20 - Children and COVID-19 with Infectious Disease Expert Dr. Kristin Moffitt
From. Kurkcu media. The. It's still here. Numbers are still climbing who would have predicted that the health and medical community would be at odds with the politicians on how we handle the climate of this pandemic. I. Know you think you heard enough about this covert virus but new developments are worth understanding and each of our actions and personal decisions will affect our families, our friends and our communities. In this episode, you'll hear some new covert nineteen facts that are worth your time. It's stuff you need to know. This medicine, we're still practicing I'm Bill Curtis. Of course, I my friend and Co host Dr Steven Tailback. He's a quadruple board certified doctor of internal medicine, Pulmonary Disease Critical Care, and neuro critical care and he's on the front lines of the covert battle out in California, for which we are eternally grateful Steve How you doing. Thanks remotely tuning in. Hey Bill. Good to see. And a very special guest Dr Kristen Mufid. She's an associate physician in the Pediatric Infectious Disease Division at Boston Children's. Hospital. And she's a multiple award winning physician and professor of Pediatrics at Harvard Medical. School. Christie is also affiliated with Brigham and Women's Hospital She's certified in general pediatrics and Infectious Diseases by the American board of Pediatrics Doctor Moffett. We'd like to thank you for breaking away in. Joining us today. All right. Thanks for having me. Tell me how is Boston Children's focused change during this virus Boston Children's like every hospital in Boston March and early April were all frenzied months as we were preparing like hospitals I'm sure all around the world for what we were anticipating to be a surge in Cova infected patients. It became fairly clear relatively early in the pandemic with data coming. Out of China that children did not seem to be suffering the same severity from this infection as older individuals in adults did we were not completely sure whether or not that data would hold true as the virus swept across the world. Luckily, that has actually held true but that should not be taken it all to mean that children don't get sick from this some children do get sick. From this some do require hospitalization in some studies up to a third of children who require hospitalization require ICU, level care. So Boston Children's was in a unique position in Boston as you know, Boston has an abundance of hospitals for people to choose from excellent hospitals, all of them, but Boston Children's is the only free standing children's hospital. There are several other children's hospitals in Boston but they all. have their physical spaces, their units, their hospital beds contained within larger hospital systems that treat adults. So a decision was made within the city for Boston Children's to be able you take care of all the after patients in Boston who required hospitalization so that the deatrich beds in those other hospitals that were within adult hospitals could be committed to carrying for adults with cooking seems like a good. Plan well, even you just mentioned that children are substantially less susceptible to this virus than people at risk of the children who do get seriously affected by this virus apparently more than seventy five percent of the fatalities in children related to this virus are those of minorities? Can you explain why that's happening? Yeah. That is very true. The disproportionate effects that this infection has had on black and individuals. That has been seen in adults is playing out very much children as well, and that's true. Both of Acute Kobe infections, and then as you may know, we were all surprised in the pediatric. Rome to start to understand this other entity called MISC or multi system inflammatory syndrome in children that seems to be overwhelming inflammation that occurs in children largely two to four weeks after a covert infection. So both acute colon and MISC are impacting minority populations in pediatrics substantially two ways that the most likely explanation is that children are most likely exposed in their households in in their communities, and those are exactly the households in the communities in which the adults are suffering the most serious consequences in highest incidents of covid nineteen infection. So I think that children really very much are reflective of that. So interesting statistic when you look at it, I know from the adult side, we certainly see in that population, there's a lot of multifamily housing multiple families living under one roof and that sort of social crowding a seems to have an impact but also of those people who are not financially immune. So to speak from the virus in that, they must go to work every day to feed their family. You can't be you know a day laborer and do. It via zoom, you actually need to show up in in any time. There is that expectation. There's not going to be a lot of social distancing at the workplace in. So we think that lower socioeconomic in general would be forced to continue their work in their jobs. In spite of the fact that the risks remain the same and the statistic is not percentages of people who get the virus it is a death toll of people who have the virus. So, is it biological that affects them differently or lifestyle or food or? Those are all definitely hypotheses that still frankly require investigation and I think that there may even be a multifactorial. For it. That is along the lines of what Stephen was