What Frontline Health Care Workers Need

Segment Description: Paul Blair, MD, MHS, MSPH, infectious disease physician at Johns Hopkins Hospital, discusses the needs of frontline health care workers.

Interview Transcript (modified slightly for readability):

Contagion®: So what do we know about the point of care diagnostics that are available for COVID-19? And are they sufficiently accurate? Is there a range between different products, things like that?

Blair: That has been one of the biggest struggles of this pandemic. There's been a lot of variability in test performance. And even in this test that do work pretty well. It's been challenging to scale it up because of the massive need that I think most people do not really anticipate.

Although there has been a lot of headway during the past 2 or 3 weeks or past couple months, there's still a lot of work that needs to be done. And it depends on the assay, the sensitivity can be between 80 or 90% using a good essay. And while that might sound good, if you have a person that seems to fit the disease that you would think and has a negative test, one or two out of 10 people have the wrong result that could eventually infect other people. I think there still has to be a lot of clinical interpretation of what we call like the pre-test probability or the clinical probability that someone might have an infection. And then you have to add in a very good understanding of the test that you're using. So it has to be both individualized from a patient standpoint, but also individualized from which test you're using. And hopefully, as we are getting more information and a better supply of a lot of essays, that this will improve, but this is still something that infectious diseases is struggling with. Another thing is the antibody tests. So there have been a number of antibody tests that basically check to see if you're, if the person has developed antibodies against the virus. But that brings in a whole host of other questions about are the antibodies Only specific to source code v2 or are they also picking up other types of Coronavirus is and also when do when are antibodies expected to appear? Because just like other diseases like HIV if, if you check blood too early right after people are infected, they won't have time for their for the body to create antibodies. So I think the test has to be that has like others has to be done appropriately. Otherwise, the results could be misleading.

Contagion®: There also sorts of other concerns for essential health care workers right now about PPE, the economic turmoil, access to child care, to name just a few. What have you observed in terms of the impact of this pandemic, on your colleagues health and safety both mentally and physically?

Blair: There's a lot to talk about there. And I think it's important to remember that we're all we're still human. We're also going through a lot of the same feelings that everyone else is. The I think, the start with I think the mental health components are really important. There's, I think there's appropriately going to be anxiety about maybe getting infected themselves. But I would say even among the colleagues I've spoken with even more of a worry about protecting their loved one. I think there's just the the, I think the horrible image that we've all thought about bringing home something and then either having a kid or a spouse or a parent, contracting disease. From your interaction with them, and I think we have it's so ingrained in us that we want to first do no harm. And so I think that that's one of the major stressors, I think from a daily standpoint.

You mentioned childcare. I think that's another challenge. So even people that are able to telework and use, like something like Zoom or FaceTime for patients, during their normal clinic hours, they, I think they're still having to juggle not having child care. And if you have two infants at home, I think that that's a lot. And especially if you have two working parents that also have to do also have to work from home. I think it's, there's no, there's no guidebook for, for how to work with these scenarios. I think the the p p one is obviously a safety issue. And I think it varies depending on the hospital. I think some hospitals are more prepared than others. But of course you have personal protection is, I think, certainly a important thing for people to that is on everyone's mind. I mean they My feeling is that one of the most important parts is that you don't want to get infected and then infect all occupations. So not I mean someone that is in their 20s or 30s, they can get sick, or even in their 40s but perhaps the from like a health care worker standpoint, but perhaps the the one of the biggest concerns is a asymptomatic shedding of a healthcare worker. Taking care of Patients with comorbidities and making sure that you're not a vector. Because the last thing someone wants to to be is worsening the outbreak rather than treating it.

Contagion®: That makes that makes a lot of sense. And I'm sure that's a really complicated mental thing to juggle, especially in terms of the possibility of bringing it home to loved ones, but also the duty that a lot of people probably feel right now. And then, I mean, even just in parallel to what you were saying earlier about trainees who can't get in volved right now, who are just watching this happen? So, the next thing I'd like to ask about is just the in terms of pandemic preparedness. What can we hopefully learn from this experience with COVID-19? Know, there were a lot of people in infectious diseases who before this happened, we're already saying it's not a matter of if it's a matter of when. Now we know for certain that that was true, and probably will remain true for the foreseeable future. I mean. Human beings we're, we're biological creatures and like any other we catch viruses. So what can we do to be prepared for the next time?

