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Dr. Shankar Kurra: Covid-19 Update

Lori Walsh: South Dakota, North Dakota, and Iowa are three of the highest risk states per capita of COVID-19 spread. Are we all more at risk now because of the size of our outbreak? What kind of treatments are available here at home? And what do we know about this virus that we didn't know even last week? Dr. Shankar Kurra is vice president of medical affairs at Monument Health, and he joins us today for a weekly update. Dr. Kurra, welcome back. Thanks for being here.

Dr. Shankar Kurra: Thank you, Lori. Pleasure as always.

Lori Walsh: Now, we're all watching the numbers and, of course, we see the national reports and the advice from public health experts across the country. But what are you seeing here at home? What does the outbreak look like in South Dakota, particularly the Rapid City and Black Hills area right now, from your perspective?

Dr. Shankar Kurra: As you correctly pointed out, Lori, North Dakota, South Dakota, Iowa, if you normalize and look at the numbers per million, population cases per million, those are up there, along with Arkansas and Tennessee. And West River is where all those cases are if you look at the recent spike. We have a higher number of cases than East River. That is to be expected. And so what we're seeing now, probably the early signs of those numbers hopefully starting to trend downward. And that's a good thing. I hope that it's true. Maybe it's a little premature, but we'll see. But their numbers at this time are plateauing, if I can use that cautiously.

Lori Walsh: And that doesn't happen accidentally. What are we doing right that makes those numbers ... Just like the spike doesn't happen outside of a vacuum, the trending down doesn't happen ... So are we on top of it with contact tracing or what's going right?

Dr. Shankar Kurra: Yeah. I think several factors. Most important, we don't at this point have a large community-wide gathering of folks from all over, which is the big reason. And the second is I think all along folks of Rapid City and the surrounding West River area have been very, I would say, cautious, careful, observing ... At least local populations have clearly benefited from distancing, wearing masks, and doing all the right things. Something we've talked about repeatedly on the show. Hopefully that has played a big role. The second big one is the fact that there is contact tracing, as you correctly pointed out. And the more efficiently we can contact trace, the more likely that we can isolate and prevent community-based transmission. I think those two factors are playing a big role right now.

Lori Walsh: A lot of people, I mean, you see something on Facebook every day where someone says "I haven't been contacted by the Department of Health, but I know I was with somebody." People are reporting that they're ahead of the contact tracers in their knowledge. And sometimes they're unsure "Should I go back to school?" for example. "Should I send my kid to class or not?" But we have a lot more education right now as individuals than we had six months ago. What, instead of waiting for the Department of Health to tell you what to do, what are some of the things that you need to be reminded of to do if you've been to a large gathering or if someone who has tested positive or if you begin to have symptoms yourself? Walk us through some of those choices that people should be making on their own.

Dr. Shankar Kurra: Great question. Yeah. We are beneficiaries of what occurred across the Eastern part of the country and the South. We have seen that. That has alerted our communities to take all the precautions. So the best thing I would advise is if you or one of your close ones suspect that you've been in contact with or been exposed, even without the Health Department contacting you, the correct thing is to monitor for signs and symptoms, fever. Mainly check your temperature at least twice daily. Try at least for the next 10 days, if you do not develop symptoms, to stay isolated as best as possible. And if you do have to venture out, continue to observe the distance, the six feet, always wear a face covering. This has been shown over and over again as a important key determinant in asymptomatic spread, especially someone who has been exposed but has no symptoms, important to have the face mask.

So if we do all the things, social distancing, six feet distance, face mask, washing your hands, isolating if possible, checking your symptoms, especially temperature. And then, if you develop symptoms, then having tests done or at least, once you develop symptoms, the ideal duration would be at least two weeks to 20 days of isolation before you go back into the public space. Now, those two weeks are predicated on the fact that you develop no further symptoms. So those are the things that we can do. And I'm hearing the same as you are. Folks are saying, "I feel like I've been exposed. I'm going to do and be safe and not spread it."

Lori Walsh: Yeah. When you talk about taking your temperature, I know as I have done that throughout this process at various times, I've discovered I run a really low temperature. So for people who are realizing that their temperature runs low, then is a fever different for those people or is a fever the same for everybody?

