 Okay, we're back. We're live on Jay Fidel. And this is protecting our kupuna from the coronavirus here on Community Matters. And we have Brad Wilcox, who's an MD who runs research and the department on a kupuna, kupuna healthcare, I guess, in Japson. And it's also involved in Kuwikini. So welcome to the show, Brad. It's very nice to have you on. Pleasure to be here, Jay. Thank you for inviting me. Can you help me with the details of your affiliations in Japson and Kuwikini? Sure. I'm a full professor and director of research at the Department of Geriatric Medicine at the John A. Burns School of Medicine at the University of Hawaii. I've been in part of the department for almost two decades now. And my other role is I'm director of an NIH Center for Biomedical Research Excellence on Aging. So it's basically a very large grant to build aging infrastructure in Hawaii so that we can understand aging better and find ways to help mitigate the costs, if you will, the health costs of aging in terms of chronic diseases and other problems. Yeah, very important, you know, with the curve going to older, you know, more elderly people in our community, especially in Hawaii. But here we have something special. I mean, I know you've been faced with viruses before in those 20 years. But certainly this is worse, isn't it, than what you've seen before? Yes. This is a pandemic. It's worldwide. And it's probably the closest thing we've seen to this is the... Well, I haven't seen it because I wasn't born at that time. I don't think you were either, Jay, but the 1918 to 1919 influenza pandemic in terms of its ability to spread across the world and its ability and its lethality. I mean, the coronavirus isn't as lethal as that influenza virus. But by sheer numbers, there's a lot more people around than there were in 1919. And there's people are a lot more connected in terms of traveling all over the world. So it has the ability to spread just as bad. Yeah, that's fantastic. This is going to be something that, you know, people will remember for the rest of their lives. Right. Yeah, the story will be told by the survivors. Well, you know, the more you learn about the coronavirus, the more you stand in awe of it. Because like other viruses, but maybe worse, you can go through the whole disease and never even know it. It can be very mild. You don't even take note of it. And yet you're spreading the virus everywhere, every day and everyone around you. That's deadly. Secondly, it doesn't take much virus. Many viral particles to infect someone else are arguably only one. Only one virion, V-I-R-I-O-N, will be enough to infect someone else. So, you know, the whole thing is so, so dangerous in a community setting. And then you find that the kupuna are the most vulnerable of all. And this is of great concern to anybody who is a kupuna or somebody like yourself who is trying to take care of them. And so I wanted to talk to you today about, you know, what things we can do to protect them in the face of this, this lethal disease, which is effectively all around us. So what is your, you know, standard way of protecting them? What is your advice to them? What kind of infrastructure do you like to put around them? How are you handling this? First of all, Jay, I entirely agree with your assessment of this really dangerous situation for kupuna as well as others that can and will get infected. And the fact that the majority of the transmission is probably through asymptomatic or mildly symptomatic vectors, especially children, that's a problem. This virus, it's an RNA virus, so it doesn't have any DNA. So technically, you could say it's not alive, but it's covered by this lipid layer and it needs your own cells to become alive. It's kind of, if you will, it's like a zombie virus. You know, a zombie, you don't know if they're dead or alive, but they eat things and they run around causing trouble. So that's what happens with coronavirus. And once they hijack your cells, like you said, like a very small amount is all that's needed. And it may well be, there's evidence suggesting now that it may well be airborne, maybe not as bad as something like tuberculosis, but certainly something to worry about and something to use extra precaution with. So getting back to your question, Jay, I mean, I think one of the most straightforward messages comes from the World Health Organization where they basically say, stay home, save lives. And so basically staying at home as much as you can, keeping a safe distance from others. Generally, we recommend about six feet, wash your hands often. The virus cannot survive soap because the soap breaks down the lipid layers of the virus and then the virus dies. So you have to do a thorough job at least 20 seconds of soaping your hands and putting the soap in between your fingers and get it just kind of as foamy as possible. And those little foam bubbles basically are virus killers. And of course, cover your cough if you have one, cough into your elbow like this so you don't spread it around. And if you're sick, definitely call a head, call your physician, call the emergency room if you're having breathing problems and listen to that advice. Don't just hop in the car and go somewhere. Yeah. So what's the level of symptoms that should make kupuna concerned? I mean, we've heard that if you have shortness of breath, if you have a cough, if you have a runny nose, if you have fever, that's a big one. Anything over, what is it? 100.4, I think something like that. Yeah, 100.4. These are the telltale signs. So suppose you only have one or possibly two of these. What do you do? When do you start getting concerned? There's actually, there's a really good, how shall I say it's kind of like a calculator where it's on the CDC website, the Centers for Disease Control and Prevention. And it gives you basically guidance on when and how to seek medical attention with things like trouble breathing, persistent pain or pressure in the chest, confusion or inability to