Transcription:
A Pediatric Infectious Disease Doctor Reflects on COVID in Texas

Welcome to the Peds Ethics podcast, where we talk to leaders in pediatric bioethics about a hot topic or a current controversy. Here’s your host, John Lantos from the Children’s Mercy Bioethics Center in Kansas City.

John Lantos (Host):  Hi everybody. Welcome back. This is John Lantos from the Children’s Mercy Hospital Bioethics Center in Kansas City, Missouri, coming to you with our pediatric bioethics podcast. Today, we have Susan Wootton, an Associate Professor of Pediatrics, Specialist in Pediatric Infectious Disease at the McGovern Medical School, part of the University of Texas in Houston, who has been really on the frontlines of the COVID pandemic down there in Houston. Welcome Dr. Wootton.

Susan Wootton, MD (Guest):  Thanks so much for having me John. It’s great to be here.

Host:  It is great to talk to you and I’m eager to hear what is going on down there. But let me start with a little background. As a pediatric infectious disease doc, I’m sure you were following this story closely when it started in China. When did it first hit you that this pandemic was going to be serious and that it was coming to Texas?

Dr. Wootton:  Yeah, I think the first tangible feeling that this was happening was when we created a backup call schedule. So, in the first 20 years of being a pediatric doctor, I’ve never had to do a backup call schedule. And the reason we did that was to cover for example if one of us got sick and again, in the 20 years of doing this, and about ten of those doing ID, I’ve never really worried about the infections for me. And so this is a real tangible change not only risks for me as a provider but also then risks for my family. That was also a new situation for me being a healthcare provider.

Host:  When was all that happening?

Dr. Wootton:  That happened probably in February was when we started to change how we were organizing our service to address what was happening locally.

Host:  And what were things like then in March and April?

Dr. Wootton:  For us I’d describe sort of over March, then April and May, there was a real difference between what we were seeing from a pediatric perspective as compared to an adult perspective. So, we had the benefit of our meetings being combined so our case conferences and our journal clubs; we have both adult and pediatric ID specialists at those meetings. And so on one hand, we heard about stories from our adult colleagues of units getting busier. This is not the case for our unit. I work in a children’s hospital that’s within an adult hospital. We take up maybe four floors. We have about 200 beds. And really, we weren’t seeing much. If anything, that first week of call that I took, which was around the end of March early April, the hospital was empty. We didn’t have any visitors. There was hardly anybody in the hospital.

It sort of felt like when we’re on Christmas break. So, very sort of different experience for these two teams. Moving into then April, was when we first started to see here locally, cases of children presenting with the inflammatory syndrome or MIS-C. And those first children who showed up were quite sick in our intensive care unit. But not many within probably 10 to 20.

And then moving again towards May, we started to see then examples of children being admitted with pneumonia. So, a real change from month to month in terms of what we were having to address.

Host:  And what are they like now? Texas is moving towards being a real hotspot. The Children’s Hospital is full.

Dr. Wootton:  Yeah, it really is. We are seeing case counts in the thousands daily. The hospital is full. The hospital is steady. I wouldn’t say all of those are COVID patients. But what we’ve allowed for some of our elective surgeries to take place. I think one thing I’ve noticed among providers is losing sort of their bearings. Any fever, many feel could be COVID. And so, there are many things that cause fever that are not COVID. And so, taking a step back, and getting I think a really good history is always important. For example, we had several children who were thought to have the inflammatory syndrome that upon further questioning we found out they have exposure to animals with fleas. And we had several who presented, it was typhus in the end which we have a lot of down here in Texas. And so, I think there is this feeling of having to kind of learn quickly on your feet a sense of urgency to keep up with what’s being published in the evidence.

Host:  Do you think things are going to keep going up there? Are the public health measures that are being imposed taking any effect? Are you at all optimistic?

Dr. Wootton:  Texas has been delayed I think in addressing this issue as evidenced by our case counts. So, we started to open the state back up before the cases had dropped to a reasonable level. So, we require masks now, but businesses are open. And so, I think at least as of this week, there’s a real call for taking measures to shut back down again to not proceed with more openings. So, I think that yes, we’ll see more cases if Texas doesn’t take more conservative measures to control the spread.