Dr. Shankar Kurra: It's the same.

Lori Walsh: It's the same. Okay.

Dr. Shankar Kurra: Yeah. Good question. So the virus, when it multiplies and replicates into millions of particles in a single cell, that's what we call the viral load. When it's significantly high, it creates this pyrogenic response because it causes the body to release these cytokines, or chemicals, that increase the temperature. And these are very distinct with viruses. Once that fever occurs, it's over a 100.1. So there's highly unlikely that you will, if you do develop symptoms ... Now, there are folks that do not develop symptoms. And that's why we say if you think you've been exposed, the smart thing would be to observe at least 10 days of asymptomatic isolation as far as possible.

Lori Walsh: Yeah. I want to talk about long-haulers. And I was reading about that this weekend, people who are sick for a long period of time, and particularly in this larger conversation about young people getting sick, as we see people going back to high school and K through 12 and college. We have been less concerned about the young people or younger people among us because the death rate is so much lower. We've been concerned about who they're going to spread it to from the beginning for certain. But are we seeing now longterm organ damage? We don't know, we're still early in this pandemic. What are we learning about the longterm implications of having a COVID-19 infection?

Dr. Shankar Kurra: Yes. More evidence is coming to light that there are clearly longterm negative consequences of getting this disease. And the question that remains is do the younger folks have it as well. And the answer is leaning towards a yes for them as well. And so, without raising too much alarm, I would say the age is not as important, unless you're really young like less than five, then the likelihood is really low, but we're talking age 10 on upwards. 10 through 17 is the pediatric age range that we're beginning to find out the disease process may not be as benign as once imagined. Now, that doesn't mean that their percentages are as high as anyone over 18 and above. Those folks are sharing the vast burden of the disease, as we know it.

One interesting study that's currently being done in Melbourne, Australia, based on this very fact, is that their hypotheses that postulate is that it's depend on how good your lining of your blood vessels are. Because what we've found about this disease is it affects the endothelium, or the lining of the blood vessels. And so anyone with a prior injury or a block or even a small damage to it, which obviously the older you get, the more natural it is that some of the lining of your blood vessels are already partly damaged, either from a lot of factors, but disease, diet, and all those things. So even a 18 year old with blood vessels that have some form of damage, either from previous disease or organic reasons, is at risk. So that's the study that's being done. A very good, strong study that we will know by October, November the results.

Lori Walsh: And can you predict in healthy people how good their blood vessels are? Or is that connected to some sort of disease that you would already know about?

Dr. Shankar Kurra: Right. So on the cases that had young people, young and elderly that had extensive blood clots in their lungs and their heart and the brain and all the organs, that's what we're beginning to learn is, and that's where the study in Melbourne is taking their cues from, is when we see these, in autopsies and pathology specimens, that there is clear damage, preexisting damage to the endothelium, either from plaques or other types of damage, that predispose them to very bad consequences from COVID. So what we're learning is the reason people with hypertension, obesity, large BMI numbers, and diabetes, these are all diseases that affect the blood vessels. So they clearly, as a subgroup, are at high risk. And the same applies to those without these diseases but with some form of vessel disease that preexisted prior to getting the disease.

Lori Walsh: Yeah. Let's talk about treatment. And we have been told from the beginning to look at hospitalization numbers, and hospitals have prepared for surges from, surge meaning different things at different times throughout this, but what are we learning about how to treat COVID-19 patients who either to keep them out of the hospital and treat them at home and to provide that supportive care at home, or some kind of care in the hospital? What are we learning today? And are we doing a better job than we did at the beginning of this of keeping people out of the hospital or treating them well once they arrive at the hospital? What can you tell us there?