mentioning is a difference in access to healthcare for these affected populations as well. It certainly is possible that there may be a biological explanation, our hospital in coalition with. The other hospitals are studying the genetics of children who are impacted by either severe ovid infection or by MISC but there isn't anything clearly being born out yet in terms of solid genetic reasons that make me immune response to these affected populations different. Necessarily, there's still some work to be done there. But as you suggested to bill the underlying potential complicating factors that might be called co morbidity in some are also higher in these populations and make them at higher risk in more susceptible to more severe sequentially of this infection. So this isn't new that we need. To find thousands of healthy people who are willing to take part in a trial for a vaccine, you're not vaccinating the people who are already sick crate. So there must be a history of being able to find people who are willing to participate in such a thing of go about finding these people. It's varied historically in terms of what the vaccine was being designed to prevent in terms of how dire the infection was and how much population was affected by a given infection but historically, some infections that especially the ones that were devastating to families and children. Families were very eager to participate in vaccine trials and bring those vaccines into children whether there was a monetary compensation that was offered or not. So I think that there will be families that are eager who be part of these trials I was surprised in our own front we're running a large trial Boston children's trying to enroll children who've had covid nineteen, and we're asking these families to bring their children. Back, our hospital for blood draws that they don't otherwise need and I really having done a number of clinical trials that involved research only blood draws was not sure that this was going to be an easy sell for families but I've been very surprised by how eager families are to contribute to the advancement of our knowledge of this infection and the response of families to enroll in study has been really amazing. What do you think the penetration of this anti vaccine sentiment is out there what percentage of the families that you are in contact with you feel are anti vaccine once we have a vaccine, what percentage of the population will accept it or looking at the other way will not accept it. Yeah. So I think it made me a little bit in terms of how unique to a CO vaccine and how that applies to a sort of anti vaccine population in general by reading that polls most recently about Kobe vaccine uptake are suggesting that it's only about sixty percent of the population that sound like. They are willing to go forward with vaccination, and that's even if one frankly is determined to be safe and effective in some of these larger trials which is concerning. So I think it's really going to depend on how data from these trials look for the public to be able to make informed decisions at that. What do you think about the theory that New York and Massachusetts because of housing being a little more crowded that there's a higher viral load that lends itself to a higher mortality as opposed to maybe a lighter viral load more of an outdoor lighter load causing a less severe disease. Yet that that may be part of it I think the other factor that started supports that Stephen is that the communities in Massachusetts that were hit the hardest when we were surging tended to be communities that were exactly those that you described dense housing multi generational homes so I think that is certainly a likely in the fatality rate in the severity rate that you just have this higher. Of individuals a higher concentration, potentially a virus and when a person is getting infected with a higher viral burden, they will have a more severe infection that being said, are you going to restaurants and if so only outdoor restaurants? Assuming that none that opened or that may be minimal that are open for indoor seating what has been your personal policy. Yeah. Massachusetts has opened indoor seating at limited capacity with lots of risk mitigation practices in place that being said I am still only doing outdoor seating me too I think the study that came out that showed it was like a two and a half higher likelihood for individuals to have dined in in the fourteen days before their cove infection. Exactly. So we're GONNA take a very quick break and we'll be back with Dr Kristen Moffitt. And when we come back, we're going to talk to her a little bit about the concept of surfaces and whether they're a danger, we'll be right back. A moment of your time. A new podcast from commedia media. Currently twenty one years old and today I like magic extended from her fingertips down to the. Era of yourself because the world needs you and every do gutter that asked about me was ready to spit on my drinks. Seniors were facing feel like your purpose in your worth is really being stopped me from. Piano. She buys walkie-talkies wonders to whom she should give the second. Love humans we never did we never will. We just find one rock climbing is that you can only focus on right now. And so are American life begins. We may need to stay apart, but let's create together available on all podcast platforms. Submit your piece at Kirk O' Dot Com, slash a moment of your time. So we're back did with Dr Kristen mop it and Dr Steven Tailback. Christie. Wonder if you would tell