Jackie Hendry: Each week we welcome local medical experts to bring us the latest on the coronavirus pandemic in South Dakota. Today, we're talking back to school, how South Dakota's COVID-19 transmission rate compares to the rest of the nation and how much information is too much information. Joining us now is Dr. Wendell Hoffman, an infectious disease specialist with Sanford Health. Dr. Hoffman, welcome back to In the Moment. Thanks for being here.
Dr. Hoffman: Thanks Jackie, for having me.
Jackie Hendry: Bring us up to speed for this morning. Over the weekend, we saw COVID-19 numbers rising in the state. What's driving that rise and what do these numbers tell you?
Dr. Hoffman: They tell me that we're on an upward trend in South Dakota. This is not surprising. We've talked for many weeks that, as people come together and interact, there going to be more cases. It's a no brainer. So the cases are rising. We are well above the 5% percent positive rate that a lot of states would like to be under. We are now consistently above that and approach eight, nine, 10%, even 12%, I think on one of the days. I think we're clearly on an upswing. I think it's related to overall social interaction from a lot of different settings within our state. I think it, therefore is producing what I would call a time of uncertainty. There's a lot of palpable anxiety out there because we have school right around the corner.
Jackie Hendry: It is that season. I'm seeing a lot of social media posts of kids going back to school today, some later this week. Each district is taking different approaches as far as safety precautions to limit that spread. What are some of the better safety precautions, in your opinion, that students can take as they're returning to school?
Dr. Hoffman: These are the same precautions that we've been talking about for weeks. It's one of the things that we could call now pretty established in terms of the science understanding of this particular virus. That is social distancing and the wearing of masks, particularly endorsed, regular hand hygiene, and then of course the environmental cleaning. But with school, it's a different kind of deal, because we really have not experienced this yet. So I want to appeal to everyone to see themselves as on the front line. Everyone is essential and particularly going into this fall and particularly when we have now introduced a whole new complexity with all of our kids coming back together and with the different school districts making the very best plans that they can. Rather than referring just to us healthcare workers as essential workers and frontline workers, on the frontline so to speak, everybody has got to see themselves as being on the frontline, because the virus is pretty much going to be everywhere. It's highly contagious. As we're seeing around the country and around the globe, it just continues to march on.
But the direct answer to your question is, are the same things applied in the individual context that we've been talking about for weeks. What we've learned increasingly, and I would parenthetically say, that COVID-19 is like a complicated jigsaw puzzle. In fact, I would call it a 3D jigsaw puzzle. The name of the puzzle is COVID-19 pandemic. But there's no picture on the front of the box. So we have to begin to piece this thing together. As we go forward, we get a better picture of what this looks like. That's what's happening. So in regards to the virus itself, we are increasingly seeing that not only does it occur asymptomatically... We've heard about these reports now for weeks that maybe up to 40% of people who come down with COVID-19 have very little symptoms. Yet we're now learning more, even in the pediatric realm. In an article in the Journal of Pediatrics, out of Boston, where they looked at, I believe it was 190 some children, what they found was that children can carry high levels of virus in their upper airways, particularly early on in their infection. Yet they display relatively mild or no symptoms. Also what that study demonstrated is that there was no age correlation with viral load indicating that infants through young adults can carry equally high levels of virus. So that's been a little bit of a wrinkle.
The study from South Korea, a number of weeks ago, demonstrated that the younger children, at least theoretically, would spread this less effectively than older children, so under 10 versus 10 and above. Now we see from this study, and again, think of this as a 3D jigsaw puzzle. Now, now we would have to be concerned, and we've always been concerned, about what happens when you put a bunch of kids together. I think it's studies like this, that suggests that the virus indeed, is going to be spread between kids and then as they come home to their own households.
The other study about asymptomatic came from South Korea again. It was about 300 patients and it occurred in a community treatment center where they were able to closely monitor and measure these patients. Basically about a third of them were asymptomatic. But what they found also was that the shedding of the virus was similar between asymptomatic and symptomatic persons.
So what is the take home? The take home is that as children come together and as teachers and children are mixing, we can expect that there is at least the potential for transmission, even going down into the younger age ranges. At least we have to plan that way. So, again, 3D puzzle, we're putting together all the pieces. We're trying to get a better picture of what this looks like. I think the potential for ongoing transmission is going to be there. That's the newest information I think that we see with regards to the asymptomatic occurrence, and then the potential for virus to spread from asymptomatic persons.
Jackie Hendry: That's been a big justification for sending students back to school in person, is this idea that children aren't as effective spreaders of COVID-19 as adults. But as you say, another piece of the puzzle comes out. We don't have the picture to guide us. This is all brand new. We have to roll with the pieces as they roll out. As you say, we can expect the number of cases to rise. Governor Noem, Mayor Paul Tenhaken here in Sioux Falls, other leaders throughout the state and the nation, are saying, "Focus less on the number of cases, focus instead on the number of hospitalizations related to COVID-19, because that's a clearer indication of our current situation." Is that a fair way for the everyday person to approach the information they're getting about this virus?
Dr. Hoffman: Well, it's only part of the story. That has been the common theme, is that all we've got to do is keep our hospitalization rates low, and we're going to somehow be in better shape. Let me just say this. What we're not factoring in there is the individual patient who comes down with these infections. So I'm going to go back to a statement that I learned when I had the privilege of training at the Mayo Clinic. The reason why the Mayo Clinic is the Mayo Clinic is because of one simple statement that Dr. Will Mayo said in 1910 to a graduating class of medical students. He said this, "The best interest of the patient is the only interest to be considered," period. That doesn't mean that there are not other interests. It simply means that comparatively speaking, they are almost like they're non-existent because the most important thing is the patient.
