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Scott Webb: There's never a bad time to talk to Dr. John Osborne, Head of Cardiology for the Low T Center. Today he shares his medical opinions about COVID-19, our response as a nation, and general wellness as we look to the future. This is Age is Just a Number, by the Low T Center. I'm Scott Webb. Dr. Osborne, long time. No podcast. I know you're not an epidemiologist, but you are a man of science. So what are your thoughts about the mortality rate of COVID-19?

Dr. Osborne: You know, I think obviously there's multiple aspects to the harm, if you will, from the COVID-19 crisis. Obviously without any doubt that it's had a tremendous economic impact as we've tried to manage and mitigate the infection. But on the medical side, the case fatality rate is very interesting. So that's what percent of patients who are infected with the virus does it ultimately kill, which is a critical issue. So if you look at prior infections, the case fatality rate of SARS was about 10%. So 10% of everybody who got it passed away. With MERS that affected only a few thousand people. The case fatality rate was about 34%, which is pretty terrifying. Ebola is an example that has changed dramatically since we have better therapies for it, but Ebola had case fatality rates in the 50 70, 80% range. So these infections can be pretty terrifying because of how many people die from them.

If you look at the case fatality rate, that does vary by countries and depends upon the populations, their medical care, medical services, as well as the age of the populations and other medical conditions. But it looks like the case fatality rate with the virus that causes it, which is SARS, Kovi two. And the disease that causes this COVID-19, it looks like the case fatality rate is in the range of about one to 2%. Now to put that in perspective, the case fatality rate from influenza comes through every year. We estimate probably about 50 million people already in the US this year, probably about 50,000 deaths from your standard flu this year. The case fatality rate from that disease though is about 0.1%. So if you sort of put these two things in perspective, the case fatality rate with COVID-19 infection is about 10 to 20 times higher than it is with the traditional yearly flu. So obviously that's why there's been so much concern about that and we've taken dramatic measures including the shelter at home approaches and social distancing, and all those factors, just because the potential for mass fatalities with this particular infection is quite high.

Host: Great perspective. Thanks doctor. Given the data that we have, have we done to deal with COVID-19 do you think our responses have been appropriate?

Dr. Osborne: I think the approach has been appropriate. I think social distancing is key. Obviously we've seen that interpreted in different ways in different places, but social distancing is important and I think that has significantly flattened the curve, as we say, for this condition. I think hand washing, those kinds of basic sanitation issues are incredibly important. The role of masks still tend to be a debatable point, particularly for out in public. On the other hand is a pretty inexpensive, cheap, simple thing to do. But again, not a whole lot of great science showing it makes much difference one way or the other. So I think what we have done has been appropriate. I think the bigger question is really the time factor. How long do we need to do it? Particularly the social isolization, the social distancing. That really has been a very big part of all this. The management mitigation, obviously has a tremendous economic consequence as well as many other consequences too.

But the big question is how long that should continue. I think the US, obviously we're very heterogeneous as far as the incidence of the condition, the disease. Some places like New York have lots of public transit. That's a big issue. That's less of an issue in places like Texas. I think the reopening, if you will, will probably be also heterogeneous based on there are some places where the, the amount of disease has been small because of variety of factors, including many of these places are just much less populated. They don't have public transit, they don't tend to have lots of masses of people coming together, unlike highly densely populated places like New York City. So I think we are going to see here shortly. I know in Texas it looks like probably by the end of the week we're going to see some stage one reopening. Whereas that will probably be delayed somewhat in places like New York.

Host: You know, it feels like COVID-19 caught average Americans off guard. But I'm guessing for experts in the field of infectious diseases, at least it probably didn't. So what's your sense of where we're headed and how we can deal with COVID-19 as we look to the future?

Dr. Osborne: Yeah, no, I think it definitely did catch most all of us off guard and particularly how quickly it erupted and spread and how easily it spread. I think even many of the experts were kind of surprised as well. But most of us knew to some degree there would be something like this that would happen. You know, obviously we've had outbreaks of everything from Zika to Ebola to West Nile to SARS, MERS, Spanish Flu, a hundred years ago. So I mean we, we knew that there was a potential that this could certainly happen, but I think this moved quicker and faster than anyone really expected it. Particularly given our incredibly mobile population now in the 21st century. If you think of this sort of in a biological way, you know, diseases that are very, very fatal and kind of rapidly fatal intrinsically have a mechanism that tends to keep the spread low because if you tend to kill off most severe infectors, the people catch the disease and as a virus you're pretty effective doing that and you do it quite quickly then by definition, it's going to be more difficult to spread.

