welcome to another MedCram COVID-19 update and I have been off for a few
days from the updating because it was my turn to take the helm of the ICU what
we're gonna be talking about is number one five new deaths in Washington State
yesterday we are definitely in the growth phase here in the United States
but we can't tell how much of a growth phase there is because we're gonna talk
about testing and the lack of testing and we're also going to talk about
preparation what to do before this hits now we'll talk about mutations we are at
a total confirmed worldwide cases here upwards of 90,000 total deaths is over
3,000 total recovered is well over 10 times that at 47,000 and those are the
published numbers I've heard a number of people talk about the numbers in Asia
and the model to look at in some people's opinion is going to be South
Korea because it is a country that's doing very aggressive testing and it's
an open and democratic country but I think the biggest thing there is the
fact that they are aggressively testing and that's not something that we're
doing yet here in the United States for a number of reasons which we'll talk
about going over to the world ometer website we look at the close cases to
kind of get an idea of where we're going on the mortality because these are close
cases you've either recovered or you haven't and if you look at this graph
you can see that the mortality rate continues to drop these are people that
were tested and we're already at about 6% that's good to go much lower than
that once we get the full scope of the infection here we have total cases
worldwide things were starting to level off here and I think the reason why
we're starting to accelerate again is because we're going into the epidemic
phase in a number of these other countries and looking at latest updates
for today March 3rd maybe a little bit behind because this is a fluid situation
by the time this gets published there are 477 new cases and six deaths
already today in South Korea of course South Korea being in the part of the
world that is the farthest ahead in time
if we look at yesterday we have the first case in Morocco this was somebody
from Italy yesterday 21 new cases and five new deaths here in the United
States and looking to Washington's going to be very important to see what's going
to work in this country and what's not going to work
notice that a lot of these people who are dying are in their 70s however there
is a man in his 40s hospitalized in critical condition in Kirkland one in
Rhode Island and that was a teenager contact of the previous case and all of
these people again went to the same trip to Italy they're saying here this is
precisely why we are being so aggressive in identifying contacts and testing
people who are symptomatic there are three people in California and Santa
Clara County including a couple whose recently traveled to Egypt and there are
now two in Oregon one an adult in a County Hospital in Walla Walla
Washington and the other is a contact of the first case in Oregon who is
recovering at home there's two new cases in Florida and that is the first one in
New York interesting interview on CNBC that's also here on the ward ometer
website dr. Mack McCarthy who is a ER physician at New York Presbyterian he
says I'm here to tell you right now at one of the busiest hospitals in the
country I don't have at my fingertips a rapid diagnostic test I still have to
make my case plead to test people this is not good we know that there are 88
cases the United States they're going to be hundreds by the middle of the week
they're going to be thousands by next week and this is a testing issue quote
in New York State the person who tested positive is only the 32nd test we've
done in this state that is a national scandal
they're testing 10,000 a day in some countries and we can't get this off the
ground McCarthy said I'm a practitioner on the firing line and I don't have the
tools to properly care for patients today and I can tell you I resonate with
that as a health care work I was in the ICU all last week seeing patients in the
emergency room we are taking protective measures to make sure that we don't get
exposed to people coming in to the hospital with kovat 19 causing a lot of
our health care workers to be quarantined and so it's really important
that if anybody goes to the emergency room to call ahead make sure that
they're following instructions make sure that they're wearing a mask especially
if they have a fever and they have symptoms because anybody that they in
fact no matter who they are will have to be quarantined and of course if those
people that are being quarantined are health care providers well that's just
less people to be able to care for other people that need it now the good news
there is that as I understand it there are going to be a lot more tests
available but they're not going to be available until later this week there
are regulations that the FDA imposes on commercial manufacturers of these tests
they have to reach certain goals and it's a long and laborious procedure to
get these things approved by the FDA those are being relaxed so we can get
enough tests on a market and get labs up and running what you ideally want to do
and this goes back to the days of medical school when he were trained in
surgery it was always a good thing if you took somebody occasionally to
surgery for appendicitis and you pulled out a completely normal appendix that
means that you were not missing any that means you work finding negative test
results true negatives so you actually need to screen widely enough so that you
know you're getting enough negative testing what you don't want to be doing
is testing so limited that the number of tests that you're getting you're not
catching the full magnitude of the infection and so I think everyone
believes and everyone's on the same page here that the amount of testing that
needs to be done right now in this country needs to be ratcheted up by
orders of magnitude over what we're getting right now here's a story that
was published in the AP couple of days ago and it talks about what's going on
especially up in Washington where the hot spots are says here as Americans
prepared researchers at the Fred Hutchinson Cancer Research Center and
the University of Washington on Sunday said that they had evidence the virus
may have been circulating in the state for up to six weeks undetected a finding
that if true could mean hundreds of undiagnosed cases in the area they
posted their research online but it was not published in a scientific journal or
reviewed by other scientists trevor bedford and associate professor who
announced the findings on the virus in Washington
State said on Twitter late Saturday that genetic similarities between the states
first case On January 20th and a case announced Friday indicated at the newer
case may have descended from the earlier one now this is gonna be something that
we're going to talk about when we talk about molecular biology is this idea
about descendants so the thing that you've got to understand is that the
virus when it infects your cell it takes over the cells machinery to create more
viruses but the genes that the virus brings in the kind of sloppy and so
because of that sloppiness there's a lot of mutations that are made and some of