arouse, bluish lips or face, those are emergency signs that you need to get to the emergency room right away. And so if you, if you actually go to the CDC website, which is easy to find through any, basically search engine such as Google, just type in CDC and coronavirus. And then you'll see the self checker for decision making. It's actually CDC.gov forward slash coronavirus. And then it'll guide you to this. But certainly, you know, those are the, the emergency signs where you should really seek help. If you only have a couple of the signs, it's still worth, you know, calling your physician to seek guidance. And because this can really turn rapidly. Often what happens is you have a small fever, which barely qualifies like 100.4. And then you start to get a little bit better. And then a few days later, all of a sudden you're at 103 degrees and you're burning up and you've got a cough and and you're really, you're really going, you know, south at that point and you really need to seek medical attention. So you say you call your primary physician. Well, I've heard it both ways. So you wouldn't just call 911 and tell them to take you away? No, you would call. Sorry, that's a good point. Yes. Yes. If you're, if you have any of those symptoms like you, new confusion or inability to rouse, you know, bluish lips or face, trouble breathing, persistent pain or pressure in the chest, you call 911. Yes, absolutely right. If they have more minor symptoms, you know, just a mild fever and just starting to get a little bit of cough and then you can seek advice from your physician. Okay, so now you call 911 and they send an ambulance for you. Where can the ambulance take you? What are you going to find? Who is going to do the triage on you? And what are they going to do? I guess, you know, it's a morbid thought, but I think people would like to know what the experience is like and what they're going to find at the end of that 911 call. Well, what will happen is the ambulance will show up and they'll make an assessment based on your vital signs. And if they decide the ambulance crew decides that you are really in serious trouble, then you will be triaged immediately into the emergency room. If you have just mild symptoms and you're stable there, if you go to various hospitals, they have different ways of triaging you, but you will be triaged into the appropriate location. And if you need admitting to the hospital, they will admit you. Currently, at least as of yesterday or the day before, I believe there were six people in the ICU in various hospitals in Hawaii. And I believe we've had one death. But there was a study actually out of University of Washington not too long ago. They have a really good epidemiology center. And they made predictions state by state on coronavirus risks and where we might be seeing things in two to three weeks. And it didn't look very good for Hawaii. I mean, it was better than most states, but they were talking about us being in similar situation to other states with having up to 300 people in the ICU. We don't have that many ICU beds right now, as well as a lot more sick people and a lot of deaths too. So we're on a trajectory right now that resembles Italy's trajectory. I don't want to panic anyone because that study was done in University of Washington before we started these self quarantine self isolation measures. So that may well affect the numbers in the study. And in fact, the governor has asked them to rerun the numbers based on that scenario where we're social distancing and self quarantine. You know, there's a sort of a dilemma choice in there somewhere where the individual may say, well, I only have a couple of these symptoms, not the others. Maybe I should weather the storm at home and I'll get some cold medicine and I'll take some aspirin from my fever and I'll see if I can tough it out because I really don't want to go to a hospital. I might catch it worse at the hospital. Hospitals are overburdened and the like. Why don't I just, you know, take my chances at home? And I suppose if you're a carpenter, that'd be a deadly choice. The other factor that works though is if you go to a hospital now, as opposed to a week from now, there might be more beds now and more ventilators now and more and more healthy staff now. So as you know, the other side of that argument is I want to get this over with. Let me take advantage of the health system that exists right now. So I have to worry about having a spot later on. What are your thoughts on that dilemma? It's an interesting argument. But the flip side of the coin is if you're going to catch coronavirus, it's more likely at a hospital than anywhere else because that's where the cases are concentrated. So I wouldn't advise that. I'm a case in point. I had a borderline fever. My temperature was 100.4, you know, the minimum qualifier. I had aches and pains. I didn't have a cough or any chest pain or, you know, trouble breathing. But I was, you know, achy and painy, kind of like, you know, symptoms that you headache that you might think of the coronavirus or could or you could think of it as a common flu. I've had my flu shot. And of course, I was hiking up the mountain the day before. So there's reason to have aches and pains. So I knew I couldn't get the test easily. And I didn't want to go out and wait in four hours in some of these medical centers that are allowing people. And I knew I wouldn't qualify. So I thought, all right, I'll just stand my room and get room service from the family for 14 days. So that's pretty much what I did. Because you have a certain amount of concern if you have any of the symptoms. But I, you know, I just want to visit the issue of testing, you know, it's kind of, it's a troublesome issue. It's a troublesome situation. And, you know, it seems to me that if you could test and get an answer back in 15 minutes, a lot of the anxiety would go out of it, you know, one way or the other, what you got. But we don't have that. And I wonder if you