us whether I should still be alcohol wiping down all my groceries and for the male let's dropped off and when this first happened I was pretty relentless and if someone approached front door pretty much sprayed them down with alcohol, which has been your lifelong policy anyway as. Well it it has. It has this thing has worked its way into a Germaphobe heart but I have to ask you is the concept of surface transmission. No. Longer a concern is it just breathing in droplet? Where do we stand on it? Yeah I I, wouldn't say zero concern I. Think it has become abundantly clear that the overwhelming majority of transmission events occurring through the air it is. Still conceivable that if somebody who was had a high viral burden. So the day of symptom onset, for example, in they had just sneezed on a doorknob and you went and touch that doorknob within minutes afterwards and then went and touched your nose, your mouth, your eyes, you could infect yourself that way. But I think short of those kinds of extreme circumstances transmission through contaminated surfaces does seem less. I think you know decontaminating the now not sure that's necessarily needed. Although I will recant the story of my my cousin, who's a economic professor in New York when cove I broke out there he was at the grocery store and witness somebody sneezing into their hands and then picked up an apple looked at the apple and put it back in the pile of apples and he was calling me and saying, should I eat fruit again or not? I think washing our fruit anything that's not already in a package. You know any any fruit where you're where you're eating the skin I think washing it makes sense but I would have said that pre-cold said so. So, let's go back to our kids I'm sure we have lots of listeners who have kids that are going to school now because it seems like a lot of our country has invited the very young kids like preschool kids to come in and experienced school in these small pods. Students or what have you, where some of the older kids are now dealing with the online thing but you can't do that with the very youngest kid. So with the very young kids, what is your advice to parents for how they explain what's going on to their kids and tell them? Yes you have to wear pants and you also have to wear a mask. Yeah. Yeah. I think it's a real challenge. I think for parents to keep the conversations age appropriate and what that means really is to have conversations with them that they can understand that aren't scary to them and it's possible to do that and at the Same time make them feel empowered like they're contributing to being a part of the solution for this. So framing things in terms of these are the things we have to do to keep our friends safe to keep our teacher safe and so that your family stay safe. So you stay safe framing it in terms of these are the things that doctors are doing to keep themselves safe when they're taking care of patients and so you can do this to and be just like a doctor and helping someone to keep other people from getting sick any techniques for the post adolescents and beyond even the eighteen to twenty five set. To be take the perspective that it really is not going to affect me, and this is my time to enjoy my life and what to take my chances without really taking into account the impact that they're having another people. I think the message needs to change and the message then needs to hit the motivation that age group is motivated. They are just inherently wired to want to be with their peers to want to congregate to want to. They want to be able to go to their sports they WANNA be able to go to whatever it is. They do for extracurricular activities, their theater group. They WANNA be in classrooms on campuses with there. Here's. So the message there is if you can't do these things collectively to he transmission under control, none of those things are going to be available to you. Campuses are going to close classrooms are gonNA close basketball teams aren't going to be able to play. So getting out the motivation and really trying to target the messaging there is going to be more impactful with that age group. So speaking of that age group I understand that there's a terrible vaping problem and I understand that while vaping is never recommended under any circumstances. Apparently, it's causing teens and young adults additional risks of contracting covert. Why would that be? Yeah. I think that there are probably changes that happen in the cells that line the respiratory track from chronic exposure to some substances that people are vaping. It may not even be necessarily what they're intending debate maybe an additive that they don't even know as there that can be having a serious impact on the cells that line their airway in terms of the effectiveness of their response to this virus. We certainly see that in in our adults pulmonary population but I've I've seen it in, you know in adolescence and. Not just a high school college problem, but this is a middle school and even grammar school. Decker Steve Does vaping in general reduce your immunity. It increases your risk of pulmonary infections because you're remain protective source is going to be the respiratory epithelium. This will call seeded epithelium, which actually has these finger like projections that beat out and beat up word any particulate matter that come into your respiratory tree and if you're gonNA do damage to that primary mechanism yet will lend itself to having ongoing and worsening lung injury. It lends itself to increase respiratory