Whereas with this disease, where certainly the case fatality rate is not huge, but it's obviously significant to the one or 2% who die from it. That's kind of the perfect number for the virus, if you will, that has permitted it to spread so quickly and broadly cause it really doesn't kill many of the people who get it, many are asymptomatic. And I think interestingly, I'll note something about that, the big question, one of the big questions, but how many people have been exposed have got it either with minimal or no symptoms and it looks like that number was ranging anywhere from two to 3%. If you look at some centers where they've done antibody screening to detect prior exposure. But in most centers, if you look at Chelsea in Boston where they've done, analyze just kind of people on the street, if you will without known symptoms, who have never had it, to also jails too, we're looking at probably at least 30% people have been exposed to COVID and had no idea.

And furthermore, when we do the testing, the testing as well, these what are called PCR testing or DNA genetic testing is how we do it with the swabs, is actually not real sensitive. 30% of those patients registered negative when in fact they do have it. And if you look at the antibody testing, we know about 30% of the patients that are the people who've had it, do not develop a significant immune response or have a minimal immune response. So whenever you hear these numbers, just appreciate that the test is, is still not as sensitive as it should be. And we'd like it to be. So if we record 30% of the population being exposed to it by antibody testing, knowing 30% or so will not produce antibodies or minimal antibodies. So that number that's actually already seen the disease have been exposed to it, even without appearance symptoms is probably closer to 40%. So in a sense that's good news because that means more people have been exposed to it.

Probably the likelihood of passing it on is then going to be minimal, if any. So that's kind of a good number because in order to get heard of unity with this disease, we have to have about 95% of people exposed to it at some point. But considering this disease was not even there six months ago anywhere really in the world and now in populations such as Boston, 30 or maybe up to 40% of patients have been exposed to it and show an immunologic response to it. Actually is a good thing just to indicate that, we're probably further along in the natural history of this disease as it sort of hits the population, affects those vulnerable to it, and then kind of just sort of moves on and dies out as well. So I think there's some promising data from the antibody testing that we're getting back already.

Host: I'm just trying to get my mind around the fact that more people being exposed to COVID-19 could be a good thing, you know, in air quotes. Interesting. Now I hope you've got your crystal ball with you Dr. Osborne. What else do we need to be concerned about as we look to the future?

Dr. Osborne: If you look at the species of viruses, so Coronavirus is one large family of viruses. Influenza by the way, is a completely different virus. Influenza is a DNA virus. This is an RA virus. So they're actually quite different. And then there's whole other families of viruses that are completely different viruses, spread differently, have different effects as well. So I think the challenge is we're probably never going to know what the next big virus is going to be just because there are so many different families of those viruses. If there is one theme, and I want to be careful, this is just a reporting of facts and how, you know, as we study viruses in cardiology in general, that in order for these viruses to kind of mutate and keep evolving rapidly until they kind of fit that perfect mutation that allows them then to cross over to humans that basically these viruses, particularly the Coronaviruses are spread and shared by a whole bunch of animals including of course bats, dogs and also pigs.

And so whenever you have populations of all of those animals altogether and interacting together that really creates a perfect little incubator to help these viruses mutate until they mutate into just the right combination of genetic mutations that allow them to easily spread to humans. And then of course, be pathogenic. And where that typically always occurs is in Asia. Just because we have lots and lots of interaction between the big ones are birds, over the avian flu, SARS, right? But also in close combination and close consort with animals like pigs. So in China and in Asia, people or very, very close contact with pigs and birds and all of these are all kind of interacting together and kind of living together, which again, just makes for a great incubator for these viruses. So that's why we tend to see these viruses tending to originate in Asia.

And so some of the things that can be done as you've heard of course is, the wet markets where we think this started, there's some debate, but these wet markets are just perfect little incubators with all kinds of animals all thrown together, all kinds of bodily fluids and all being, you know, exchanged all over the place. So they're really perfect little incubators and virus factories and virus mutation factories to help promote all these different mutations into one that finally sort of sticks. So I think shutting down these wet markets I think is certainly a very, very good idea scientifically. And certainly we don't have anything like that here in the States or in most developed countries because our food supply is pretty carefully and tightly regulated by FDA and with lots of rules and regulations to help to avoid this. That's certainly one thing that needs to be attended to, and rectified to minimize the environments that allow these viruses to mutate, and then ultimately turn into things like COVID-19.

Host: So how important is it to have good habits to limit the spread of poor cardiac health to our kids? If we're committed to washing our hands, phones and computers, shouldn't we be committed to a healthy diet, exercise preventative screening to similarly change the curve of disease prevalence progression and premature death in cardiac cases?

