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David Pong, M.D.

By: David Pong, M.D. on October 1st, 2020

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COVID-19 Update 10/1: Numbers, Variables, Spread, and More

COVID-19 | Facebook Live Recap

With Dr. Bishop on vacation, Dr. David Pong took over this week's COVID-19 update. He provided an update on the latest numbers, discussed one of the variables driving the pandemic, discussed how and why COVID continues to spread, and more. Watch the full video below and read on for a full transcript. 

Latest Numbers

Unfortunately, and sadly, we have passed a couple of significant milestones since we were last together. We have now passed 1 million people in the world who have died from COVID-19.

And in the United States, one of the most affluent and technically strong countries in the world, we have over 200,000 who have perished.

In Virginia, our numbers look a bit better. We've had a total of almost 150,000 cases identified. We've had about 3,200 deaths, 3,228 as of numbers today. Our current case positivity rate looks quite good.

We're at about 4.5% percent of the people being tested who were coming up positive. That's the current seven-day moving average and that's been falling for the last month or so. Similarly, the rates of death in Virginia have been falling for about three weeks and we've hit new lows there as well. So currently what we're experiencing Virginia is reassuring.

I think that these rates are probably about as good as it's going to get. I think it's likely that over the next several months, we will see a rise in the overall number of people getting sick with something that could look like COVID. So I think we're going to be seeing some influenza. We're going to be seeing colds, and we're going to be seeing a rise in COVID. And I think this is the time when it will be so important to double down on the efforts that we've made that have brought us to this place.

The reason I believe that our numbers are low is because of all the work that's been done, where people are actively wearing masks, keeping some distance, and doing the hand washing to try and minimize transmission of the virus.

We're all getting tired of it. I have grandchildren that I dearly miss getting to hug, getting to hold, getting to read to in close quarters. We're all definitely getting weary of masking and distance with the people that we love, but that we don't necessarily live with, but I gotta tell ya, I think that what we've been doing is practicing, and I think the practice we've made has been successful, and we need to increase our vigilance as we go into the winter months. I think one of the things that has helped us dramatically has been good weather and being able to be outdoors significantly reduces the risk of transmission of this virus.

And so as we move into the colder winter months and we find ourselves needing to be indoors more and yet dearly missing that social engagement with people, especially as we move towards the holidays, we need to become more flexible, more adaptable. We need to find ways to get that interaction that we miss and that we want, but ways that do that, where we're not in close quarters, indoors, sharing the air, increasing the risk. So I encourage you to try not to have the attitude of either, I must stay locked behind this iron curtain, and I can't be with anyone in any way, nor would I recommend taking a Woodstock approach where it feels like we've done this long enough, and I'm going to exercise my rights to individual freedom and go be in a very unprotected setting.

I would encourage us all to think about flexibility and adaptability and figuring out how we can be with other people in ways that is safe.

This Overlooked Variable is the Key to the Pandemic

To that end, this is a really great article. This is called "This Overlooked Variable is the Key to the Pandemic." The good news is I think it's a really excellent article to use to kind of jumpstart our conversation. The bad news for you is I just read it this morning. So I'm going to be needing to look at it a bit while we talk, but those of you who've been looking at some of the news, reading some of the science may remember that early in the pandemic, a lot of conversation was had about a variable called R-naught, and R-naught reflects an estimate of the number of people who infect any one person with the disease.

So if I have COVID and I infect three people, and I represented the whole pandemic, then R-naught would be three. And you can imagine that the higher R-naught is the higher the number of people each infected person is infecting and the thing is growing.

So a positive R-naught, something above one, means that we are infecting more people. Each person who's sick is infecting more people. We always have been aiming at thinking about steps we could take to bring the R-naught of this infection down below one.

And we talk about R-naught as a way of thinking about the infectivity of the virus and ways to understand it in relation to other things we know about. So for example, the R-naught of measles is something north of 15. So a person with measles often infects many people before things are brought under control.

The R-naught for influenza is usually somewhere in the two to three range, maybe a little bit less. The R-naught for the coronavirus infections we've had in the past have often been in that two to three range.

