8 Months In…

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Conversations: Covid-19 — 8 Months In

Candace Hoffmann: Our journal club podcasts are designed to provide a lively discussion about current, relevant topics from research and the medical literature as well as providing a convenient way to earn CME/CE credit.

But sometimes, our experts continue a discussion that goes beyond the CME/CE activity and gives a greater depth and context to the topic.

This was certainly the case after we finished recording the Journal Club in Oncology podcast, Considerations in Oncology and Covid-19, which can be found at JournalClubPodcasts.com/ClinicalOncology.

But Dr. Len Lichtenfeld, the former chief medical officer of the American Cancer Society in Atlanta, and Dr. Otis Brawley, a professor in the department of oncology at Johns Hopkins University, Baltimore, had much more to say about Covid-19—particularly preventable deaths and cases, vaccines, and the long-term aftermath of the coronavirus pandemic.

I’m Candace Hoffmann, your host for our Journal club podcasts and along with Drs. Lichtenfeld and Brawley, we were also joined by Peggy Peck, Vice President and Editor-in-Chief of BreakingMED.org, the news arm of @Point of Care and Projects In Knowledge.

Let’s join this discussion.

Dr. Otis Brawley: Yeah, I tell you the paper I really would have loved to talk about and Len’s probably going to pick on me later today because I’ve been quoting this paper for almost 3 months, the Columbia paper that just came out.

What they did was, they looked at every major country and they said, if the United States had done what South Korea did there would be currently 2400 Americans dead.

Candace Hoffmann: The paper Dr. Brawley is referencing is by Irwin Redlener and colleagues and is from the National Center for Disaster Preparedness at Columbia University. The researchers did a comparative analysis between the United States and other high-income countries. They compared deaths per 100,000 population and found some startling statistics.

Looking at S. Korea vs the United States, both countries reported the first Covid-19 cases on January 20, but S. Korea’s aggressive testing and isolation strategies resulted in 78 times fewer deaths than the United States.

From a per capita perspective, S. Korea has .85 deaths per 100,000 vs 66.33 US deaths per 100,000 population.

Similarly, Japan had 1.31, Australia, 3.56, Germany 11.72, Canada 25.95, and France 49.43 per 100,000 population respectively.

Redlener and colleagues wrote in their conclusion: “The failure of the federal government to (a) create a rigorous national strategy for testing and contact tracing, (b) coordinate data collection and coordination among US states, or (c) recognize the scientific validity of nonpharmaceutical interventions like face covering and social distancing reflect a deeply inadequate national response when contrasted to other high-income countries.

“Our comparative analysis estimates that somewhere between 130,000 and 210,000 American deaths to date could have been avoided.”

Dr. Lichtenfeld also noted that there was another recent paper published in JAMA by Zeke Emmanuel and colleagues that was also another comparative analysis. It again showed that the United States’ death rate from Covid was far beyond that of other nations that took more stringent measures.

Dr. Len Lichtenfeld: The data is exceptionally clear. The death rate in the United States was about 60 some per hundred thousand. The next closest was 10 or 20 per hundred thousand. That’s a three to six times fold increase and if we have the Australian rates the rates would have been substantially lower. So, we have had a serious problem.

Another example, we didn’t even get to, but there was an article, Peter. Peter at Brigham, at Brigham Women’s rather…

Dr. Brawley: Used to be Peter Bent Brigham

Dr. Lichtenfeld: Yeah. Yeah, it used to be when they changed it.

Anyway, they actually published the paper. Again, I get confused between JAMA journals, but it was one of the ones of those recently, how they had this outstanding experience and nobody in-hospital got Covid.

About 2 weeks later, the New York Times came out with an article about cluster outbreaks in Brigham. So even if you do the best you can possibly do. And I have every reason to believe, I’m not picking on them, I’m not saying they were bad, but they did everything they could to prevent that from happening … you still have weak links.

And unfortunately, that plays out in the general population. And so the decline and we all know in heart disease, admission, deaths, and stroke and … cancer care all that plays out, and if the second wave hits it’s going to be anywhere near…

I did a tweet the other day when I posted the IHME death rates for Georgia and if that comes anywhere near reality, we won’t have anybody going anywhere near any medical facility for months to come.

Because the community will see what what’s going on. And unfortunately, in some communities. There was even a doctor in the AJC, The Atlanta Journal Constitution, they talk about here… I’m in north Georgia right now… who abrogated any prevention strategies in his office, and somebody had an 88-year-old father, they took and refused to take him back.

So, we’ve got a big mix of things going on here that are, unfortunately, sadly, we’re talking about the best institutes. Wait till that happens. We’re talking about Brigham, we’re talking about MD Anderson, you know, the best institutions, but not everybody in the country is following those guidelines, nobody believes in the need to follow the guidelines. Naturally, the sad commentary.

Dr. Brawley: Yeah, we have doctors’ offices that are not following CDC guidelines. That’s terrible.

Candace Hoffmann: The Covid-19 pandemic is not yet a year old. Each day brings more information as to what it is, and possible pathways to therapeutics and vaccines, but what about long term—long term like 40 or 50 years from now? Dr. Brawley addressed this question.

Dr. Brawley: The other thing that hasn’t been talked about that you guys might want to think about is the history of the H1N1 1918-1919 epidemic. There were aspects of that epidemic that were only discovered in the 1950s. For example, after the Korean War, it was discovered that people who got the Spanish flu were at higher risk of Parkinson’s disease.

