AUSTIN, Texas — With misinformation and fear surrounding coronavirus, KVUE Senior Reporter Tony Plohetski sat down with Dr. James Evans, an infectious disease specialist with St. David's HealthCare, to discuss the possibility of an outbreak in the city and best practices for self-care and prevention.
Tony Plohetski: "I want to give people a little bit of context for our conversation this morning. Obviously, coronavirus and COVID-19 have been a huge part of the conversation nationally, worldwide, even here in Austin. We're gonna try to keep this conversation really about the Austin community, about preparation and education. Obviously, I think many health care officials believe it is inevitable that we are going to get our first case of the virus. But Dr. Evans, I do want to start with just kind of as an underlay for all of that. Can you just bring us up to date on what we know as a world about the coronavirus and COVID-19?"
Dr. James Evans: "Yeah, I think that would set the stage for local really well, fundamentally COVID-19 is a new strain of coronavirus. Coronaviruses have been around forever. They infect all sorts of different species. There are four human coronaviruses that circulate regularly and account for about 15 to 20 percent of common colds. So those are the coronaviruses that we've seen. What's different is this coronavirus emerged from a different animal. So the human population has never seen it. We have no personal or community immunity to it. So literally, everyone is vulnerable to getting this infection. And that's different than when the other strains are moving through and the majority of the population have already seen them. So it's hard for those strains to ever create epidemic thresholds because they are stopped by so many people that have immunity, and that really ends up explaining why certain populations have such a difficult time, namely the elderly and those who are sick. They don't bring any immunity to the table and their own immune systems, not as strong as it once was. The other issue is basically COVID-19 is here to stay. So, part of what was tricky early on in the epidemic was we were comparing it to SARS and MERS, and honestly, those epidemic strains petered out. They weren't able to maintain sustained transmission. This one clearly has we know it's got staying power. It's coming, it's here, and at this stage, we've seen that it moves through populations basically as efficiently as flu does. That doesn't mean everybody gets it, but it means everybody that has an adequate exposure or inoculate is going to get an infection, just a varying severity. The other thing is we know exactly how it's spread. So there's nothing novel about how it's spread. It's a respiratory virus, and like all respiratory viruses, basically, they're shed in the respiratory secretions, typically expelled as droplets. What people often miss is most times that means surfaces get contaminated. I mean, unless someone coughs in my face, those droplets are landing on surfaces or landing on hands, ending up on common surfaces. I touch that surface, then I have to touch myself. I have to inoculate my eyes or my nose. So, you know, the problem is the way we humans enjoy being with each other, handshakes, being in common spaces, having that time is actually a perfect medium for spread from this virus, but nothing magical about its spread."
Tony Plohetski: "And it may seem like common sense, but just to reiterate, you may be exposed to the virus or someone who has the virus, but that does not necessarily mean you're going to get the virus?"
Dr. James Evans: "Exactly. In order to get any infection, you have to have an adequate inoculate of that organism, and that has everything to do with distance. So if our cameraman sneezed over there, literally, that would pose no risk to me. About a six foot diameter around me if I was to sneeze, the droplets are not sustained airborne. So unlike, say, measles or chickenpox, which many of our viewers will remember, you're probably too young, but those were airborne infections. You come in the room, if it's there, you would get it. This is not like that. It's droplet, you know, transmission with limited diameter and almost, you know, mostly surfaces in shared spaces and handshakes."
Tony Plohetski: "I want to talk about where we are as an Austin, Central Texas community. As of this morning, there have been no reported cases of Coronavirus, COVID-19, in Austin or in Central Texas, for that matter. Authorities will tell you that they believe that it is inevitable that we will begin seeing our first cases. But, that does give us a continued window here in this community to become educated and to get prepared. So, I do want to ask if you are a healthy person living in this community today, what should you be doing right now?"
Dr. James Evans: "So honestly, the whole goal right now is to mitigate spread, that term mitigation is out there, but basically we need to control the spread, the rate at which the virus moves through any community. One, to protect those at greatest risk, two just to minimize the impact on the local community of many people being sick at once and three, honestly, to maintain the integrity of our health care systems. So for a healthy person here in Austin, it's basically go about your daily business at the moment, very informed, knowing exactly how to protect yourself, and implementing those precautions in a really disciplined way. And honestly, that's the tricky bit, I think, is being disciplined about it. So I'm going to rag on you here."
