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Bill Klaproth (Host):  So, we are in the midst of a global pandemic that has been lifechanging for all of us but what happens next? Le Bonheur Children’s Hospital Pediatrician and Chief and Chief Operating Officer of the College of Medicine at the University of Tennessee Health Science Center, Dr. Jon McCullers who is an expert on pandemics and specializes in flu research is here with us to talk about the Novel Coronavirus outbreak and what we can expect in the weeks, months and even years moving forward.

This is the Peds Pod by Le Bonheur Children’s Hospital. I’m Bill Klaproth. Dr. McCullers, thank you so much for your time. So, we’re now in the midst of this outbreak and have been told to do things like stay at home, social distance, wear masks if we have to go out in public and really do whatever we can to stop the spread. Why is all of this important?

Jon McCullers, MD (Guest):  Well this is very a dangerous virus as we’ve seen with the worldwide spread and with the relatively high mortality rate that has been shown up here in the United States as well as in other countries. So, it’s something that we want to be able to control and try to restrict as much as possible. The social distancing measures we are putting in are really an effort to slow down the transmission of the virus and hopefully eliminate in many cases the transmission of the virus at least locally.

Host:  So, from what you’re seeing, are these measures working?

Dr. McCullers:  Well here in Memphis and in the mid-south region, we are starting to see a flattening of our case curve. Initially when this epidemic started in Memphis, we were seeing a doubling of the number of cases about every three days. About two weeks ago, this was about every five days we’d see a doubling in the cases and right now it’s about every nine days. So, it’s clearly, although we continue to see new cases, it’s clearly slowing down the rate of the new cases.

Host:  And that is really good news. So, looking ahead, what else do you think we need to do now to prevent issues later such as investments in public health and things like that, so we are really more prepared if we get a second wave this summer or fall?

Dr. McCullers:  Yeah, the biggest issues that we see right now are number one, testing. We have to be able to test very, very broadly across the population. We have to be able to test every single person when they are first symptomatic, and we have to get the test results back very quickly which is almost as important as being able to test very broadly. We can’t act on the test results if they are not coming back within a day or so after we send them.

The second thing is we need a very large public health response. We need to be able to not just identify patients but do contact tracing and then isolate or quarantine contacts to try to limit the spread as much as possible. And then I think the other piece that we’re doing right now here to try to prepare for the second wave or for future waves is developing tests for antibodies so we can determine how many people are immune and kind of certify those people as being immune so that they can take on tasks in society, maybe frontline healthcare worker jobs or so on without so much fear of the virus.

Host:  Yeah, all of that really makes sense. So, tests and not only the ability to test but get those test results back quickly, then you also said make sure we have a really strong public health response and then we need to understand who is positive right away so we can quarantine those positives if you will and then as we look ahead, test for antibodies as well to protect against another wave. So, if we do have multiple waves of this disease, since you brought up waves; what do you think is the best way to handle that besides the tests for antibodies?

Dr. McCullers:  Well, we’ve been able to control the first wave in some locales, like I think in Memphis but certainly some countries such as Singapore and South Korea and Iceland have done a good job with this by social distancing measures, by this intense testing and this intense public health tracing. In order to kind of dampen or eliminate second wave, third wave, subsequent waves, I think we need to continue with a subset of those strategies. We have to be able to test. We have to be able to test rapidly. We have to be able to do our public health tracing and isolation and quarantine. And we’re going to have to continue at some level to do social distancing. So, this idea of trying not to come into physical contact with people, don’t shake hands anymore, stay six feet apart when you are in public and avoiding mass gatherings of 50 people or more, I think is going to stay with us for the next couple of years until we are able to do a vaccine.

It's out hope that we’re going to be able to relax some of the more stringent measures like closing businesses and closing schools and be able to maintain more or a normal society with the virus still circulating in future waves, but I think that’s the strategy.

Host:  So I was just going to ask you in your expert opinion, how long is this going to last? So, long range you say about two years, is that right?

Dr. McCullers:  Yeah, it depends a little bit on whether we are able to develop an effective vaccine or effective therapeutics for this. the time horizon I see if that’s possible is that we ought to have that in about two years and then a vaccine would then be able to control the spread of the virus enough that we could get back to normal. I think very effective therapeutics might have a similar course. If we are unable to do those and it’s very possible that we can’t develop a vaccine or at least can’t develop one quickly; then you would think it would be two to three years before we would have enough herd immunity in the population. And of course, we’re altering the course of development of herd immunity right now by these mitigation measures to prevent the spread. Two years would be a typical timeframe to develop herd immunity if we just let a virus burn through the population. But if we keep up with these mitigation measures it might take a lot longer.

