COVID-19 Breaking News: An Interview with John Mattison, MD

COVID-19 Breaking News: An Interview with John Mattison, MD

What follows is a transcript for the podcast: Let's Stop COVID-19: Social Isolation & The Latest News

Former Chief Medical Information Officer at Kaiser Permanente Speaks on COVID-19

Heather Sandison, ND: Hi, Dr. John Mattison, thank you so much for joining us on such short notice. This is a very timely topic and I feel so grateful to have you here to share your insights.

Dr. Mattison is working currently on COVID policy, diagnostics, critical care, and he's also an expert in health technology, virtual care, telemedicine, very timely health informatics, and he is a former chief health information officer at Kaiser Permanente.

Dr. Mattison, thank you so much for being here today to answer all our questions, our burning questions about COVID-19.

John Mattison, MD: It's my pleasure. Thank you so much.

Importance of Social Isolation and Social Distancing to Beat COVID-19

Heather Sandison, ND: So, social isolation versus social distancing. Now, is social distancing, at this point in the game, is that enough or do we need to go all the way into social isolation?

John Mattison, MD: That's probably the most significant policy question that we need to address today. And because so many people have not really prepared for social isolation, I think a brief period of social distancing is really appropriate so people can acquire the supplies they need to have a more extreme social isolation.

In terms of the difference between the two and the biology of the virus, this virus can be stopped dead in its tracks. We know that China succeeded in that. We know that Taiwan, and Hong Kong, and Singapore have been able to implement a very significant social isolation and just really get a good handle around this virus and really prevent it from becoming a huge issue like it is in Italy and in much of the EU right now.

We do know that the further you go in towards social isolation from social distancing, the more rapidly you can halt this thing. I don't think the country is yet prepared for a hard social isolation. I think there's some logistic issues associated with that, and I think that the folks in Washington, DC are really aligned and taking it very seriously. I think we're seeing a lot more bipartisan support for moving forward, which is essential. This is not a time for political maneuvering. This is a time where we all come together and all row in the same direction. I think that we're beginning to see that at the national leadership level in a way that was inconceivable before this COVID attack.

So the first thing I would say is, as much of an issue historically, as this event is, one of the silver linings is that we're pulling together as a country. So as we begin to prepare the logistics of social isolation, we are better positioned to go into a mode where our impact on people's lives, and their jobs, and their ability to make a living, and pay their rent and their mortgage, is something that really has to be carefully thought through in terms of the supply chain for all public services.

I think that we're seeing very wise movement in that direction coming from all quarters. And if you listen to the leadership in New York, where one of the major hotspots in the country, the calm, cool, deliberate approach to how to go incrementally from social distancing to more significant social isolation is really manageable. And I think this is a time that tests our character individually and collectively, who we are as a society, how we take care of those that that are more vulnerable, those that are more at risk of COVID, is really critical.

Already we're seeing on the next door application communities coming together and identifying people who are more vulnerable and who can't go out for whatever reason, and their community stepping up to help them. This is what we're seeing around the country, and I think we're going to be seeing more of it so that we can move into higher levels of social isolation more quickly, more safely, and crush this thing, and win this war against the COVID virus much more quickly with much less of a sustained economic impact than if we drag our heels.

One of the last things I want to say about that, is that what we can't afford to do is have a rolling kind of isolation where one community does it today, and then they come off, and another community does it tomorrow, because there still is a critical need logistically to have some communication between communities. So the sooner we reach a point where we can get to fairly significant social isolation across the nation and, quite frankly, across the globe so that we can crush this thing simultaneously rather than dealing with what I call the ricochet effect of bouncing virus back and forth between the communities that are on and off of some various extent of social isolation.

Then the final thing is regarding the biology of the virus. The reason that this virus is expanding so quickly is because of a concept called the R naught, which is how many people on average does somebody else infect in the course of their disease. Once you get that below one, once one person affects one person or less, you see the decline. The fastest way to get there is with a more significant levels of social isolation at scale.

The biology of this is that once you reach that point of less than one, you'll see a decline in the new cases, you'll see a decline in the number of people that are infected any point in time, and if you maintain that until the transmission stops, and you take care of those people that are in the hospital and discharge them and they are no longer shedding virus.