infections you want to avoid vaping at all costs. Doctor Moffett can I just ask you when you picture someone smoking and they exhale the smoke is that kind of a good representation of what these droplets could be doing when someone is simply well. Blowing out in that kind of form in your space. Yeah. I think that the active excavation from vaping or smoking is probably a bit more forceful than are just sort of sitting here inhaling and exhaling, and if you want to see really amazing pictures of droplets, respiratory droplets, there are some researchers in fluid dynamics that have taken these like unbelievably slowed down time lapse photographs of sneezes. For example, if you haven't seen them that are enough to make, you absolutely want to live in a bubble. So Dr Mufid I wonder if you could tell me, do you expect there to be a different type of covid season this fall in Massachusetts, compared to California and Florida from weather standpoint I think that the impact of the weather on this virus does not seem to be very impressive. I mean if you look at the parts of our country that were surging when it was warm and we were in better control in places where it was cooler, I think it's really hard to say there may be a modest impact in terms of the virus actually having specific viral characteristics that make it may be more likely to cause infections in the cold weather but I think it's going to be more social determinants of cold weather that are. Going to put those parts of the country where we get cold weather at higher risks, we're starting to hear more and more about the viral load and how if somebody sneezes in your face and you get a large viral load, you might get a bad case of the disease on the other hand. This virus is very small and I know there's no such thing as just one or two. But let's say you got one or two viral cells. Are you still going to build up an antibody to the disease if you get a very small load? A great question it's actively being studied because it's such an important question and I think it still may be a little too early to say for sure. But there are data already that suggests that if you had a relatively mild infection, you don't mount at least the same antibody response that those with more severe infection. So those who get very sick from this infection seemed to have what's called neutralizing antibody with really the most important type of antibody to measure you, WanNa know how capable antibodies detectable in a person's blood after they've had this infection capable it is of actually neutralizing this virus in a petri dish and it does seem that those who had milder asymptomatic infection have. Much, lower levels of that neutralizing antibody in their blood levels that don't seem to last as long. Okay. Well, we're going to take another quick break and we'll be right back with Dr Moffitt and we're going to talk about long haulers the folks that get this virus and it appears that they have it for a very, very long term we'll be right back. Welcome to life done better listen to the weekly episodes where supermodel and health coach Jill young talks to some of the world's most inspiring women in health and wellness. It's the place for all the UNICORNS who strive to create a life on their own terms join us to explore, discover and create a life done better together. Listen and subscribe from Kurt Co Media Media for your mind. What we're back with Dr Moffitt and Dr Steven, tailback and. There's this kind of new term being thrown around long haulers people who've suffered from covid nineteen and do so chronically for long periods of time wizard reason why some have such long standing symptoms and even when they're healthier than others who should by all rights the more at risk you have these long haul can't seem to get rid of the virus ways that I think from the adult side what we see and it's it's variable because there are some people who seem to smolder along and get better, and then we do see that period of time of people smoldering along, and then they hit a critical time in day seven today nine. The. Completely compensate and they wind up going to our ICU and on many times on ventilators. It's rare that we find somebody who actually gets better almost completely resolved and then D. compensates it's not been my experience. If you're smoldering, you're on low level oxygen and you seem to be holding your own, they can deteriorate in that magic window of seven to nine days. One concern is that your? Body is doing its best to keep the virus at bay on because you do mount a response in maybe initially, you can keep the virus at bay and then with any war from the virus that starts mounting a stronger and stronger response, and then just overwhelms your ability to completely defend against it, and now you're feeling the brunt of it getting the better of you at least at that time. Kristie, what are your thoughts about that? Yeah. I think that there's been a lot of debate in the pediatric worlds because we were. So surprised by this semi Sei entity, this multi system inflammatory syndrome in children that seems pretty clearly to occur about two to four weeks after an acute cove infection, and frankly in the majority of children who've experienced MISC, their acute infection was very mild and sometimes even as symptomatic. So we are often relying to figure out whether or not a patient. Is Experiencing MISC, they present with symptoms of fever and overwhelming inflammation. So they're hyper inflamed in that inflammation is affecting their body in different ways, but