Blair: I think from a high level this this is an issue as being biological organisms we are, or biological people, we are limited by some of our evolutionary machinery and in often thinking emotionally rather than pragmatically. We often don't prepare for outbreaks as much as we very robustly respond to them. So I think the the I think hopefully there is a shift and I do think there will be a shift in this, this horrible awakening that we do need to put more resources into preparing and prevention and surveillance and thinking of new ways to detect emergence of disease and when those diseases emerge out to more rapidly and robustly respond. I think we go through cycles of having an outbreak. there being a lot of attention to that a couple years past, and then funding goes away for emerging infectious diseases. And then the cycle just repeats when there's another outbreak. So I'm hoping that now that the majority of clinicians and researchers and policymakers and leadership on so many levels are now so affected by this that this will be something that we can To grow from and prevent future pandemics. But, it is a major challenge. Because I think that in the past we, we have had a hard time sustaining prevention and putting infrastructure into response. But until it's been too late, but this is the current situation that we're having is, again, unprecedented in in most of our lifetimes. And I'm hopeful that we'll be able to use this sense of unity that we have right now to both combat the virus currently, but also to think of ways to sustainably Try to counteract or prevent this from happening again.

Contagion®: The last thing I want to get to is that we started out talking about how much this has become a fixation and something we're all, whether we're journalists or clinicians, we're all following pretty closely. But eventually, things are going to wind down. That doesn't mean necessarily they go back to normal, but things are going to slow in terms and the rest of medical science research treatment is going to have to start up again, I mean, in terms of clinical trials, even things like that. And so I was just wondering sort of what a couple of your other research interests are, and in a sense, what are what are you looking forward to getting back to when we obviously the priority here is get through this crisis, right, but When we do

Blair: Yeah, and I think there's research needed. I could create a very long list. But one thing that I'm passionate about is, and this was something that I was passionate about even before the pandemic, but I think it's been even more relevant is improving our ability to inform clinical decision making to, to detect emerging viruses, both using information from the host, so looking at clinical changes and immune responses, but then adding in the diagnostic information because I think we need more of a comprehensive approach to not only I densification of disease, but also stratification treatment.

I think our sepsis models are I think they've really improved mortality. But there's been a little bit of plateauing where we, we have had a little bit of difficulty using algorithms to effect sepsis care and in situations like this with or with a bola or with Coronavirus. The pathophysiology does not fit neatly into ways that we retreat sepsis for something like community acquired pneumonia.

Finding new ways to identify different sepsis pathways that could be from emerging infectious diseases could hopefully improve the outcomes because sepsis from, from these diseases does not neatly fit into a one size fits all package.

I'm hoping that we can quickly find ways like using host biomarkers to, to detect patients that may benefit from something that I've been passionate about, and that is immunomodulatory therapy. But I think that's only really become a pervasive consideration. Now during this pandemic, and I think we need to continue to, to think about how we can identify people that may benefit from augmenting or preventing a collateral damage, depending on where people are in their disease trajectory.

I think, specific to Coronavirus. There's still a ton of questions that need to be answered. I think there's we need to understand more about viral shedding both in our patients in the community, but also just while we are picking up virus and different specimens like sputum or respiratory specimen or stool, I think there's still a lot of questions about who needs to be quarantined or isolated, and how effective someone is at a certain stage. And I think incorporating that information again with the way that the individualized care, the patient and the immune response to the patient, and I think really could leverage this. This interest in precision or personalized medicine, towards affecting in a positive way the care of patients with these emerging infectious diseases.

Contagion®: Thanks so much for all of your thoughtful answers and what you and your colleagues are doing right now. It's appreciated.

Blair: It’s our honor.