This is achievable. This is something we can do as a collective community if we keep our heads. If we stay cool, if we sit back and nourish ourselves, our souls, our families, our friends, and through virtual communication rather than physical communication, sit back and read poetry. Start with Rudyard Kipling's poem If which talks about how we keep our cool in the time of crisis and how we share with humility what we can with each other. We can and will conquer this. There's no question that it's possible.

The only question is how long will it take us? And the corollary of that is how truly and wisely do we transition from no control down to fairly high levels of social isolation across the country and across the planet?

Why Coronavirus is Different From the Flu

Heather Sandison, ND: Can you explain a bit about why this is different from the flu? What makes us panic this year when hundreds of thousands of people around the world die every year from the flu?

John Mattison, MD: There are a couple of things. The first thing to say is that we've had centuries of experience, and a full century of research, on influenza. We have three months of experience in data with COVID. This is really a truly novel virus, and it is different from influenza in several ways that we know already.

It's mortality rate is higher. When all is said and done, and we know the full extent of who's infected and who's not, we'll probably see a mortality rates somewhat under 1%. The influenza typically is about 0.1% so it does have about 10 times the mortality.

The other thing that we observe about that's unique, is that there's virtually no immunity to it. So 100% of the population is vulnerable. Whereas with influenza, there is some cross-reactivity year-to-year between different strains, and we have vaccination campaigns. So we have a global population that doesn't have immunity to this virus, and we don't have a vaccine yet. The first dose of a trial was given at Kaiser Permanente in Washington yesterday, a trial of a vaccine, and there are many companies around the world that are creating vaccines that are going into test phase now.

The differences, again, are we have no immunity, we don't have a vaccine, we're not sure about effective therapy although there's some encouraging news on the therapy front. So, because of the lack of immunity, lack of vaccines, it's spreading very, very quickly. The concept of herd immunity where if 80% of the population is immune to it spreads much more slowly because only 20% of the population can be a vector for it. We have 100% of the population potentially serving as a vector. And the other related thing about transmission that's really unique is that this seems to be relatively sparing young people. It obviously, and everybody's aware of the fact that the older you are and the more chronic disease you have, whether it's heart or lung or kidney or liver or diabetes, the more at risk you are of getting severely ill, ending up in a hospital, or even dying and in that situation. So, this virus tends to spare youth disproportionately compared to the flu.

So those are the major differences. One, we don't have enough experience to know yet enough data. We're still learning. Every day there's significant new information. Two, we don't have any natural immunity or vaccine campaigns. And three, it is unusually disproportionately affecting the elderly, vulnerable population. So those are all different things. And then the fourth, of course, is it does have a higher mortality rate for all of those reasons, as well as some not fully understood reasons, at this time, compared to the influenza.

Why COVID-19 is More Aggressive in the Older Population

Heather Sandison, ND: I know some of this is speculation, but just because of what you just said, that it's so new, it's so novel and so new. But do we have an idea of the physiology of why it would spare children, but be so aggressive in the older population?

John Mattison, MD: So far we only have hypotheses. We don't really have good data, but there are couple of things. The first hypothesis is that the aging immune system, particularly if compromised by, we call them a co-morbidity, of diabetes or heart disease or lung disease, that the immune system is not as effective at rallying a defense against the virus as quickly as what happens in youth.

The second hypothesis, which is the exact opposite of the first hypothesis, is that those people who are older may well have seen other Coronaviruses that may cross react with this, but may have a delayed response with their immune system. And when that happens something called a cytokine storm happens. A cytokine storm is where your immune system overreacts in a sense of it creates its own form of disease, more inflammation, more fluid in the lungs, more difficulty breathing, more disruption of our homeostasis, our control of a healthy set point for all of our various physiologic functions. So that's the second hypothesis.

The third hypothesis is that it's somehow related to the prevalence of some specific changes in the lungs with age. This is very, very early and we don't really understand it, and it may have nothing to do with it, but there is some indication that there's a particular kind of receptor in the lungs called the ACE2 receptor. That receptor may be more vulnerable as we age for unclear reasons, and may allow the virus to get a toehold, a beachhead, in our lungs more quickly, and then spread more quickly within our lungs if we have this disadvantage of having a change in those ACE2 receptors with age.