Dr. Shankar Kurra: Yeah. The second part is very true. We are doing a better job than we ever did. We have much more information, knowledge, and experience about how to treat these folks that are really ill when they come into the hospital and then how to manage them as an outpatient basis. I think the big ones there, as you know, this disease predominantly affects the respiratory system, the lungs, the breathing, the ability for us to use our lungs to efficiently oxygenate our tissues is what is affected. So most folks that get in trouble because their oxygen levels are lower than you would normally expect. And what we've learned is putting them on any form of mechanical ventilation is not necessarily an important or a good treatment option. The ideal way to treat these folks is just provide oxygen and try to, if possible, avoid those kinds of mechanical ventilation where it's an intrusive method of actively ventilating or supplying air into the lungs. That we found actually is harmful. In some instances, it is required. In some instances, it is not. But the larger number of cases, if we can avoid that, that's one.

The other thing, a recent meta analysis of all the studies that we've done on using steroids, these are not the bodybuilding steroids but what we call the corticosteroids, the ones that reduce inflammation, these are shown to clearly decrease the length of stay, even decrease mortality. And so that's another treatment modality that we are now using that we didn't in the early cases. So there's a couple of things. These other tests or treatments that we're currently using, like Remdesivir and all these other newer agents, have not yet been proven. So we use them more as a option rather than knowing that they will actually help folks. But we have definitely improved our ability to treat, keep people safe, and hopefully recover.

Lori Walsh: What have we learned about convalescent plasma therapy? We've been talking about that for months, and now it's become more of a national talking point as well. Is that something that's still in use in South Dakota in some cases? And what are the promises or limitations of that?

Dr. Shankar Kurra: Yeah. The best evidence, and let's talk evidence because these, what I call, science by press doesn't help, but the best scientific evidence based on all the researchers and the scientists that have done the hard work on plasma is it's only gone through studies that test safety, which means if I gave you the test, did you develop a reaction? Gave you the plasma, did you develop a reaction that could harm you more than the disease itself? And that part we are clear that you could safely administer plasma in COVID-19. And we've administered plasma as a treatment therapy in the past 50 years or more for other diseases.

What we do not know yet, and there is no case control study, and that's the gold standard study, whether this is truly creating better outcomes, saving lives. So we don't know that. The evidence for that does not exist because there have been no case control studies done yet. In order to do those, that has to be done, like good research is done, with a review by a board. And unfortunately, in the meantime, because it's safe but we don't know if it's effective, emergency use authorization, once you give permission to use it, then outside of a study, it's harder to actually understand if it helps or hurts. So bottom line is, right now, there is no evidence at least existing that shows convalescent plasma treatment improves outcomes. What it does do is it's a safe treatment option that we still have to study. And there's a study undergoing right now. Hopefully that will give us a better answer.

Lori Walsh: And finally, with more cases in South Dakota right now, I think it's a good time to remind people, how do you take care of yourself or someone in your family, if you are sick? How do you get through this at home? Hoping, of course, that you don't have to go into the hospital. What are some of the things that you should ... We were all stocking up on Tylenol and wondering about Advil a few months ago. How do you prepare for illness in your house?

Dr. Shankar Kurra: Yeah. I'd say the approach should be just like you would a bad case of the flu, check your temperature. If you're able to control the temperature at home with Tylenol, great, as long as you're having some symptoms that are just like the flu and nothing more. The ones I would look out for is if you're having a hard time breathing, let's say, commonly described by patients is they feel a heavy weight on their chest because they can't get enough oxygen, that's the first sign. They won't know it otherwise. They can't do simple steps that they normally would do: get out of bed, walk to the bathroom, or even do a simple thing like walk a small flight of stairs. That's a sign that you need to go to the hospital right away, because then we can just place them on oxygen. And most of them, when you do that, recover within three to four days. And a few require more intensive treatments. But that's what I would look for.

Lori Walsh: Yeah. I think that's important for people because there was, early on, there was a lot of fear about intubation or being on a ventilator. And, really, going to the hospital is a good thing if you need it. And the treatment might be different than it was six months ago, let's say.

Dr. Shankar Kurra: Absolutely. There are better modalities right now. Yep.

Lori Walsh: Wash your hands, watch your distance, and wear mask. Dr. Dr. Shankar Kurra, thank you so much for being here with us throughout this journey. We really appreciate your input as we continue to figure out how to live our lives during a pandemic. Thanks.

Dr. Shankar Kurra: Thank you, Lori. Glad to be here.