Host:  I think it’s important what you just said. I think we all need to in our minds, understand this is going to be a long fight. We’ve heard other health experts say this isn’t like a light switch in June everything is back to normal. So, what do you think our new normal in the interim, the next three to six months, what do you think that looks like?

Dr. McCullers:  Yes, I think after the first wave comes through and we start to open things back up, the new normal is going to show us, we are going to have businesses open, but they are going to be opened with modified rules where people again, are still practicing social distancing in the businesses, are not congregating together, are not having physical contact. Certain businesses might be disrupted where there is physical contact required such as the massage industry, the tattoo industry, those may need even further modification. We are going to have trouble getting schools back in session, because when you have all these kids go back to school, and maybe the virus starts to be spread in schools and be brought back to the home; we may have some starts and stops if we have outbreaks related to the schools.

We’re going to have to stop having mass gatherings entirely for the next two years and this is one of the biggest things that people are a little bit in disbelief about the idea that we can’t have large church services with people crammed together in the pews together. We can’t have concerts. We can’t have sporting events with spectators. I think those are going to be the really difficult adjustments so say those things we are so used to are going to have to be on hold for a couple of years or are going to have to be done in a modified fashion maybe using streaming technologies and so on.

Host:  So, right about that. I can’t imagine going to a sporting event or a music concert and being around 15,000 other people right now. I just can’t imagine that. So, let’s talk about treatment. We’re hearing a lot about experimental drugs and other treatments. What are your thoughts on the research being done and give us your thoughts on the timeline for a vaccine.

Dr. McCullers:  I’d say 18 to 24 months would be an optimistic scenario for a vaccine. For drugs, we have a few drugs that are already out there right now that are being repurposed and are being studied around whether they might have some impact on the virus. One of these is the hydroxychloroquine we’ve heard so much about from the president. There’s a couple of drugs that are used against other viruses that might can be repurposed here. I don’t have a lot of optimism about any of those current drugs that are being repurposed. Now, the hydroxychloroquine in particular, it’s very clear that that’s not going to be one of the answers for us. That drug’s been tried against every virus the last 30 years and is not effective in humans or even in animal models. It’s only effective in a test tube in a laboratory. So, I don’t see that as being anything important.

The other ones may have some more promise. They need to be tested. They need to be rigorously evaluated in controlled trials but again, I don’t have a lot of optimism around that. The pharmaceutical companies though are bringing through new drugs and will be starting to do studies with experimental therapeutics, and I think there’s some chance that some of those that are really designed against coronaviruses will have some efficacy but that’s going to be a couple of years. it will be probably two or three years before we are able to go through all the testing and hit on a drug like that which may have some utility.

Host:  Do you think until that point over the next several months maybe by fall, we’ll at least have a course of treatment on okay here’s what we have to do first, here’s what we have to do second with what we have available?

Dr. McCullers:  I think the only thing to me that we might be able to get into the pipeline and have some sort of algorithm for use is convalescent plasma therapy. So, this is when somebody’s had the infection, they’ve recovered, they now have antibodies against the virus that are protective against the virus, can we draw blood from them, can we isolate out the part of the blood that contains those antibodies and infuse it into someone else and help them recover from the virus. This is being done here in Memphis and a lot of other places around the country. We’re not sure how effective it is. It’s effective against some other diseases like this was a treatment for Ebola for instance and it probably will be effective in some situations with the Novel Coronavirus. Probably early in the disease is best after you get organ dysfunction or the cytokine storm, we see it probably isn’t going to be very effective.

But that’s the only thing that I see that we’re going to be using in the near term that’s going to have any likelihood of impacting the course of the pandemic.

Host:  Right and that is very promising what’s happening. So, certainly a story to watch. So, speaking of your said research happening there. What kind of research and innovation is happening in Memphis and at Le Bonheur as a result of the outbreak?

Dr. McCullers:  So, the University of Tennessee Health Science Center has a very active Coronavirus research program here. We have one of about a dozen or so regional biocontainment laboratories here in Memphis at UTHSC. These are special high containment laboratories that are designed to study viruses like this that were put into place about two decades ago by the NIH for precisely this reason. So, we’ve been studying the Novel Coronavirus for several months and in particular, are screening a large library of potential drugs against it to try to find new drugs that could be used as therapeutics. So, a lot of research there. We have a lot of research that’s around kind of what’s the effectiveness of a number of these measures that we’re doing such as the convalescent plasma therapy. We have research around what’s the impact. What’s the impact of shutting down a lot of our health care services on our patients. If you have diabetes and now you are not able to see your doctor because we’re cutting all these visits off. What does that do to impact your health? Those are some of the things that we’re interested in looking at here at Le Bonheur and around the UT system.