There is already a mouse model that demonstrates the same phenomenon, where giving them the virus when they're young mice doesn't cause the kind of disease it does to older mice with the exact same genetic background. So there's some experimental clues that that may have a role, but those are all three hypotheses, and it's even imaginable that there's additional factors that we don't yet understand. It's also possible that all three of those hypotheses are correct and that they affect different people at different phases of life in different ways and either protect or make us more vulnerable to the effects of the virus.

The Role of Testing in Crushing this Pandemic

Heather Sandison, ND: At a population epidemiological level, do we have to have testing widely available in order to get this under control? Right now, testing is kind of spotty. It's being used just for people who are in critical condition or at least have some set of factors. They have to have a travel history, high fever, right, and shortness of breath or cough. If you don't have those things then you don't get tested. So my question to you is do we have to have the testing in place in order to get ahead of this?

John Mattison, MD: Here's the role of testing in a typical... I'm going to go back to the influenza motto because we have a lot more information about that, then I'll come back to COVID.

In the influenza model, the CDC every year, which one of our national treasures, is the CDC and the people who just dedicate their lives to public health and safety. What they do typically during a flu epidemic is when people come in early in the season with symptoms of the flu, we test quite a few people to understand which viruses, to quickly know is the vaccine that we gave this year effective against that virus, what is the prevalence of the different types of influenza that are circulating? We also, at the same time, have many other viruses like respiratory syncytial virus, or RSV, and other types of viruses that can cause very similar symptoms. So the purpose of early detection is to just know what's going on and what we're treating so we'll know how best to treat people with different kinds of viruses in this condition.

What we're living with right now is somebody can come in with the same symptoms as COVID and have one of the other prevalent viruses. In fact, in countries that are doing massive testing like South Korea, what they've seen is there's a high proportion of people who are sick with an upper respiratory condition that do not have COVID. So having testing to know is this a COVID case and treat it appropriately, or is this an influenza or an RSV case? That's very helpful.

The other thing that's very helpful about early testing is that you can do contact tracing so that if you find... Early on in something like this you can, like in Seattle in the first case, you can go back and say who have you been around? And the CDC and epidemiologists, this is their bread and butter [inaudible] of epidemics, and even more so in pandemics, where you trace the contacts back, find those people who they may have been contacted with, test them, and then you can have a very controlled approach to containment so that you then isolate all the people that you back chained from the index individual that you have in front of you, and isolate them.

That is typical of what we do when we have the full availability of the testing infrastructure and everything in place. This thing is so novel and moving so fast that it has increased the number of people infected so quickly that we're really past the containment phase. And because of the variety of problems that have been well-exposed in the media, we didn't get the tests that we would have liked to have had early on. That's water under the bridge.

Where are we now? We have a number of tests coming in from multiple commercial entities, as well as universities, around the country who have created their own tests using the same technology. It's reverse transcriptase polymerase chain reaction, or RT-PCR, it's the same technology that all of these tests use. And as we begin testing, we're going to see a huge spike in the number of people that are diagnosed with COVID because we're catching up with a backlog of undiagnosed people for lack of the test. So we're going to start seeing those numbers go up quickly. It doesn't mean that it's spreading any faster. It spreads fast enough. The number of people infected without any isolation or distancing is doubling about every four days. So you double the number of people infected every four days pretty much with an unmanaged situation, without social distancing or social isolation.

As we introduce these social distancing and social isolation policies, we're going to see that doubling first go to a much longer period of time and then stop altogether. When we get are not, less than one where each one of us that's affected infects one person or less, we'll see the numbers decline. So the purpose of testing right now is more about let's make sure that we do the appropriate isolation and treatment of that individual that's different than influenza because there are some promising drugs for COVID that are just around the corner. And there are proven drugs for influenza, so we need to know how to treat. So that diagnosis becomes very important to know what we're dealing with and treat appropriately.

The other thing is, and this is not far off... So as we go to more significant measures around reducing the are-not to one or less by using social distancing and social isolation, we will begin to see our entire country recover from this. And this could happen fairly soon, depending upon how aggressive and how pervasive we get with the social distancing and social isolation. So then what happens? We need to get people back in the workforce because they need a job. They need the income. We need their help in the supply chain for critical public services, first and foremost, water, power, food, the law enforcement, the basics of public infrastructure. And in order to get them back out safely, we need to test them to know that they're no longer shedding the virus so we can put them back out in the public square and have them interacting with lots of people in their critical roles of public services and then get everybody back to work when we get it under control.