The Problem with R-Naught

The only problem that this article raises with R-naught and limiting our thinking to R-naught in terms of control is that R-naught is something that is calculated across the whole population, but we can see just looking at the cases as they start popping up in different parts of the country, that the disease doesn't really work like that. It's not a disease that is kind of moving across the country evenly. If we look back in the early days of the pandemic here in the United States, New York City had a huge number of cases and a huge number of people who were then infected.

If we watched over time, we could see that that number rose and then fell as steps were taken to bring things under control. And we've seen generally that the disease has spread from the coasts more into the center of the country. It's spread from big cities into smaller towns, and generally has been spreading more into the South, but it doesn't do it evenly.

And we've heard stories about cases where an individual has been in a situation with other people where a large number of people were then infected. The highest one I'm aware of was a woman in South Korea. She's referred to as patient 31 and patient 31 has been found through contact tracing to infect 5,000 other people. 5,000 infections can be traced back to this one patient who attended a large mega church gathering in South Korea. And the importance of that can be maybe thought of in an analogy.

You have heard this before for other things. If you take a bar full of a hundred people, regular average people, and Jeff Bezos with Amazon walks into the bar, the average wealth of the people in the bar just went up to over a billion dollars. Clearly looking at the average, which is like looking at R-naught for this infection, for this pandemic. The average only goes so far because in that bar, not everybody feels the same wealth as it would suggest, that the average wealth is a billion dollars, but most of us still feel like we don't have anywhere near that much.

Certainly if I walk into the bar at that moment, I don't change the number very much at all. I have very little impact. So if you take that analogy to COVID, I imagine that there are some people who may be more infectious and they will add to the overall risk the way Jeff Bezos adds to the overall wealth. In terms of COVID, what really matters is the setting.

Why The Setting Matters

And we're learning more and more that if you look at the episodes, the transmission events where big groups of people are infected, what you find is that they have many things in common. The factors that tend to be most in common are that the locations or the settings in which these spreader events happen, tend to be places where there are a lot of people, where you need to have obviously somebody who's infected,and usually there'll be somebody who is highly infectious.

And then the place where these people are gathered needs to be fairly close quarters, and it needs to have relatively poor ventilation, because we're learning that the virus is not only transmitted through droplets, as we've been talking about for months now, and the droplets of course are reduced by masks, the droplet transmission is reduced significantly by keeping distance, but if we spend time indoors in poorly ventilated settings with someone who is highly infectious, we know that there is some aerosolization of the virus and we're getting transmission by breathing the air that has become infected and more concentrated with the virus over time.

So there certainly are other factors that would be in play, but these factors seem to be present in almost every significant event. And while we don't, it would be great to understand all of the factors. If we understand those factors, then we actually have a leg up in trying to figure out how to prevent transmission and by preventing ourselves from being in settings like that.

So not going into places that are poorly ventilated, crowded full of people without masks, and particularly not doing that at a time when the community spread of the disease is higher, so that the likelihood of someone being in that setting, who has the virus, you know, when that likelihood goes up, then the risk is going up for us to become part of a super spreading event, an event where many people will get infected.

COVID-19 and the Pareto Principle

There's another principle to think about. It's called the Pareto principle. It's named after Vilfredo Pareto, who came up with this years ago. And again, you've heard of this, it's called the 80/20 rule. And the idea is that 80% of the outcomes we care about are often driven by 20% of the people involved. It doesn't have to be 80/20, but we all know this to be true. If we think about almost any service industry, that type of work, we all have been had the experience of finding that 80% of the problems we have to deal with, 80% of the work that we're doing, is driven by about 20% of the people.

If we knew that this disease process was driven that way, then the approach we would take would be like what we might do in a service sector situation. If we know that there are certain people who drive most of the concerns or problems or work, then we focus our attention on those things.

