 28th the WHO supported the initiation of what's called the Solidarity trial. And essentially what the Solidarity trial is doing is taking I think is the top five potential candidates of therapeutic options. And some of them are detailed in this critical care article. You know, the primary one being Remdesivir, which is an antiviral. Chloroquine or hydroxy chloroquine, Ritonavir and Lapinovir and Interferon beta is another one. And then the fifth one being Tocilizumab, which I don't know, I may be mispronouncing that, but the interleukin six antagonists. So that worldwide study, so the Solidarity study just started last week. So obviously we're not going to find anything out about that at this point.

There are some reports that are coming out from other individual trials that are coming out and again, the New England journal, you know, they have an article come out last week where they address the fact that Ritonavir, Lopinovir therapeutic option was equivalent to placebo. There was originally a Lancet article, several weeks ago that that was promising for this particular antiviral combination. But then the New England Journal article kind of disputed that. And again, there are a number of other trials which I think my plan is to share some of this documentation, kind of this summary review in the next week or so. Because there are trials for specific medicines. Again, like I mentioned Tocilizumab, Remdesivir has trials ongoing and some of the results may be coming out in the next two to four weeks. So for some of this we may be able to see that those results.

Host: All right, so I guess maybe it would be just worth a quick layman's view. So some of these medications work in a way of trying to block the replication. So they interrupt the RNA or the DNA sequencing, is that the goal here is to try and impact that or it's still unknown?

Dr. Girio-Herrera: No. So the mechanism of action for let's say Remdesivir, chloroquine are known. Some of them are about disrupting the DNA and RNA processing. Some of them may be disrupting how the virus gets into a cell you know, maybe the medicine facilitates the encapsulation of the virus into the cells so it doesn't replicate. So each medicine does have a different mechanism of action and hopefully we'll get to the bottom point is, you know, does it stop replication on infection. So, that's what the clinical trials are coming down in the next few weeks. Should let us know.

Host: Okay. So it's April 2nd. We've heard a lot about social distancing and trying to flatten the curve. So give us a reason for optimism on April 2nd. You know, how are things working and what's the future hold for us here?

Dr. Girio-Herrera: Sure. No, I mean the, the message of optimism is that I think that we are, we're being aggressive in dealing with this pandemic. You know, I think that if you ask people outside of the medical community, the question is are we over reacting? Are we doing enough? Should we be doing more? And I think there's been a kind of a trickle down of what should we be doing? I think right now with the social distancing, you know, only essential businesses being open, that is the right response to essentially make sure that this virus does not continue to spread in our communities. And whatever virus is in our communities, hopefully it will stop with each particular individual who stays at home, lets the virus run its course and you know, the people who are less fortunate, if they're in the hospital, hopefully we can get them through their illness.

But we are here for the long haul. It's tough to say, Hey, you know, we're going to be out of this in two weeks. You know that I want to say that. But that's not the truth. I think that what's important is that I think we do see everyone doing their part. The government is doing their part, the state and local departments doing their part, medical personnel. And then, you know, the nonmedical personnel are also very encouraged. It's encouraging to see so many individuals in the community with their businesses, with their ideas trying to help and contribute to how we fight this illness. And that certainly is an encouraging thing. So I think we'll get through it. It's going to be several weeks, several months. But we'll get through it.

Host: Awesome. And I echo those comments. I think we're seeing a lot of collaboration and teamwork really across the continuum of care and with just everyday citizens trying to do their part.

Dr. Girio-Herrera: Absolutely.

Host: Thank you. All right. Thank you. Dr. Girio-Herrera. This is certainly an evolving situation and we want to connect with you again in the future as you learn more about what strategies for treatment are being developed and how we can fight against COVID-19.

Dr. Girio-Herrera: No problem. Thank you.

Host: Alright. In the meantime, if you're looking for additional information about COVID-19 please be sure to check out our website, umms.org/Coronavirus. You can go there and you can learn all about the University of Maryland Medical System response to this pandemic. For Dr. Leo. I'm Colin ward, and you've been listening to the University of Maryland Upper Chesapeake Health Hero Podcast.