Tony Plohetski: "I was going to bring that up. I mean, the first thing I did when I saw you this morning, which we had never met before, I extended my hand for a handshake."
Dr. James Evans: "Yeah, exactly, and that's literally muscle memory. That's how we like to be with each other is to have that sort of touching communication. For those of us in the health care industry, we've been practicing infection control in the hospital for years. I've been doing infectious disease for 25 years, and I can honestly say I've never contracted an infection from a patient that I've cared for. But it's because of those processes of appropriate infection control work and we're used to doing them, but of course, the general public's not. So, literally, if people can kind of keep in mind that stay away from those who are sick, a good six foot barrier, particularly in hardworking communities like every community in United States, people tend to go to work sick, and that's not acceptable in this setting. People need to stay home. They need to take care of themselves and mostly protect their neighbors. But when we're in common spaces, we need to be really thoughtful that they are potentially contaminated. Wash our hands regularly, clean our workspaces, and then, to the extent that we can, be very mindful about not touching our face. On average, humans touch their face about every three to four minutes."
Tony Plohetski: "How do those steps differ, or do they differ, or are there more things that a person should do if they are elderly or have an underlying medical condition?"
Dr. James Evans: "Yes, that's a great question, Tony. Because really, this epidemic is all about protecting the high risk individuals. So I'm older than you are, but even at my age, if I was to contract coronavirus, the likelihood of me having anything more than a frustrating flu like illness that would make me feel ill for a period of time is very small. As you probably are aware, you know, at least 80 percent of those who get the virus are going to have a mild to moderate respiratory tract infection that they'll fully recover from. But they're not really who I'm worried about, except to the extent that they're efficient transmitters to the high risk individuals. So for those who are in their 70s and older, particularly, the risk for severe complications and mortality jumps dramatically. So it's for those individuals. We need to circle the wagons around them and they need to stay in the homestead and really minimize their exposure, because that's what will tip the balance not only in morbidity and mortality, but in the strain on the local system."
Tony Plohetski: "So it's not me or you, it's our parents and grandparents, people who who do have chronic conditions or other line underlying medical problems?"
Dr. James Evans: "As far as a motivator, I want people to think about their mom, their grandma, their elderly neighbor, those people around them, and sort of take a societal pledge almost to do what we can to protect them."
Tony Plohetski: "We are all in this together and this is where a sense of community, I think is really important for people to understand. I do want to ask how doctors like yourself in the Austin community are getting information, accurate, reliable information about this virus day to day, even hour to hour?"
Dr. James Evans: "So that's actually one thing there's not a lack of. Honestly, the CDC has put together wonderful web sites that I access on a regular basis, mostly for counts, but also for travel advisories and other things. But they actually have separate, you know, web sites for providers and for people of the general public, so that there's appropriate language for each. Johns Hopkins has a wonderful web site that we all access regularly. I have access to other resources including like Infectious Disease Society of America and wonderful resources out there. Locally, we actually have great resources as well. So the DSHS, Department of State Health and Human Services, and our local public health are putting up bulletins on a daily basis. Even Austin American-Statesman, programs like yourselves, are really making this a priority and presenting it to the public. Within the health care systems, I can speak for St. David's because that's where I round, daily bulletins from the administration updating us regarding literally, 'how do we move about if somebody comes to the hospital and we need to test them?' At this point there's one phone call you have to make, and all of that is triggered in a really efficient manner. As far as infection control policies, preparedness with personal protective devices, those things have moved forward really efficiently to the credit of the local community."
Tony Plohetski: "Without getting too much in the weeds, I wanted to ask if a patient is exhibiting symptoms that are indicative of coronavirus, what literally happens? You take a sample? Is it a swab at this point?"
Dr. James Evans: "So what literally happens for everyone, if you develop symptoms that concern you, we want you to reach out to your primary care provider and let them do the initial triage. Ultimately, if they feel that you need to be tested based on some simple screening questions regarding fever, exposures, cough, respiratory stuff, then we're going to coordinate getting you in for testing. Testing is literally a swab of the nostrils and a swab of the oral pharynx or the back of the throat. Basically, those two separate ones are sent for the same test. The test actually looks for the virus itself by kind of finding its genetic information and is actually a very sensitive and specific test."
Tony Plohetski: "And they're sent to the state, the state of Texas is performing all testing in the state of Texas?"