Host:  So, let me ask you a few questions about your own personal choices about what you’ll do or not do as a infectious disease specialist. Have you gone out to a restaurant?

Dr. Wootton:  So, we went once. So, this all started for us March 13^th. And we went one time, so that’s in over 100 days. And it was for a relative’s birthday. The restaurant was outside with a lot of open air. At that time, I think they were allowing 25% capacity. But what was interesting to note was, I think other than the servers, my husband and I were the only ones wearing masks in the whole restaurant.

Host:  When was that?

Dr. Wootton:  That was middle of April. So, for us, I think personally, it felt uncomfortable and we haven’t been back out. We’ve done take out but not been to any restaurants.

Host:  Have you gone to the gym?

Dr. Wootton:  No way.

Host:  No way.

Dr. Wootton:  No, no. I’ve been doing a lot of walking sort of out and about but it’s getting hot John, so hot. Yeah, I would not go to a gym.

Host:  Would you get on an airplane?

Dr. Wootton:  Not yet. Well, let me back up. I think if it was a family emergency, I’d get on but just me. What it would take for me to get on an airplane, I think it would depend on a lot of factors. The community spread within the cities. So, for example, for me to get on a airplane here in Houston, no way with what is sort of circulating at the moment. Whereas getting on an airplane where my mom lives in Richmond, might be different. I know at least as of today; I’m not getting on one.

Host:  Okay. Really based on the local prevalence and new case rate.

Dr. Wootton:  Yeah. definitely. And I think also, there seems to be lack of a unified policy across airlines as to how to handle or address social distancing. If I knew for sure that the middle seat would be open or guaranteed, maybe. But it doesn’t seem to me that those policies are in place.

Host:  So, then looking to the future and the fall in particular; one of the big debates it seems is about kids going back to school. You have some school-aged children I believe?

Dr. Wootton:  That’s right John. I have two age seven and eleven. That is a big point of discussion here and I think the main message for everyone is flexibility. I think what might be appropriate in certain communities may not be appropriate in others. And that factor being the level of transmission within that community. So, we already have districts here, around Houston, that have stated they are not going to open and that it will be all remote learning, at least to start. And so, how each district decides that is probably going to be variable and unfortunately, confusing for families. So, I have friends for example with kids who cross districts. So, one district is open, the other district is remote. So, unfortunately, it won’t be a unified policy for families which will create confusion but I think as we go through this, the expectation should be that the policies will be changing and that families can begin to think about how to address the upcoming year in terms of connecting with a provider, connecting with their school and figuring out a plan that works for their family unit.

Host:  You know the American Academy of Pediatrics recommends that schools open for in person learning and the American Federation of Teachers supported that, school superintendent. Has that been a source of confusion? Are you getting calls from parents about what to do?

Dr. Wootton:  Not too many calls from parents but calls from friends and a lot of discussion among various mom’s groups that I’m part of both as a physician mom and to say mom who is part of this community. What are you going to do? What are you going to do with your kids? And at least here locally, it really is spanning the gamut. So, I have some friends who have decided to hire a tutor. I have some friends who are just going to keep their kids home and do home learning. And other friends who said there’s no way that’s going to work. We have to have our kids in school to be able to work. And so, I think yes, it’s very confusing for families to try and figure out the next best step. So, I think as we learn about this each week, or each month; we’ll have more information about how this will play out. This issue is and I think we’ve talked about this in your course is when there’s not data, there’s a lot of variability in policy. And going into the school year, there’s a lot of unknowns. We’ve never had COVID in the US when the schools are open. And so the first few weeks are going to be really important to figuring out safe policies for families and for school districts.

Weighing the benefits and the cost of schools being open and closed is a very I think complicated decision and needs to really factor in all kids, not just those with access to a computer or can do home learning successfully. But we really should be thinking about models that address I think kids who are most at risk, most in need to be in a school environment, to have access to food, things like that.

Host:  And some of the things people have talked about, you mentioned food; for a lot of kids schools are where they get two hot meals a day.

Dr. Wootton:  Yeah.

Host:  The other thing that people have talked about is monitoring for child abuse. Schools are probably the most common place where reports of abuse come from.