So we do know... That's another thing that appears to be a little bit unique about this virus is that people who are affected may not have any symptoms at all and be shedding. They can be sick with a minor cold or severely ill and have a full clinical recovery where they feel just fine, but they can still shed virus for up to a month.

So we're going to be doing even more testing to prove that people are safe to go back to work. So testing has a virtue in the early phase of an epidemic to know how to contact everybody, isolate them, and quash it before it gets out the barn, if you will. And then the second phase is to make sure that we're diagnosing and treating appropriately to that virus because it's different for different viruses. And then the third phase is ensuring that people are ready to go back into the public square, go back to work, especially in the critical public services.

So today for example, it was announced by Amazon that they're hiring 100,000 people to make sure that we can keep the supply chain flowing of food and supplies that everybody needs and without people having to go into the public square and go shopping, which is problematic right now.

So we're beginning to see a multitude of responses both in the public policy arena as well as in the commercial arena, as well in the public service arena. These are all very promising. We are seeing that collectively our character is being tested, our ability to overcome partisan politics is being tested. And we are Americans, and we are rising to that challenge. And I'm very optimistic that we are on a trend for healing ourselves, for healing our communities, for healing our country, not just from the COVID virus, but from the toxic partisan politics that have made us more vulnerable to this problem quite frankly.

So we need to really pull together as a community and address these issues because this virus is not from a red state or a blue state, and it doesn't matter what country it emerged from. It's affecting everybody on the planet. So this is our opportunity to really hit the reset button on who we are as individuals and who we are as a community. And we can do this, and we will do this.

Managing Disinformation About Coronavirus 

Heather Sandison, ND: Yeah, and it also really pulls back the veil around misinformation and this symptom that we have of not having a reliable source or feeling like we don't have a reliable source. Certainly when we're talking about things like mass isolation, not feeling like you can trust the government or not feeling like you can trust the news becomes a really, really big issue and one of the things that will delay getting people into the isolation that's so critical to success here.

John Mattison, MD: Well that's a really good point, and I'm glad you bring it up because there are two very critical aspects of that. So be very careful about what you see on social media. Social media is just ripe for disinformation. And the leaders of social media really are taking this seriously. This has been a problem in the past, but I think we're seeing those who manage social media stepping up.

This is another silver lining of this... Getting around to managing disinformation. So there's two things that I would encourage people to do. Rely on trusted sources like the CDC, like the NIH, like the national treasures of Tony Fauci, Dr. Fauci, who's been doing this epidemic after epidemic around the globe. He is truly a national treasure. Sanjay Gupta is doing a brilliant job of capturing what's happening moment to moment, day to day and what we can do to stop it.

The second aspect of this is that we've seen disinformation emerging from people. Some of it is just not authoritative and just wrong. And bad news travels faster than anything. But some of it is very deliberate from nation state actors outside the US who we're seeing in this vulnerable state and propagating disinformation to amplify the chaos associated with fears. We need to get over our fear. Don't open emails that come from people you don't know right now because there are efforts that can disable our devices and disable us through fear and through misinformation.

So rely on trusted sources. Do not believe anything you read that doesn't come clearly from a trusted source. And we'll be fine. And we'll get through this.

Avoiding NSAIDs and How They May Amplify This Infection

Heather Sandison, ND: So you've mentioned treatments. Maybe we can just do like a quick rapid... Like what do you think about aspirin and ibuprofen right now?

John Mattison, MD: So again, we only have three months of information. But there's some concern that using aspirin and ibuprofen or any of the so-called nonsteroidal anti-inflammatories, there's a large number of them, that they may in fact amplify the risks associated with our immune reaction to the virus.

So there's some concern that we should back off on those now, and that's probably a relatively safe thing to do. Tylenol, acetaminophen, is a good alternative for managing fever. And when fever is really high and really, really stresses our body, it's not a good thing. But we do know that our immune system is more active in general with fever. That's the purpose of fever is to really rev up our immune system.