Dr. James Evans: "So, right, as of last week, fortunately, the state labs do have the kits to do this. I think that remains a major concern. The kits are limited. They're being increased in number week by week as the people respond to having more kits available. But right now, if I was to be tested locally, it would go across, you know, just across a few streets to the state lab. And theoretically, we'd have an answer the same day or more likely the next day."
Tony Plohetski: "And then again, not to get too far into the weeds, but what happens in the event of a positive result? What does that trigger exactly?"
Dr. James Evans: "A positive result absolutely engages the local public health department and that will then result in a otherwise healthy person with a mild to moderate disease, basically being on home isolation in which they can communicate regularly with their primary care provider, and, if anything becomes untoward, present to the hospital. But for the majority of patients, it's I have a flu-like illness, I need to be in home quarantine for all intents and purposes, because at that point we've gone from sort of mitigation to containment. That's a positive case. We want it isolated. We don't want any spread from that case."
Tony Plohetski: "What about private testing? Have we seen those make it into Austin yet?
Dr. James Evans: "There are many big labs, CPL, LabCorp, Quest, others, all of whom are looking into their own production of ultimately certified testing. One of them did come online recently and was promptly overwhelmed and actually was pulled back. Having said that, all of them are capable of ramping up in a meaningful way. So I expect, personally, within the next few weeks that actually the testing piece will be far more accessible to primary care providers. If through those commercial means, hospital settings, still maybe through the state lab, but we're not really at that place. So like you were suggesting earlier, we're somewhat fortunate or downright lucky that we haven't gotten this epidemic yet here in town. We have time to ramp those things up. And I'm hopeful that that will happen in a way that allows us to test everybody that needs to be tested."
Tony Plohetski: "I did want to ask you this, you use the word lucky, I think authorities here in Austin will use the word lucky as well, I'm just curious, why do you think it is the case? How are we so fortunate that we've not had a positive case yet? Why do you think that is?"
Dr. James Evans: "I think it's a combination of honestly the initial surge, literally were people coming from the highest risk areas. So particularly Seattle, we all know got hit terribly, but just as far as influx of flights from that area at Seattle, San Francisco, L.A., were the most hard hit initially and that's sort of a surprise. Then there's a degree of just chaos theory, right, so if somebody goes to a high risk area and returns home, and home can be any number of places, but if you think even within Texas, it's Houston and you know, Houston's are gate of entry for so many flights coming from places that are international based, and that's where it started really with one individual that came from an area of high risk."
Tony Plohetski: "There is a term that is getting used a lot in the media and among officials as well. It is 'presumptive positive.' Can you explain what exactly that means? What is the difference between a true positive and a presumptive positive?"
Dr. James Evans: "So that's really just down at the level of the test. So if somebody like, for example, multiple localities have created their own testing strategy in Seattle, they didn't have access to enough kits, and the good scientists up there created their own similar test. So initially when we were calling people presumptive positive, that's a preliminary test positivity that hasn't had CDC kit test confirmation. So at this stage, with multiple different testings being done, confirmed cases are those that are confirmed by the standard test that the CDC offers. Having said that, there's tremendous, basically, consistency across those testings right now. It's not like we're seeing a lot of false positives. So I think we're all gathering a lot of confidence in the different testings that have been done. But in the end, the CDC still stands as the standard of test."
Tony Plohetski: "But the bottom line is that if you were tested and your test was sent to the state and it comes back positive, for all intents and purposes, you're positive?"
Dr. James Evans: "Exactly."
Tony Plohetski: "We do have spring break around the corner, obviously, next week. Some people have travel plans. Some people have plans to host people from other parts of the country. If a patient calls you today and says, Dr. Evans, do I take my family to Disney World or to, you know, fill in the blank destination? What would be your advice to people who right now live in a community that has no coronavirus positive testing right now?"
Dr. James Evans: "That's a very challenging question, and there's layers to that, but fundamentally, people need to step back and say, 'OK, I'm in a community that has no virus. Where am I planning to go? What is the density?' These are regional epidemics within the umbrella of the pandemic. So there are areas of the country that have a much higher density of virus and an increased risk that in common spaces you are more likely to come in contact with the virus. So step one would be: Where am I? I'm in Austin. There's no disease right now. I'm wanting to go to X space and, one, what is the status of the epidemic in that area? Two, when you talk about Disney World, I don't want to get in trouble with Disney, but the reality is you also are thinking in terms of, 'OK, how many people am I going to be coming in contact with and from what variety of locations?' So one of the challenges with a resort-type situation is that people are coming from probably all over the world. Now we know there's increasing travel restrictions that are limiting that, but then the other piece I want folks to think about is, 'OK, if I do contract the virus retreating home, what does that mean to me and my family?' Because often it's not so much that I'm worried that anything awful is going to happen to most families in the United States except the consequences (of) community spread and suddenly now they're in a 14 day quarantine, and the impact on families can actually be significant. So you think not about just the travel, but the return and the consequence of being positive. If you can put that in a context that's like, 'OK, the risk is relatively low. I know how I'm going to manage the back end if worst case scenario happens,' then I think at this stage, to the extent that we can continue to enjoy doing what we enjoy is great."