Dr. Osborne: We know that certain populations really have a much higher rate of mortality. Those particularly include people who are overweight or obese, people who have high blood pressure, people with prior existing heart and or lung disease. So people with a history of smoking and or exposure to pollution as well, and then the patients with diabetes. So interestingly, there's a whole array of risk factors for mortality that can dramatically increase mortality from COVID-19, but are also dramatic enhancers and risk factors for cardiovascular disease, which is and will continue to be the largest cause of death both globally, as well as in the US. So it is important that all of the things that we're doing to stay healthy and also if we were to catch COVID to catch the virus, to help to minimize the likelihood that we have a bad outcome from it. Or also the things that generally we should be doing to promote our own cardiovascular health as well. So eating right, exercising, not using tobacco, trying to maintain height, weight, proportionality. If you have high blood pressure taken care of it. But again, diet, exercise, weight loss can be very highly effective for that. And of course, the same thing with diabetes too. So there's an interesting overlap with respect to the risk factors for very poor outcome with the viral infection, and developing a COVID-19 because it very much overlaps with cardiovascular risk factors.

Host: Okay. So let's talk about preventative screening and how it's especially important in families with poor habits. You highly recommend that, right?

Dr. Osborne: Oh absolutely. And again, getting back to heart disease and my view of it is cardiologist, it is absolutely critical as you can imagine, to detect this disease early so that we can better mitigate it whether we're mitigating a virus or a heart disease. So, the earlier we detect it, the more accurately we detect it, the more effectively are to ensure that we don't suffer a bad outcome down the road. So there's a lot of analogies with this and COVID-19 or, or even oncology and cancer as well. I've always been very, very interested in tools for early detection of heart disease. And one of the most important useful tools that's developed is a test called a coronary artery calcium scoring. We call it CAC or CAC scores. And these are very, very simple, easy tools that can detect heart disease long before it ever becomes symptomatic. Because what we do is we put somebody in the CAT scanner, we do a limited cat scan of the chest.

And what we're looking for is the very easy to identify on a cat scan calcifications in the blood vessels of the heart. And these calcifications are literally that term hardening of the arteries. And if you see that, if you see these calcifications or hardening of the arteries, what that tells you, even though the patient has no symptoms, that they already have the disease of atherosclerosis, it's already started. So that can be extremely useful for identifying people early. Conversely, it also excludes a lot of people who may have respecters. And if you have a zero score, your long-term prognosis with respect to heart disease is extremely good. So it allows us to better target therapy so that we can target the people who have positive calcium scores with highly effective tools long before you ever have a stent, a balloon, bypass surgery, heart attack, or have a cardiovascular death. And at the same time, about 40% of the population who looks like they have risk factors and they do have risk factors.

40% of the population will have a zero score, in which case basically the prescription is eat right, exercise, don't start smoking, and keep an eye on your blood pressure and we're all good even if your cholesterol is high. So the calcium scoring or CAC score has really been a tremendously useful, effective test. It takes only a few minutes. It's a fantastic tool and interestingly, there's a little interface I'll mention between calcium scoring as an early detection tool, which by the way, we use extensively within the Low T Centers and Her care. If you look at the sensitivity, which I alluded to before of the DNA testing that we use, the swabs and all that of the nose and mouth, it's about 70% sensitive. So there's 30% of the people will actually have the virus. And the test would be negative. Data shows that if you use cat scanning as a tool to detect whether you have the COVID-19 virus that the cat scanning, to look at certain changes in the lungs, is probably 98% sensitive. So this tool that's highly effective to help us identify early on heart disease in patients who have no symptoms. Whereas I like to call the calcium score, I call it the cardiac colonoscopy because the idea is we want to find the polyp long before we have the cancer. It is actually also highly sensitive to detect patients with COVID-19.

Host: Yeah, I know we've talked about CAC before. It's quick, easy, inexpensive, and could be a literal lifesaver. I know there's not much that the low T center can do for people who test positive for COVID-19, but generally speaking, how can we tie things together for people?

Dr. Osborne: If you want to maintain your health, reduce your likelihood of getting the virus and if you were to get it, have the best chance of quick early recovery, really involves all the things that we stress for cardiovascular health at the Low T Centers, which is again, all of those important factors of minding and taking care of your, your weight. Tobacco use, blood pressure, cholesterol and diabetes. So an interesting parallel between these two very dissimilar, separate conditions. The solutions to both, to both prevent them and prevent significant mortality and, and harm from these conditions, are actually very, very similar

Host: Way to bring it all together for us. Dr. Osborne, one of these days, I'm going to be able to stump you, but you are on your game today as always. That's Dr. John Osborne, head of cardiology for the Low T Center, call (866) 806-8235. Or go to lowtcenter.com for more information or to book an appointment. And thanks for listening to Age is Just a Number, a podcast by the Low T Center. If you find this podcast helpful, please share it on your social channels to check out our entire podcast library for topics of interest to you. I'm Scott Webb. Stay well and we'll talk again soon.