So because we have the second hypothesis I referred to earlier about why this is such a toxic virus, it is in particularly in older people, the concern is maybe our immune system is overactive. So there is reported risk that that aspirin and ibuprofen other non-steroidals may well be amplifying that risk. We don't know. But it may be safer to back off now. And Tylenol appears to be safe. But a warning about Tylenol... Tylenol, if you take too much of it, is a problem. So do not exceed the recommendations for your weight in terms of how much Tylenol you take because it itself can be a problem.

Pharmaceuticals That May Be Effective Against COVID-19

Heather Sandison, ND: And then other treatments... So at a pharmaceutical level, it does look like there's potentially some data coming out on things like Plaquenil or the malarial drugs being used. Do we have a good sense of how much that's going to shift things and how quickly and also you know supply chain you mentioned... Is there any concern about running out of enough of it?

John Mattison, MD: Yes to both. There are very encouraging reports about really critically ill people who are getting both the old anti-malarial drug, chloroquine, in its various forms. Plaquenil is one of those forms.

They're very encouraging early reports. Similarly for a number of drugs that have been in clinical trials and China and Japan and South Korea, there's a number of them... Remdesivir is one of them that early reports indicate that it may be very, very helpful. And so as far as supply chain for both of those, ramping up production because we don't prescribe a lot of anti-malarial drugs in this country certainly. And so the supply chain may not be where it needs to be. And these other drugs are experimental that are being trialed. And so ramping up the production of those medications is something that we want to accelerate.

So again, this is where public policy and research can help increase the supply chain of those drugs so that they're widely available. We don't fully understand yet who to get them to and when and how much because it's only three months old. The whole thing is three months old. That's like a nanosecond in the history of understanding medicine and biology. But we're getting some very encouraging reports, and as we ramp up the supply chain, that's one of the things that's going to really help us stop this virus dead in its tracks.

What the Former CMIO of Kaiser Permanente is Doing to Protect Himself

Heather Sandison, ND: So what are you doing personally to protect yourself? When we had chatted, I have a 15 month old in my life, and you've got one in yours. So you haven't seen your grandkids in three weeks you said?

John Mattison, MD: We are doing social distancing, so my wife and I are going over to our daughter and our granddaughter's home, and we are watching her throw the ball for her two pet dogs in the front lawn, keeping our distance so that she still has visual contact with her grandparents but we are staying... My wife and I are perfectly healthy, and we are keeping our distance but still giving her the visual.

We are Skyping and doing video conferencing with family and friends all over the country now. And so we can maintain our social relationships while implementing social distancing.

Now if social isolation becomes the imperative, then we'll just rely on what you and I are doing right now. This is a widely available technology. Anybody that has a cell phone and access to the web can do what we're doing right now by having a face-to-face conversation without any risk of COVID coming through my wireless router and infecting me or infecting you.

So we have a lot of opportunity to maintain our social connectedness. And one of the things that comes out of historic crises like this, and this has been true of every pandemic, is it brings out the best in our character.

And one of the things that I see happening is that the suffering associated with those who are just affected with us brings out a real humility that we are vulnerable. We are less vulnerable to the extent that we work together. We are less vulnerable to the extent that we care about each other and express our compassion and manifest our compassion towards each other.

And the more that we realize that this is a major silver lining, this reset button that we're hitting right now, the more humility we have about who we are and about how our experience of life and the joy and the celebration and the happiness that we experience is very much related to how we relate to our friends, our family, and especially to perfect strangers that we can manifest a much broader construct of who our family is.

Our family is much more than the people that live in our household or the people that are genetically related to us. We are all one. This is a global phenomenon. This virus doesn't pick and choose any particular country or city or race or ethnicity or religion.

We are all one. And to the extent that we really recognize and manifest and respond to our community, independent of race, creed, color, or any other aspect of what it is to be human, we will be stronger. We will be better, and we will rise to this challenge and conquer it.

How to Support Each Other Through This Global Pandemic

Heather Sandison, ND: So there's a few practical things I think that are coming out of this... Donating to food banks, right? That so many young children who aren't going to school won't get their hot meal or won't get breakfast and lunch.

So making sure that food banks have the resources that they need to feed the children of our community. That has been a popular one. Are there other things that you're seeing people do that have been particularly inspiring?

John Mattison, MD: I think some of the things that are happening on Next Door across the country, people are just spontaneously... So those of you who aren't aware of Next Door, sign up today because it's a local community-based social network within your own communities. And people are rising to the challenge of saying, "Does anybody know of anybody who need a hot meal that we can deliver to their front doorstep?"