there are a number of other entities. That can look like that as well. So we're relying on whether or not. They still have a positive piece tr for covid in their upper airway or whether or not. They've mounted antibody response yet took Ovid, what is the age range where that tends to hit yet? So the the median age is about ten to eleven, but it is being seen in some older teenagers and young adults and it is being seen in some even down into infancy. Christie one of the things that were apparently supposed to avoid if our kids get covid is giving them aspirin. Why is that? So Aspirin in the setting of specific infections in general, a handful of viral infections in general children has been associated with a very, very serious condition called Rice Syndrome that can severely impact a lot of your vital organs. So Aspirin in general is not recommended in children if children are experiencing fever from possible infection or discomfort otherwise than either AGRIPPA or Acetaminophen products would be recommended. Also understand for adults. Ibuprofen is not a good idea as compared to other types of Anti inflammatories. So initially, it was off the list now that I don't believe that there's any warning against non steroidal in the adult population, we tend to use tylenol for fever Bateman and for pain control just because it's easier on the kidneys and it's easier on. The stomach provided, you're not getting to the point where you're getting to liver toxicity, but it's much easier to damage your kidneys with a non steroidal anti inflammatory like Ibuprofen than it is to hurt deliver with Tylenol Mifflin thoughts about that on the pediatric side in general in Pediatrics for for pain. Ibuprofen, if you're over the age of six months, Ibuprofen has. Recommended just tends to be very effective particularly for fever reduction and as long as it's correctly in knock into higher dose or given to frequently children in particular tolerate it very well but acetaminophen products would certainly be an option to. So, I wonder if we could take a little detour here and talk to you about reinfection and what we know because when would think this has now been going on since March we're now in October I wonder if you could tell us if we know anything more about whether people are getting this virus for a second time, there was a lot of alarm thing with the first clearly documented case of reinfection. So the the trick to documenting reinfection is that you really can't rely on just continued positive are testing because some people stay positive for a very long. Time from their primary infection. So the first documented cases reinfection occurred in individual in Asia who was infected. I if I recall initially April march or April return from traveling sometime in the last month or so and only had a repeat Cova test as a travel screen for from having been elsewhere and tested positive but was a dramatic but they actually were able to sequence the virus from the first test compared to the second test to confirm that it was a different viral sequence in there for this was indeed reinfection is the virus mutating that much at this point. It's not that the virus mutating much but there were detectable enough different says to ascertain it was two different viral infections basically, and then the big question is was the primary infection that confer immunity on the second because you can reinfect me all day. Long if I don't have symptoms I'm probably not GONNA BE UPSET? About that. So I think with with that first case report, I think that scientists were relieved actually and said, well, of course he was. With the second infection in that just proves what we would suspect which is that the first infection confers immunity against getting very sick from this if you see it again but of course, not too long after that, there was the second case report of reinfection in which again, because of two different viral sequences they will confirm it was indeed reinfection in the individual actually was. Sick with the second infection, so everyone will meet. He took a little bit of reassurance from the first case report that was quickly gone away with the second case report but I think in general infections. It's not surprising now that we have millions and millions and millions of cases that we will see reinfection 's from seasonal coronavirus experience we know that even if you get. Some immunity from seasonal coronavirus its longevity is not such that reinfection is an impossibility but encouraging that it seems to be very low rates because I know I have not seen any patients came in at least at the hospital that had to be readmitted within would seem to be a new infection. So Christie if your best friend comes down with Cova and isn't bad enough. Yet, to check themselves into the hospital but this is your best friend, and now we have all these treatments like rim, de Severe and otherwise to Roydon and what have you do you recommend to your best friend that they begin a regimen to try to minimize the virus or do you wait for it to get so bad that they have to go to the hospital At this point, there's really nothing that has solid evidence to suggest taking it when you're only mildly ill is going to really have an impact on your outcome. So at this point, my recommendation would still be if you're feeling crummy, but you're still able enough to be at home that continued what's referred to as supportive care, which is hydration fever control making yourself comfortable would be my recommended if I for that individual. But if they're