could, you know, discuss that with me and tell me what we do have and when we might have a 15 minute test possibility. That's a really excellent question. And it really reminds me of the situation that made the path that this country might have gone down had we had the test kits available, like they had in South Korea and done a lot of testing. That's the way you understand how much disease there is in the community. You take a large sample, you know, you test healthy people, you test unhealthy people, and then you make some decisions based on that. We didn't have many tests. No, we had in the beginning, we had to go through the Department of Health in Hawaii. If you had a, you know, case that you thought might be coronavirus, then you send a, you know, a swab sample, nasal swab sample to the Department of Health, and you have to fill it filled out a form. And if you didn't meet the CDC criteria, then they wouldn't send it to the CDC to get tested. But so, you know, we got really far behind the curve in this country, including in Hawaii. And, but there, you know, there's places like South Korea, like I said, they tested hundreds of thousands of people, and they got a really good, they tracked down the people in the beginning, what their contacts were, and isolated all these people, and they didn't have to shut down their economy, you know, there wasn't a, you know, of course, there was social distancing and that kind of thing, but it didn't have the, the same massive effects that it's having in this country, because we've, we've had to take all these, these measures for social distancing and closing down restaurants and closing down, you know, pubs and gyms and, you know, any place that people gather. But, you know, getting to the second part of the question is that, you know, what, what can you do about it? And when's there going to be testing? Well, there is actually a couple of tests that have, are in development. There's a company called Inovio that also is working really hard on getting testing and, and a vaccine available. There's about half a dozen vaccine companies. But the testing, you know, before I go into that area, the testing is real important. And there is some hope. There's a five minute test that Abbott Labs has developed. And they're going to be making it widely available in the next few weeks. So I see over the next, you know, month or two that we may well all be able to get a quick test without standing in line for four hours. And there's also a 45 minute test that another company has developed. So there's, that's definitely going to happen. And that's going to help a lot with the situation, because we'll really get a better idea of what we're dealing with. What about the mask issue, Brad? You know, it's been, it's the, I guess the CDC has changed its mind about that. At first, they said, you know, if you didn't have the disease, you didn't need the mask. But that's changed. Now they're suggesting everybody should wear a mask. And unfortunately, it's hard to find a mask. And I believe that one of the reasons they were withholding instructions to use a mask before is because they knew it's hard to find a mask. But now their advice is changing maybe because there are more masks, although I don't, I don't know where they are. Can you talk about what to do on masks? Yeah, I think that's an, it's the CDC and the WHO are still at odds with that. The WHO say, oh, you know, don't need to wear a mask. And, you know, it's, it was, you know, reasonable if you're distancing, you know, six feet from each other. And if you're going out exercise and then the wind's blowing and, you know, nobody's coughing around you. Yeah, that's okay. But now, yes, the CDC is, I don't know if they came out with the official announcement. You might be ahead of me on that one. But I know that they're, they're expert committee that also the committee that advises the White House is saying that it sounds like they're talking about, if they haven't already, then talking about coming out with an official announcement that you should wear a mask if you go outside. And of course, if you've got a family members that are sick, you know, they need to be self isolated in a room and, and, and other people if they go near that room should be wearing a mask. Now they're getting back to the best kind of mask is the N95 mask, which is the kind of mask that you wear for tuberculosis and other highly infectious airborne viruses. And as we mentioned before, there's evidence now that suggests that COVID-19 may well be airborne. So the, I think we're probably going to come to this point where you, yeah, everyone, if you go outside, you go shop and wear a mask, you know, you may be, you may be an asymptomatic carrier and, and spreading it all over the place. So a mask might help mitigate that. Now the masks that again are the best of the N95 and those are the ones that you just can't get because even medical professionals like we're running out of those in the hospitals. When I ran, was working the wards before, you know, we had to test for this N95 mask every, every year make, make sure it fit and, and that it worked. And I've got one lying around somewhere in my house. But, but, you know, even though the, you know, the, the, the CDC is leaning toward, or like I said, is moving in the direction, if they haven't already with the mask, that it's not going to fully protect you, obviously, like an N95, because those particles are really small for COVID-19. But it'll help a little bit anyway. It's something that they're saying, even if you can't find a mask, it said, they're not, they're saying, do not buy the N95 because we need those for the medical professionals. Even a homemade mask, where you take a scarf or something like that and just make a mask out of it will, will help something, you know, especially if you're, you're coughing and that kind of thing. Can we talk about some of the medicines? I mean, this is sort of not yet approved, not yet FDA tested. No, no, no