We need to be careful about this that people are not spreading disease with this kind of thing, but if people are out of food and they can't drive, and they can't get a delivery of food because of the supply chain issues, even with some of the major supply chain pathways, it's important that we do help each other and our community. So yes, there's lots going on in that space.

Heather Sandison, ND: Or even if you've got some extra hand sanitizer or alcohol or hydrogen peroxide that you can share with your neighbors so that they can spray down the lasagna that someone drops off.

John Mattison, MD: Exactly.

Heather Sandison, ND: Then that could be very helpful. I saw that there was a toilet paper share going on in my neighborhood.

John Mattison, MD: I'm glad you brought up the toilet paper issue because here's the interesting thing... While there are some gastrointestinal, some people with COVID do have a need for more toilet paper. That is not typical.

There should have never been a run on toilet paper. There is no need for it. It happened in China. People heard about it, so they stocked up here. People are stocking up on water. This virus is not waterborne. Your tap water is as safe today as it was last week, last month, last year.

So there are these artificial scarcities that are emerging out of fear. And so to the extent that that has depleted the shelves of toilet paper, and there are people who are out of toilet paper and can't find any on the shelves temporarily, that will be resolved soon. But sharing something as simple as toilet paper with neighbors who are out makes perfect sense. And so absolutely, that kind of sharing is going on.

Symptoms of COVID-19

Heather Sandison, ND: So diarrhea is not a symptom, or not a common symptom anyways. Can we talk through those symptoms? So I had listed what I understand are the most common symptoms. It's a high fever, shortness of breath, and a dry cough. And then obviously if you know you've been exposed to someone who is positive, or if you've been traveling, then that makes the risk a little higher.

I've had patients all week long asking me about sore throats or runny noses. I know sneezing is almost never present in a COVID-19 infection. Can you speak to when to, when do I worry?

John Mattison, MD: Sure. Great question. So there's several published reports that do catalog symptoms associated with COVID. Now, one thing, one caveat that I think is worth mentioning is that, again, this is a very new virus. It does mutate. It has mutated quite a bit since its original DNA sequencing. In China, [inaudible] mutations are relatively minor mutations. There appear to be... And they're conflicting reports, but there appears that there may be two major strains, but lots and lots of minor strains. So these symptoms may change. So the only caveat I'm calling out is if someone a month or two months from now adds symptoms to the list, that's plausible and conceivably related to evolution and mutation of the virus.

But today, fairly consistently, the symptoms you listed are exactly right. So the fevers, they don't necessarily have to be high fevers. The second thing is the dry cough and shortness of breath. In addition, it's fairly common to get kind of the achy muscle sort of fatigue and aches that you get with the influenza. There are some people who get nausea, vomiting and diarrhea, but not as much as those other symptoms.

And absolutely correct, if you're sneezing and have a stuffy nose, you probably have one of the many viruses that cause the run of the mill cold. It's kind of remarkable how insignificant the sneezing and runny nose, anything affecting the nose is with this particular virus. So if you're sneezing or have a runny nose, and you feel like you've got a cold, you probably have a cold, and not the COVID. But we also need to remember that over time this profile may change a little bit.

Heather Sandison, ND: And what about sore throat?

John Mattison, MD: It doesn't appear that it's as prominent, but I don't think, like sneezing tends to lead you to say it's not COVID. Sore throat, I don't think is as useful as saying, oh, that won't be COVID then because I think some people do and some people don't. I have not... Someone has probably published on that. I have to say I have not seen a definitive study that says what percent of COVID is associated with a sore throat. But it does not appear to be a prominent or universal feature.

Heather Sandison, ND: Or classic sign. Okay.

John Mattison, MD: Right.

Heather Sandison, ND: Well, that's very helpful. That speaks to kind of the necessity of testing, is that there is this overlap in symptomology, and oh, wouldn't it be nice if we could go back to work or not worry quite so much about social isolation if we knew we were in negative. So benefits to knowing you're positive and benefits to knowing you're not. Do we have a sense of how long people continue viral shedding after their symptoms resolve?