starting to feel shortness of breath chest pain, any of the myriad of symptoms should prompt a very, very urgent evaluation. Any patient that would come to the adult floor who is not requiring oxygen or Hadlow a mediator levels, low fat and low CRP things that we for better or worse we are monitoring. We will be sending those patients home. Doctor Moffett ice sat around with family the other day, and we were drinking some wine and I said, you know I can't taste this wine and of course, everybody laughs and said. Why. Is it that supposedly one of the symptoms of having covert is loss of taste. I have been reading headlines about some clear impacts of the virus directly on your olfactory cells in particular, which are basically our sense of smell cells, and our sense of smell is so innately linked to our sense of taste that whatever it is that the virus is seeming to target in our mel cells seems to be having this rather unique symptom I'm asked often, how are we going to tell the difference between flu and Kobe Nineteen? How are we gonNA tell the difference between other winter respiratory viruses in covid nineteen and My short answer is we're not there is so much overlap in the symptoms of influenza in. Kobe. Nineteen that it will be nearly impossible to distinguish the two based on symptoms alone with the exception of someone may be having lost their sense of taste or smell which seems pretty unique to covid nineteen. Do you expect that we're going to get some good news about treatments or vaccines over the course of the next six months or should we be digging in and assume that we just have to get used to this while? I think we will be getting good news. I. Don't know that I would assume that in that timeframe, it's going to be associated with a confidence that we can lighten up on what we're already doing but I think we will get good news I. Think the best part of the vaccine landscape is that there are over two hundred vaccine candidates in development over half a dozen in which have already advanced into retrials, and so the best vaccine outcome and I think even the vaccine makers would say this the best vaccine outcome is that there are multiple Kobe, nineteen vaccines that are shown to be safe and effective and therefore. You could move several into populations yet our world vaccinated more quickly than if there was just a single contender that came out on top, for example, that showed to be safe and effective that's the silver lining in many ways right to the global nature. This means that we're so many resources are being mobilized in being brought to bear this. The says it's not a an orphan illness. It's something that affects every country. Every person that I think is very encouraging and do you expect countries to export their vaccines to other countries in that event or just pass on the technology and the biochemical solutions that led to that vaccine? I think a lot of those discussions have already even happened in terms of how the vaccine development got funded. So a lot of the funding that was offered to support development of the vaccine was. Upon access in different populations in different nations. So I, think a lot of ways in which the vaccines will be distributed by the different vaccine makers is already baked into the cake in economic forces for free economies I think pushed in that direction as well. Right I mean it's better for the economy. It's better for that corporation to sell it to multiple countries. Why would they limit it? So I think in that regard, economics actually works and everybody's favor. So as we wrap up, I just want to ask you one question about Harvard in how you teach there what will be permanently changed in the way you communicate and what you communicate to your students from this experience with covert nineteen. I think personally for me as an infectious diseases physician. But I, think most physicians in general in all fields. Say This right now is that there has never been in my lifetime as humbling a public health events a public health crisis as cove nineteen I. Think of the Times in March when we were watching this sort of March, its way from China I think I personally still had some sense that we were. Going to fair okay that we would certainly see this virus come our way. We would see it start to circulate in the United States but that we would be able to keep it from becoming as unbelievably rampant as it has become and I think that I never could have expected in. So many people I think in infectious diseases in medicine in general never could've expected just how unbelievably destructive this pandemic could have been. So you may inject humility into your teachings at Harvard. Going forward. I think that this panic really struck a tone of just how much we don't have control over things that happen naturally and even when they're infectious, it's really been astonishing. Dr Kristen MOFFITT. Thank you for joining us today. We WanNa thank Dr, Steven Tailback Dr Kristen Moffitt and we WANNA. Thank J. P. Morgan Private Bank for introducing us to today's guest as well as last week Stocker George. Rutherford. So thanks Jamie. This is medicine we're still practicing and it produced by Moseley Music for we're still practicing composed and performed by Celeste and Eric Dick. Please send this episode to your friends and have a socially distant zoom cocktail with them and chat about it, and of course, don't forget to leave us a review. Catch you next time on medicine we're still practicing. By by everybody. down. Room Kirk. Oh media. Media for. Your. mind.