It is likely that in 2050 and 2060 we’re going to realize that people who got Covid-19 are at higher risk of other maladies that we haven’t even thought of yet.

You know, there’s been a little bit of discussion about myocarditis in young athletes who are getting it, the young people who seem to be asymptomatic now they may have hell to pay for having gotten coronavirus in 30 years

Peggy Peck: Dr. Brawley I want to ask you about something and you too Len.

Do you think that this virus has, I’ve been talking to other journalists since the beginning about the possibility that the virus has a reservoir in organs and I keep thinking the natural history of HCV which starts in most cases as a small, like viral, outbreak in the person, but then it lives in the liver and then leads to fibrosis and which I read these things about fibrosis in lungs and liver fibrosis goes to hepatitis and you know, hepatocellular carcinoma.

Do you, are you fearful. Are you fearful that we could see something like [this]?

Dr. Lichtenfeld: I can weigh in on this. I’m gonna take this one. Okay. I always defer to him and give him first opportunity. There are viruses, you know, shingles, zoster that lingers in the body for a long time.

And HIV certainly has lingered in the body for a long time, and escapes surveillance.

So, and we know that this virus goes to multiple organ, we know it goes to the central nervous system. It’s been recovered in the brains of people who have died.

We know it goes to the heart. There’s a study that showed … I have to be conscious of this because I had a severe viral infection a couple of years ago and ended up with cardiomyopathy, and left ventricular wall abnormal motion which fortunately has resolved completely, but there was a study published recently in JAMA, again one of the JAMA journals there are 1500 of them now. Right. The JAMA rubric.

Talking about virus particles in the hearts and the long-term structural changes in the hearts of people who’ve been infected with Covid.

So you’re absolutely right.

We have no clue. And, you know, one of the things I’ve been sort of tweeting about this, what’s called the long hauler syndrome.

And now institutions are setting up long-term follow ups for patients with Covid. Just like we don’t know everything there is to know I promise you [about] the long-term file with cancer patients. We have in adults, we’re doing a national academy a seminar in a couple of weeks about 2, 3 weeks, I guess it is.

And it’s focused on the effects of cancer. And Larry Schulman and I are both the older folks on the panel. We talked about the long-term effects of Hodgkin disease. Hodgkin treatment from when we were younger, that people aren’t paying any attention to today. I actually had a patient that died as a result of that.

That’s an accusation of lack of surveillance of cardiac effects. So yeah, there’s a lot we don’t know, we will be studying this, and we need to pay attention to it. And I agree. I agree with Otis. So I think you’re going to find out things we don’t yet.

Candace Hoffmann: And among other things that we do not know yet and which might become evident in the short term are what therapeutics and vaccines will be a viable foe against Covid-19? And also, what might be some stumbling blocks along the way before we find the right concoction? Drs. Lichtenfeld and Brawley shared thoughts on this as well.

Dr. Lichtenfeld: I sort of alluded to the fact that the vaccines are novel technologies.

And one of the conversations, Otis, I think you and I’ve had that conversation. I asked a number of months ago about what’s called an add on an animistic response.

So, you could have theoretically… And then, lo and behold, couple weeks later I heard Fauci actually mentioned that in one of his comments. But you can have a vaccine that depends on T-cell stimulation to in order to produce antibodies. In other words, you did the vaccine that vaccines, a novel mechanism but when the virus shows up the immune system responds vigorously. And this is only the highly theoretical. I don’t even know if any real immunologist would say there’s any purpose to it.

But you wonder if you couldn’t accelerate the immune response with notice the same and have a cytokine storm as a result of a challenge, a natural virus challenge from a person, a vaccine that a person received in the past. Now I hope that doesn’t happen, but Otis and I talked about it quite a number of times.

I was around in ’76, I guess it was, when they had the swine flu. I was at Hopkins as a resident we all stood up and got our swine flu shots and then Guillain-Barre showed up.

And man that put—I mean, notwithstanding the fact that the epidemic never happened—but it put a complete kibosh on it and so when we start hearing about these isolated…10,000 people got the vaccine and somebody’s got a myelitis or they got this, I got that. Yeah, we lived that in the past in this country and there’s no medication around. Yeah.

When you start giving it to well people, to healthy people, that doesn’t show up with something and somebody doesn’t like what will happen in some way, shape, or form.

Dr. Brawley: Yeah Sencer, who was the head of the CDC lost his job because of that swine flu debacle with the vaccine debacle. He just died a couple years ago. He’s a very good friend of mine.

Peggy Peck: Well, I think that I, this has been great, and you guys all know me, I could go on like this forever.

Dr. Lichtenfeld: We appreciate it as well. We enjoy doing this. So, thank you.

Dr. Brawley: Alright, thanks.

Candace Hoffmann: Thank you for listening to our Covid-19 conversation with Dr. Len Lichtenfeld and Dr. Otis Brawley. And be sure to listen to their discussion and CME/CE activity on the podcast Journal Club in Oncology: Special Considerations in Clinical Oncology and Covid-19, which you can find by visiting journalclubpodcasts.com/clinicaloncology.

The journal club podcasts are developed in collaboration with @Point of Care and Projects In Knowledge and are part of a continuing medical education series.

Candace Hoffmann, Managing Editor, BreakingMED™

Cat ID: 125

Topic ID: 79,125,730,933,125,190,926,192,927,151,928,925,934