John Mattison, MD: I have not seen a prospective study of a large number of people. I suspect there's one that hasn't been published yet, or is just recently published that I haven't seen, but we do know in individual circumstances that individual people have shed for, remember it's only three months old that this has been on the global stage, and only really two months on the global stage because one month was contained to China. But what we know is that some individuals do shed virus when they never have clinical symptoms. We do know that people who get sick and recover can shed for up to 30 days, but we don't know if typically someone is no longer infectious two days after their last last cough or 10 days after their last cough. So I don't think that we have enough data to have a rule of thumb as to when someone is no longer contagious. But we will have that data soon. I would check in on that periodically in the next few weeks because I think we will have much better information.

But more importantly for someone who has a role in society that, say law enforcement or a healthcare worker, where they're interacting closely with the public a lot, and they get sick, and they recover, we really, really will benefit by being able to test them to show that at least the concentration of virus in their nose or in their throat is down below levels that we can detect it.

So one of the things is is that the tests that are being used don't all have the same level of sensitivity. That is, in some people when the virus particles are not very concentrated, where you just don't have a lot of it, the test may appear to be negative. That probably correlates reasonably well with them not being as infectious as someone with a high titer. But again, this is something we're still learning as to what is the threshold of the virus presence that makes it contagious. Do you have to have a cough to be contagious? Those sorts of issues we're still sorting out.

Can People be Reinfected?

Heather Sandison, ND: And then re-infection rates, so that's something I've seen mixed reports on. Most viruses, once you get one, you develop some immunity to it, and you're less likely to pass it on even if you are exposed again, less likely to get it and less likely to pass it on if you're exposed a second time. Now with COVID-19, do we know about that? Do we know if you can be reinfected?

John Mattison, MD: There are several case reports of individuals who appear to have haven't recovered fully, and then gotten it again. But if you at what happened in China, where they imposed the fairly austere social isolation, and then they're letting people go back to work, and they're not so far seeing a resurgence of the virus, one would say the herd immunity of that being so many people were infected, particularly in the Wuhan, Hubei province area that just from an epidemiologic standpoint, it doesn't look like reinfection is a common thing because we know even in China, there's still a few new cases here and there, and it's not spreading like wildfire the way it did before there was herd immunity. So if in fact it were common to get reinfected, one would expect that they're putting people back in the public square, back to work would have backfired by now. And it doesn't seem to have done so.

The good news is they know how to contain it if it does. And we are adopting here in the US, social norms that are different than anything we've ever experienced before in terms of social isolation and social distancing. And so if in fact, something happens that leads to reinfection in more than a handful of people, we know how to respond. We know how to contain it. We will have a diagnostic test at that point in time to do the case tracking backwards to find out who all was exposed to that individual and contain it before we get a resurgence and a recurrent outbreak. So again, I think we have a new normal. And the new normal is that social isolation and social containment are part of the management of these kinds of infections.

And here's another silver lining. The flu virus kills 10,000 plus people every year. And so could we be more aggressive next fall with flu seasons, with social norms that have changed, have shifted because of COVID? Will we need to implement social distancing and social isolation next fall if we contain this thing over the summer. Is it going to come back in the fall? Nobody really knows how much it's going to diminish over the summer, the so-called seasonality is untested. We have some indirect information that there is some seasonality. We do know that the virus is less stable outside human body in warmer climates. I mean that's a fact. And we're hopeful, but not convinced, we're hopeful there'll be some seasonality.

But that means two things. One, it'll get better in the summer. And two, it probably will come back in the fall. And so we need to be prepared to, with the full benefit by then hopefully of having both effective treatment, as well as highly available diagnostic tests. And there are some companies now that are able to mail the test kit to home. You swab your nose or cough into a tube and mail it back in. And you don't even have to go into a clinic in order to be tested. So those are going to be scaled. So next fall we're going to be prepared probably with some effective therapy, clearly with some new social norms about how to do social isolation, and with a high availability of diagnostic tests so we can do the early containment that we were just simply unable to do this year because the inavailability of testing and the novelty of the disease.

The Reasons We Should Be Optimistic

Heather Sandison, ND: That sounds very optimistic. Can we get you on the phone with the stock market?