So the translatable here is the most important interest here is the child, are our kids. That doesn't mean that the interest of teachers are not there. Absolutely are. In fact, in another study, it suggests that maybe up to 50% of teachers nationwide have at least one risk factor for serious disease. So we have to be mindful of that. Just like in healthcare, the person who is next most important, either in the patient or the child, is the person who's directly interacting with them. In other words, the healthcare worker, or in this case, the teacher. So we cannot minimize the fact that spread could occur and that teachers could come down with this. However, the good news is that when we use these mitigating strategies, we think, just like in many other contexts, the the transmission of the virus will be minimized.
I want to go back just to one thing, and then I'll be quiet for a second. I'm usually told, "Less is more Wendell. Less is more." I'll try to be less is more.
I do want to highlight though, that just because you weren't hospitalized but had COVID and had a milder syndrome, or just because you were in the hospital and didn't die, doesn't mean that things are over. We are now seeing what we could call post COVID syndromes. In one study out of Italy, 87% had at least one symptom at 60 days, most prominently fatigue, next dyspnea, shortness of breath, joint pain, chest pain. Also 20 to 30% of hospitalized patients have cardiac involvement. So we're worried about the longterm implications of that. Lastly, the psychiatric phenomena that occur, another study in 400 patients, one month followup, 40% had anxiety, 31% had depression, 40% had insomnia, 28% had post traumatic stress disorder. So that's a long way of answering your very important question, Jackie, it's not just keeping the hospitalizations down.
The way we get at this is that we don't just manage a number. We don't just manage a population. Mayo didn't say that the best interest of the population was the only interest to be considered. He said the best interest of the patient. The patient is there for the first person of the population. The child is the first student in a population of individuals. So we have to consider that as well. Now, the second half of what Mayo said is also true. After he said, "The best interest of the patient is the only interest to be considered," he said this, "And in order for the patient to benefit from advancing knowledge, union of forces is necessary." What Mayo did famously is that they focused on two things. They focused on the person and they focused on the team. In order that the person gets the best care, the best teaching, the team is necessary. In healthcare, we are very team oriented, in order to give the individual person the best potential care possible. I think those are transferable concepts, as we go forward, that it's not just about hospitalization rates. It's about everybody who gets sick and don't we want to prevent even mild illnesses. Because we really don't know. So that's why all of us everywhere, we need to see ourselves as part of the team.
So the message goes out, small businesses, churches, school systems, any place where people are gathered, all of those people need to see themselves as being part of the team so that the individual can be best managed and protected.
Jackie Hendry: Yet another piece of that 3D puzzle. I want to shift again to another one. Becker's Hospital Review put out something fairly recently, within the last couple of weeks, saying South Dakota has the second fastest rate of COVID-19 spread in the country. That came out a couple of weeks ago, gaining some traction on social media late last week. What can you tell us about that piece of the puzzle and how people should interpret that report?
Dr. Hoffman: That piece, it's based upon a very interesting metric and actually people can just Google RT Live, which has to do with the reproductive number of the virus. Basically the R0, R naught is what they call it, which is simply a term for the reproductive number. If it's above one, then that means that the epidemic is much more likely to spread. If it's less than one, which is where you want it, it's more likely that it will begin to decrease. In the example you cited in South Dakota, and I checked on this last night. Last night we were number three in the country, as far as our RT, our R0 number. So what that says to me is exactly what we began with, is that the trend line is up. Our percent positive numbers are up. It's time, like at no other, as we enter a very uncertain period coming into the fall, that everybody in our state take this responsibly and seriously.
South Dakota is an open state, right? We have few rules. Okay. In some ways that's really great. I'm thrilled that the businesses and our economy is opening up because the secondary effects of closing down are incalculable. That's now being seen increasingly. So I think the bottom line is we all need to be engaged, and we all need to see this as our responsibility. I think there's an old saying that says, "With fewer rules, you need more leadership." Fewer rules, more leadership, not less leadership. Because if you pass a law and you say, "Masks are mandatory." Everybody goes, "Okay, I'm going to wear a mask because I have to." Many people have expressed themselves in our state. They don't want a mandatory mass mandate. Okay, if you're not going to do that, then you have to see yourself as having an obligation because of the nature of the personality of this virus to take responsible steps.
I've had people tell me that they're trying to plan based upon the personality of their group. I'm sorry, but I have to disagree. This is not based upon the personality of your group. This is based upon the personality of the virus and its personality is that it doesn't care about personalities. It's going to spread to whomever. So all of us need to see our part, like Mayo said, "In order for the patient to benefit from advancing knowledge, a union of forces is necessary." We need a big team approach to this and our leaders need to continue to be out in front of us. Just because we're an open state doesn't mean... We really need more leadership arguably than less.
Jackie Hendry: Unfortunately we're out of time for now, but my guest has been Dr. Wendell Hoffman, infectious disease specialist with Sanford Health, walking us through the latest COVID-19 information. Dr. Hoffman, always enlightening to talk with you. Really enjoyed it. Thank you for your time today. You're welcome back anytime.
Dr. Hoffman: Thanks, Jackie.