Tony Plohetski: "And I would assume, too, that you would want to consider possibly whether you're traveling by air or by car or some other means of public transportation?"
Dr. James Evans: "Absolutely. You're thinking in terms of how am I getting there? Air travel is a slightly higher risk. But even public transportation and other forms can be a slightly higher risk, and that's really all about recognizing your space, trying to kind of get it clean. I talk in terms of safe spaces. So I have to fly later this week and I am going to wipe down my tabletop. I am going to wipe down my armrests. I'm going to have a mask with me, not to wear on the plane, but if somebody is right next to me and coughing, I'm going to try to move or have a mask. You have to think through all those processes. And then one other thing, Tony, is you really also need to think about who's with you. The idea of circling the wagons around the elderly and the most at risk here in town is perfect sense. For those individuals to get on a plane and take additional risk makes no sense. If you are traveling and coming back to an elderly member living in your household, that means you've got to have it in mind as well."
Tony Plohetski: "This is where people have just got to, according to experts like yourself, they've just got to use good judgment and take personal responsibility for themselves?"
Dr. James Evans: "It really is common sense in the end, understanding how the transmission occurs and then becoming very disciplined about minimizing individual family and ultimately community risk."
Tony Plohetski: "So just one last question, because I know you're very busy with seeing patients, but also working on this issue and studying this issue. Experts will tell you here in this community that it is inevitable that we are going to get our first positive coronavirus test. What would be your advice to this community, to Austin, to Central Texas once that happens? Because I think some people may be inclined to perhaps hit a panic button."
Dr. James Evans: "I don't like to compare this to flu because we've gotten in trouble doing that. But I really in many ways it's appropriate to think in terms of influenza and how that would impact you in your life. So in other words, when coronavirus hits, ultimately, hopefully we've already been practicing the things we've talked about as I'm thinking about my workspace, as I'm thinking about my commute, as I'm thinking about my daily activities, going to church, going to HEB, wherever it happens to be, I'm thinking in terms of, you know, is that relatively safe for me to do? Given who I am my age, etc. and what can I do to protect those people around me? The reality isn't going to change when the first case shows up. The reality is already out there, if that makes sense. In fact, you know, I don't mean to be gloom and doom. But there's a good chance there's already a first case in Austin. We just haven't diagnosed it yet. We're testing people pretty much on a daily basis. So the precautions we've talked about need to be put into place. Now, if people are practicing them, doing them regularly. Honestly, the individual risk doesn't change dramatically. Once we've gotten a case or a few cases in the absolute need to mitigate becomes more intense. But for people making choices about commuting to work, trying to work from home, the same paradigm exists, you know. So again, it's like if flu is in Houston, you know, flu is coming to Austin and how we respond both before and when it's here should be very similar. Personal protection, community protection, thinking through risks and, you know, kind of responding to those."
Tony Plohetski: "A steady, reasoned, rational approach."
Dr. James Evans: "In the end, some of the more robust precautions that are being taken right now, limiting travel, stopping NBA, doing these things, those are literally containment measures to try to shut down rapid progression of this epidemic. And I think all of those are well-taken. Those are different than the individual thinking through their daily process. I think what can become alarming is when we see things like suddenly the NBA is not playing in front of crowds anymore. That can be very concerning to the individual because, 'oh, my gosh, that's never happened before.'"
Tony Plohetski: "In our minds, create a level of anxiety?"
Dr. James Evans: "Absolutely. And in a sense, a little anxiety is good. A lot of anxiety can be crippling. Back to common sense, back to being well educated, knowing how the virus spreads, taking appropriate precautions for yourself, your family, and definitely putting into context all those variables in your daily life: Who's with you? Who's around you? Elderly, high risk, those kinds of things. So in the end, practice now because it's coming and then you'll be ready for the game when it's here."
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