John Mattison, MD: I'm an optimist by nature, but I do think there's lots of reasons that we should be optimistic. And people are worried about their jobs and their future and the stock market and their 401Ks and on and on and on. I'm pretty confident a year from now, we're going to have a very robust economy, and people will be back to work with different social norms, and hopefully some of those persistent social norms include the ability to implement the social distancing [inaudible 00:00:46:32].

But for the influenza itself, when we have a bad year, to adopt some of these procedures, some of the careful consideration, if you're sneezing, don't go out in public. Don't go back to work. I just saw people who were sneezing at work just recently. Now they don't have COVID, but they're spreading a virus, potentially the influenza, any one of the other viruses. We need to have a different mindset about what it means to be responsible and not go to work. So one of the things there is paid sick leave.

Heather Sandison, ND: Right. I was going to mention.

John Mattison, MD: Yeah. How is our policy going to shift as a result of this for paid sick leave? We really need to be able to keep people home so that if you look at the cost to society, to the workforce, to the stock market, as you brought up earlier, of people showing up sick and infecting their colleagues, I think we're going to see a real shift in social norms about when it's okay to go to work and when it's not okay to go to work and how liberal we are with paid sick leave. I think these things are going to change, and I think it's going to be for the better. And not only will it be the better for COVID and any recurrence in the fall, but it'll apply to the other viruses, including influenza, and even more importantly, this is not the last pandemic we're going to see.

We live in a global community now. Transportation and travel is part of our lifestyle. Is that going to change? Yes, it's going to diminish somewhat, but it's not going to be a cataclysmic drop off like we're seeing right now. That's not going to persist. We're still going to have global supply chains. We're still going to have travel and vacations around the world. But what we're going to see is that people are going to be much more conscious of not stepping on a plane when they have a fever and a cough or sneezing, and not going back to work. So there's a lot of things that we could have been doing in the past that this particular pandemic is going to really inform us to change how we behave in the public square.

And we will have more pandemics like this in the future. Hopefully not for a long time, but we're going to be so much better prepared. What we have in the biotech industry to be able... China was able to sequence this virus and share the sequence of this virus so all the vaccine manufacturers around the world could begin ramping up vaccine production from a piece of software code, from the description of the RNA sequence of the COVID virus. And we're going to learn from this experience how to accelerate the whole life cycle of developing new vaccines. So there's a whole lot of benefit that we're getting out of this that will apply the next time something like this happens.

So this one's going to come to a stop. This one is... We're going to recover, and we're going to recover better than we were before. Not for those unfortunate, my heart goes out to the families who have already lost family members, beloved people. So far, not that many in the US, but clearly there's going to be a lot more. And my heart does go out to them. And we do need to be very mindful and compassionate of the huge impact it has on those people who are getting so sick that they don't recover.

But at the same time, in order to prevent those very deaths with the next pandemic or to limit it to very, very small numbers, we are going to be far better prepared than at any other point in history. The next fall, if it does come back, and the next virus that that escapes from a nonhuman source, like a bat or a pig or a chicken, sort of the classic reservoirs that jump into humans both with influenza and COVID, and with any future viruses. So this is not the last time we'll see this, but we're going to be so much better prepared the next time it happens.

Heather Sandison, ND: John, your optimism is as infectious as this pandemic, this COVID-19.

John Mattison, MD: I hope so.

Heather Sandison, ND: What a wonderful way for me to start the day. I really needed this conversation personally, and so I cannot wait to get this out there so that other people can hear just the perspective of the opportunity in what's happening right now. It's very easy to get bogged down by the panic and the worry and the fear. And to hear what you have to say and to hear your perspective just shines a light on all the opportunity. And like you said, the preparation for next time, the potential to come together. And so thank you so much for sharing all of that. It's been an absolute pleasure to have you on today. And the value you bring is huge. Thank you.

John Mattison, MD: Well, thank you very much. And let me just close with one last comment. The people who are on the front lines of containing this are putting their lives at risk every day. And the amount of fear and anxiety that is circulating amongst those healthcare workers and public service people who are putting their lives on the line to protect the rest of us, and to take care of those who unfortunately have fallen severely ill with it, please share your gratitude with them at every opportunity for what they do because this is a time where love and compassion are critical to our recovery. And those people especially deserve a tremendous amount of gratitude.

Heather Sandison, ND: Thank you.

John Mattison, MD: Thank you.

Heather Sandison, ND: Good advice.

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