Host:  So, we know there are people that are asymptomatic to this and some people who seem to be immune. Can we test for that to help understand what’s going on there?

Dr. McCullers:  Well I wouldn’t necessarily say that they are immune to the virus. They are still going to catch the virus. As far as you are still going to infect them and go through it’s normal processes, but some people seem to not have as much symptoms with it or to have no symptoms with it at all. This is true for most viruses. If we take something like influenza, something like 15 to 18% of persons who contract influenza don’t have any symptoms and so there’s just a spectrum from no symptoms to very severe symptoms that probably is tied into our genetics, also tied into what are some of our health conditions or comorbidities and then maybe tied into how big was the original dose of the virus we got and so how rapidly was it able to spread within us.

The estimates right now for the Novel Coronavirus, are kind of all over the map. We’ve heard it might be kind of like influenza where 15 or 20% are asymptomatic. We’ve had some people suggest maybe 80 or 85% are asymptomatic. There’s some studies that are being done right now including one published from Iceland yesterday that suggested maybe at the lower end when they surveyed about 9000 people across Iceland, just kind of randomly and they found only about a half a percent or so had the virus which would imply a fairly reasonably low level of disease out there in the normal asymptomatic population.

Host:  Yeah, when you say it’s all over the map, that certainly is the case. So, even at this point, in the Coronavirus pandemic, are there any big takeaways or lessons that we’ve learned from the outbreak that you think maybe we can use to make positive changes?

Dr. McCullers:  Yeah, the biggest takeaway for me is we’ve clearly shown that we were not prepared for this pandemic. We went through a big exercise about 20 years ago when we were worried about bird flu, you know the avian influenza outbreak and we got the country prepared I think for a bird flu pandemic. It didn’t come and we’ve really let our guard down over the last 10 years or so where we clearly just weren’t prepared for this. So, lesson number one is we need to increase our preparedness for when this happens again because it is going to happen again.

The second issue is it’s really exposing flaws in our healthcare system. Flaws we knew were there, we don’t have universal healthcare coverage, we know that those who are poor and underserved and in Memphis, particularly that is our African American population are not benefiting from the healthcare system the way they should and when something like this strikes, those inequities become very obvious because that’s who is getting sick, that’s who is having worse outcomes because they already have existing chronic disease. So, we have to fix that, and we have to have an increased emphasis on public health, on prevention, on primary care and everyone having access to those.

Host:  Well is we can learn those lessons and apply them, then we will be better prepared for the next time this happens and at least something positive will have come out of this. And then last question Dr. McCullers and thank you so much for your time. What message do you have for parents who are worried about their children and worried about the length of time it’s going to take to get back to normal? How can we best cope with the news that it might take years as you’ve mentioned?

Dr. McCullers:  Well, for parents I would say, first of all, kids are resilient. They’re going to get through this okay. I think we as parents, need to just have a steady hand and a level head on this and use common sense and say this is what it’s like be forthright with the kids. It’s going to be a while but we’re going to adapt, we’re going to get through it, you’re going to be fine is the approach we need to take. We know this is going to disrupt school, it’s clearly disrupting it’s year at the end of the school year and will probably disrupt it throughout the school year next year as we have some openings and closings and maybe have to modify the way we deliver curriculum. So, there’s going to be a bumpy road ahead I think for kids, but kids are resilient. We just have to be honest and upfront with them and tell them how it is and provide them the support that they need, and I think we’ll be fine.

Host:  Yeah, that’s a great point. Honest and upfront and then just help them through the process as we’re all going through the process as well. Dr. McCullers, this has been really informative and insightful. Thank you so much for your time.

Dr. McCullers:  You’re very welcome.

Host:  That’s Dr. Jon McCullers, Pediatrician in Chief at Le Bonheurs children’s Hospital.  And if you want to learn more, please visit www.lebonheur.org/podcasts and be sure to subscribe to the Peds Pod in Apple Podcasts, Google Play or wherever you listen to your podcasts. You can also check out www.lebonheur.org/podcasts to view our full podcast library. And if you found this podcast helpful, we ask that you please share it on your social channels. This is the Peds Pod by Le Bonheur Children’s Hospital. Thanks for listening.