If we knew that it was not like that, and that it was just an average that everybody contributes 5% to my work day of the 20 people I see, every one of them brings 5%, then the action I take would be taking care of that 5% need across the board. But if I know that of the 20 people, I see that three of them are going to account for all the work, I would try and tailor what I do to those three. Well, it turns out that COVID is, like that, it's an 80/20 kind of thing.

The majority of the spreading events that happen are not evenly distributed. They're happening when an infected person is in close quarters over time with a group of people who are accessible or available to be infected, they're not immune.

So as we approach our own lives, whether we think of it as the workplace, whether we think of it as our families, whether we think of it as the bigger communities we live and work in, trying to avoid those settings, trying to minimize the chance of being part of that or of creating that setting, I think is our biggest obligation.

You've heard me say before that, I think so much of what goes on right now at a time in this pandemic when we don't have a vaccine that's working yet, when we don't have treatment that can be offered in the early stages of the infection that matters, when we don't really have a rapid way to test that is inexpensive and widely available, the stuff that's been working has been masking, hand washing, distancing, and that takes on a kind of a bigger, a higher priority or a bigger meaning as we go into this season when the tendency for us in the winter months, as we go into the holidays, is to try and find a way to grab our families, get people together, sing together, eat together, laugh together, drink together. The normal thing would be to do that.

And yet, at a time when COVID is at higher rates in the population, we have to accept that that's going to increase our risk, and we need to try and figure out how to do it more flexibly that doesn't allow that.

One thing about this way of thinking, this difference between looking at averages and looking at this idea of dispersion and dispersion of the virus not being an even kind of thing I think is to be able to look and say, we also cannot necessarily be comforted as much as we wish by the low rates of spread we see in our community.

Right now in Virginia, again, low rate of spread, but it wouldn't take a lot to let it take off again if some of the few infected people out there were able to be in a setting with a lot of people where they could transmit the virus.

So if we think about it as an even distribution than one could say, "Oh great, there's only four and a half percent of the people out there, and it really is safer." And that's true in a sense. It's safer to go to the grocery store. I think it's safer right now to be in medical offices because most of us at running, open businesses right now are working quite hard to minimize that risk, to make it hard to catch the disease in our businesses.

I worry about what I hear about, let's say in Florida, where they have opened the gates essentially, and they're allowing bars and restaurants to be open without really doing any active processes to reduce the spread.

I worry that what we'll end up seeing is that those locations will become an opportunity for clusters that will lead to more and more in the population. And unfortunately, when we start seeing enough different outbreaks, then we get enough chains of transmission going that it starts looking like a pandemic, like a flu pandemic, like something where now there's so much of it in the community that we're going to see a lot of spread just in our regular day to day lives. And actually at that point, the only tool we have would be locking down again. So we'd like to try and avoid that.

Your Questions, Answered. 

  • Of the vaccines in the later stages of development, which are you most optimistic about, if any?

    Right now I believe we have four of them in phase three trials. Until about a week ago, I was most optimistic about the Johnson and Johnson one actually, mostly because it appeared that one dose was going to do it. Some of their data suggests that maybe they're not getting quite the antibody response they hoped for out of that first dose. If you made me bet, I think they'll likely end up needing to add a booster. I don't have a favorite beyond that idea though. I think that we really need to see how the phase three trials shake out.

    I think, as we've talked about earlier, a successful vaccine needs to have side effects that are relatively low compared to the risk of the thing that's preventing. You need to have a lot of doses easily accessible, so the cost has to be low and the availability has to be high and you need to make a lot of antibodies. So they need to be protective. And I haven't seen enough of the outcomes myself to be able to make a stronger comment there.
  • Why is the flu vaccine scarce at my location in Owings Mills? I’m waiting to get it, but I know it’s available at Walgreens and other local pharmacies. I’m waiting because it’s probably safer at PartnerMD. But why is it difficult to keep it in stock?

    I think the biggest issue here is, best we understand there has not been a problem in manufacturing flu vaccines this year. The amount of vaccine that has been produced and will be available through the season is supposed to be adequate for the need. We have absolutely had a difficult time with distribution.