Dr. Wootton:  Correct. Schools, school nurses, school teachers are really our essential sort of frontline health providers to pick up those complaints and then in particular, sort of mental health. Schools provide structure, activity, play, that’s the job of a child is to play and to be with their friends. These are really, really important questions and I don’t think at least in my lifetime, we’ve had to think about how to navigate a global pandemic and then these school situations, or school challenges. The bottom line is, we don’t know. There’s a lot of variability and I think being flexible is the key. So, what we do as a family is, I take it one day at a time or one week at a time to say what’s our plan for this week. I I start to think too far in the future, it just becomes too overwhelming.

Host:  And are the infectious disease docs at your hospital or the hospital administration trying to come up with their own policies to advise parents or is everybody out there on their own on this one?

Dr. Wootton:  That’s an interesting question. Not that I’m aware of in terms of specific policies about navigating school. We are as an institution, making a concerted effort to address some components of this. For example, the falling vaccine rates. And that’s directly linked in some part to not being in school. So, schools play and school requirements for vaccines are critical for addressing rates. And when kids aren’t in school, their vaccine records aren’t being checked. And so, at least locally, within our pediatric department, we are trying to think of ways to reach families to be sure in the midst of all of this, at least our vaccine rates are appropriate.

Host:  Yeah. So, that’s not so much taking care of COVID itself, but trying to prevent all the things that we’re always trying to prevent in spite of COVID, right?

Dr. Wootton:  Correct. We’ve talked about a triple threat for respiratory viral season. So, flu and then measles with dropping vaccine rates and then COVID. And so for infectious disease providers, this upcoming respiratory season is going to be tricky, if we have potentially all three circulating.

Host:  And RSV? Of course. So, the only hope for putting an end to this it seems is to develop an effective vaccine. Have you been following the research on that? And what’s your read on when we might see one?

Dr. Wootton:  Yeah, I think it’s going depend. So, probably I’d say within the next year. There are a lot of questions though about even if we have the vaccine, then barriers in terms of distribution and then access. So, just because you have a product that works, it then has to be manufactured to capacity to reach the population. And then the population has to want the vaccine. And so, really, I think probably one of our bigger barriers are going to be addressing uptake and being sure that we reach levels to get to herd immunity. And so, as you know here in Texas, we have a large antivaccine community here. I think in many ways, that will be probably the bigger battle.

Host:  Do you think the typical antivaccine arguments will hold for COVID or will this one be easier to sell the vaccine to hesitant parents?

Dr. Wootton:  That’s a good question. I don’t know if we know. If anything, I think antivaccine parents may be more suspicious of this one. Perhaps because of the rapidity in which it’s going to be developed and then distributed. So, again, I think there are unknowns, but I would not anticipate it being less of a problem.

Host:  Anything we can do in terms of public education? I know there was a Op-Ed by Phoebe Danziger in the New York Times this last week.

Dr. Wootton:  I read that. Wonderful. Yeah, I was really happy to see that. I think all of her messages in that were really good about education, community efforts, really a single sort of public health message are all really important to remember. Having a medical home, having a provider that you trust, starting those discussions now will all be helpful.

Host:  Any other thoughts on where we’re going with this or how to deal with what’s likely to be a crazy fall season?

Dr. Wootton:  Sometimes it does feel crazy. On the other hand, one part of this that I found just incredible is the collaboration among sort of the medical and scientific community. It really is amazing to see the different teams coming together from all over the planet and to watch at least the flexibility here within the hospital as to how the teams are addressing and getting better at managing COVID patients. Being a provider, it is sort of questioning about I guess being in the midst of this but, at the heart of it I think is a lot of hope and it’s an exciting time to be in clinical research and to be part of infectious diseases. So, right now, it feels scary for many, but I think we’re headed in the right direction and we’ll get there. It just may take a little bit.

Host:  Well that’s a nice upbeat not upon which to finish. Thank you so much for taking the time.

Dr. Wootton:  Yeah. thanks for having me John.

Host:  Talking to Dr. Susie Wootton an Associate Professor of Pediatrics and Infectious Disease at the McGovern School of Medicine, University of Texas. Thanks for joining the Pediatric Ethics podcast from Children’s Mercy Hospital in Kansas City.