those mutations may actually end up changing amino acids some of those
mutations won't translate into difference in amino acids but you can
still see those mutations and as you track those mutations in time you can
see which virus strain descended from another now those mutations can occur
randomly anywhere along the genetic thread the RNA as it turns out in this
case with corona virus but if those mutations affect a key component for
instance the binding protein or the spike protein on the corona virus that
allows it to infect human cells well that virus is just not going to be
able to infect the next human cell but because there's millions and millions
that are made there's always another one right behind it that's going to happen
the bottom line is you rarely are going to see viruses copies of the virus
infecting human cells that have a mutation that is critical in the binding
of that protein and therefore the binding of that site now in this case
the binding site in the human being is the ACE 2 receptor in the cells in the
bronchi or the lining of the lungs so that's a highly conserved area why is
that it's highly conserved because those are the only viruses that are going to
infect the human being but if you look at these just like the human race has
different families different last names because they're related to each other
different coronaviruses different SARS come to different kovat 19 viruses in
other words if you were to look at the ones in wuhan versus the ones in
Washington they are not identical to each other they have mutated in some way
and what you can do is actually come up with
family tree and you can see where these things came from they say I believe
we're facing an already substantial outbreak in Washington State that was
not detected until now due to narrow case definition requiring direct travel
to China scientists not affiliated with the research said the results did not
necessarily surprise them and pointed out that for many people especially the
younger healthier ones the symptoms are not much worse than the flu or a bad
colds he says we think that this has been a pretty high rate of mild symptoms
and can be asymptomatic the symptoms are pretty nonspecific and testing criteria
that has been pretty strict and this is really the key here up to this point you
could not get testing unless you had traveled to that specific portion of
China where the virus was so these combinations of factors means that it
easily could have been circulating for a bit without knowing suggestin less ler
so people are saying that this is high quality work so what I want to do is
talk a little bit more about what is going on with this mutation and I want
to introduce you to a really cool site and that website is called neck strain
and this actually does real-time tracking of pathogen evolution if we
click on the latest data and analysis here what we've got here is the SARS
cuff to genome and I think this is really cool what you can see here we
have the initial strain over here and we can see how through time the DIF
mutations have occurred in a different family trees so if we play this you can
see that things started out here in Wuhan but as things have spread across
the world there's been mutations and we can see what the descendants are as we
track it so interestingly the one here in California it shows that there are
nucleotide mutations from the original there are amino acid mutations in the
ORF 1a gene we'll talk more about that that is the gene in the virus that codes
for the protein that allows it to reproduce the RNA genome of the virus
and if we look down here we can actually see the genome of the virus
is the entire RNA of the corona virus specifically that we're talking about
here the ORF 1 aging and the ORF 1b gene for those of you who are molecular
biology buffs there's actually a overlap in that gene right here that requires a
frame shift on the ribosome to be able to translate both of these and we'll
talk more about that in the coming sessions and updates what this here
represents is where these mutations in the genome are occurring we see that
there's a lot of mutations occurring down here in these small genes and not
so much here this s gene right here it codes for the S protein we can see that
there are some mutations some of these mutations may not be actually changing
amino acids however this s protein is the spike
protein on the very outside of the cell this is the protein that is going to be
binding to the ACE 2 protein on the human lung cells that allows it to bind
and infect them abstence ibly this is the portion of the RNA genome of the
virus that they would be injecting into your cells as a possible vaccine so that
your cells could take this instruction make the S protein inside your body
which would cause a antibody response which would then give you the vaccine
against the corona virus at this point I'd like to talk to healthcare providers
and people who are leaders in their community people who are members of
medical groups this is the time now to start communicating with your patients
educate them what are they supposed to do if they get sick if they develop a
fever if they develop a sore throat if they are otherwise healthy they don't
have shortness of breath they're not hypotensive the best thing to do is to
self quarantine and stay home do not overburden your health care delivery
system they're going to be plenty busy with people who are worse off if you are
going to go to the hospital make sure you call ahead find out what the
procedures are because they're going to want to make sure that you're isolated
they're gonna probably give you a mask things to think about as well as make a
plan on where to go there are hotlines people are going to
be calling in if you have a nurse advice line make sure you double it or
Triplette because the volume of calls are going to increase people are going
to be very concerned if you have the ability to do telemedicine that's what
you should do the corona virus cannot infect somebody
over the phone next thing we need to do is plan for a surge so that means that
people who are in the hospital may be overwhelmed and they may need to get
into resources that are normally in the outpatient setting people who are doing
for instance well checks hospitals themselves need to start thinking about
hospitals within hospitals so in other words a dedicated unit for
people that you suspect as having coronavirus a place that you would need
to have negative pressure rooms so that you're not blowing out the aerosolize
coronavirus into other parts of the hospital something as practical as
understanding that most operating rooms are under positive pressure some of the
more modern ones can switch to negative pressure but if you take a coronavirus
patient into a positive pressure operating room that's not going to be a
good thing it could also be very expensive to have the ability to have
coronavirus treatment all throughout the hospital you need to have a dedicated
place where contact is minimized and the people working in that area are going to
have maximal PPE or personal protective equipment and not have to burn through a
lot of these materials because they're going to be limited so the time is now
to start putting these procedures in place now of course this situation is
very fluid right now thanks for joining us
you