    Our distributor has told us that we've had trouble getting the vaccine because of some of the weather problems we've seen in the country, fires on the west coast, floods in the South. I don't know exactly the detail about how that's affected it, but I think what you're seeing in terms of why we're struggling to have vaccine for you here in our office and why Walgreen's has it is straight up numbers. When we order vaccine we're ordering in the hundreds or low thousands of doses and when Walgreens or CVS is ordering, they're ordering millions. And so they're finding it easier to keep in stock because they're being prioritized.

    I actually think it's appropriate. As much as I love our patients, we represent relatively fewer patients and by getting it into the chain pharmacies, more people across the country are able to be vaccinated earlier. My best understanding from our distributor is within the next two to three weeks, we should be supplied particularly with the high dose vaccine. And I would anticipate being able to vaccinate the majority of our folks during the month October.

    What I'm saying to my patients here in Richmond is that if we go forward and in the next two or three weeks, we have not contacted you, or you've not seen something on our website, I would strongly encourage you to go ahead and get vaccinated.

    As Dr. Bishop and I spoke about last week, there are a number of families who are doing it also because there are rewards out there. So at my Publix or at my Target or at my CVS there are gift cards being given to folks who are getting flu shots and who can deny the joy of a gift card at one of those places? So unfortunately, I don't think I can promise you availability inside of a PartnerMD facility widely for the next couple of weeks. But I do think it's likely we'll have plenty of vaccine available, whether we get it at PartnerMD or in the pharmacy.

One Final Thought

You know, I've said this a few times in different settings. My belief about COVID is that it strongly is reminding us that we are responsible for each other. The current things that work when we try to prevent COVID transmission are not generally things that I do to protect me from someone else. Hand washing is probably the primary thing that I would do. And outside of a medical setting, I think the great majority of the work we're doing is about doing what we need to not become a source patient. I don't want to be patient 31 where I could be the source of disease for thousands of people. I don't want to be the one who gives it to my grandchildren or my father or my wife.

And I think the work here is trying to figure out how do we help everyone around us. Both those who we would call believers, right? Those of us who believe in the science and who believe in our responsibility AND those people who right now, perhaps in our families or in our social settings, who have a more flexible sense of this and feel a bit like they're too strong to be having to worry about COVID.

My hope would be that we could try to spend time understanding what needs that the people have out there who are going maskless, who are going into group settings, and try and help them figure out a way to become part of the in-crowd, because if we're going to successfully put COVID down through this winter season and put the flu down where we don't have overwhelming numbers of sick people, it's all about choosing to be responsible for the health of other people.

One of the articles I was going to present today looks at the differences of what happens in a given family. And there are studies going on across the country of groups of people who share genetics and who likely were exposed to the same strain of virus who have remarkably different outcomes in their events.

The key part of that for me is that it reminds us that I can get sick with this virus and have minimal symptoms. And I can give it to someone who looks like they're low risk and they can die. I can give it to someone who looks like they're low risk and they can end up on a ventilator.

So I feel like I'm trying to think about ways to help other people around me and continue to keep my own self strong in the work that I do to try not to be a source. And I just encourage you to think of it as something that we're all taking responsibility for, not just for ourselves, but to reach out into our networks, into our work partners, into our families, to try to help people find that place in themselves to do that.

This is not a cognitive exercise. The energy for making choices comes from emotion. Daniel Kahneman... Nobel prize in economics about 20 years ago... wrote an article where he talked about that.

We come to our choices by cognitive work, but we make our choices emotionally. And the problem we face is that many people in the country have no emotional connection with COVID. They've not seen it. They've not seen people who are sick. They don't have people who've died in their family, but they have felt the economic burden of some of the closures and some of the limitations.

And we have to try to help them understand that the importance of trying to still be protecting those around them. And we have to understand, we who are are able to keep working and able to keep earning a livelihood during this, we have to understand ways to help them find flexibility as well.

And we have to be flexible for recognizing that what works in one setting won't always work in another. So I just encourage that. I encourage that grace and understanding, and that responsibility, that sense that we are responsible for what happens to our families and our communities. It is the biggest tool we have right now.