trials for coronavirus have been conducted. And yet there are people who claim that they've been cured or the disease has been ameliorated. Daniel Day-Kim was a good example. The actor went on, made a video about how these various malaria drugs saved his life. What about that? I mean, is this advisable? Is it, is it worth studying? Is it worth doing? And what do you think is going to happen in the future? There's also apparently is a, there, there are a number of anti immune system drugs that are used for other diseases. The killing feature in this virus is that it, it provokes your immune system into, you know, over responding, then you can't breathe. And if you could stop the over response, then you know, you might survive. And there are drugs that stop the over response. I don't know how far along they are. They're used for other, other diseases. But I wonder, what do you think about these non yet approved type medicines that are being bandied around as candidates potentially for either, for a cure? I don't know if there's anything being banded around for a vaccine, but for a cure. But what, what should we consider if anything? Well, I think that, that's a really good question. And the, I would say that the most promised, there's at least half a dozen medications, including the antivirals, like general ones, like hydroxychloroquine, that all otherwise known as plaque when all the president has been touting quite a bit. And, and his advisor, Dr. Fauci is sort of saying, well, we need, you know, really need to see randomized controlled trials. But the problem is, you know, if you're, if you've got a severely ill patient, you know, and, and, and you don't have anything else, what do you do? So hydroxychloroquine has been shown in, you know, in clinical use. Now, this is sort of more anecdotal, not, not, not as evidence based, but in France, and in China, China is doing several placebo controlled trials right now, randomized trial with the, with the medication, with, with this hydroxychloroquine and in combination with other medications. And they're reporting in their early results, although not yet published, that it's efficacious, and it basically cuts down the days you're ill by a substantial number of days, and it cuts down your symptoms as well. Now, there's half a dozen other antiviral medications that one isn't in use in Japan. Japan's running a clinical trial on that. But, you know, to get definitive evidence, it's going to take time. And, but in emergency situations, doctors might be choosing to use some of these they have in France and they have in China. So if you've got nothing else, you know, then it's, you have to make that clinical decision on a risk, risk reward base. Yeah, I just wonder, you know, at that point, when you're, when you're in trouble, is the patient customarily conscious to make that decision? Is it, you know, the doctor says we have some drugs, they've been used for, you know, other other diseases. Would you like to try it? Or is the patient, you know, non compass? And, you know, he doesn't really have any have the wherewithal to answer that question. How does it work in practice? Well, I think that you nailed it. If, if the patient's conscious, then they can make, and they have the capacity to make that decision. Then the patient can, in conjunction with their physician, decide what, whether they want to go that route or not. If they're not conscious, then it'll fall onto usually a family member. Most patients these days, especially elderly patients have, you know, a living will or, you know, a document that states their wishes and who is going to be the healthcare proxy, you know, and that proxy usually in conjunction with, after consulting with other family members, but not necessarily makes, makes that decision. So this is a way to, to get, to get at the answer. Yeah. So there's no medical, there's no medical practice reason to withhold that drug. In other words, if I say, I would like hydroxychloroquine, I would like that doctor's going to give it to me. He's not going to say, well, you know, it hasn't been through trials and blah, blah, blah. And it's not really appropriate for it. Because of that, it's not appropriate. I mean, he's going to give it to me if I ask, because there's enough evidence out there that suggests it could have a positive effect. Am I right about that? Yeah. I mean, there are some contraindications, like with any medications, but it's a, you know, you know, if you're allergic to it, or, or so, but the contra, the, the, in terms of medications, you know, it's reasonably safe. It's not something that's hydroxychloroquine. Chloroquine itself is not, not quite as safe. But you can have some side effects. But if it works, it works. And I don't, you know, the, I don't think most doctors would describe it unless you were, you were pretty sick. And yeah, but it's, it's something that the CDC is looking at very closely. And I think if I'm not mistaken, they may have allowed it for compassionate use, you know, if it looks like there's no, no other choice. But if it's, if it's prescribed, then by your doctor, it is an off-label prescription. So it doesn't have a, it's not approved by the, by the, you know, the federal authorities, FDA, it's not FDA approved for treating it. But as an off-label treatment, that's the, between the physician and their patient, they make that decision jointly. Yeah. But I'll tell you why. Good luck getting some hydroxychloroquine, because I think people, there's been a run on it at the pharmacies in Hawaii and all over the country. And I, you know, I think it's going to be really, really difficult to get it. So I heard that one of the companies is going to be making a million doses and contributing it for free to all over the country. So it may, may become available. But if you call your typical pharmacy and call your doctor and say, well, you know, maybe I can have a little bit of this at home just for safe, safety reasons. Good luck. Let me know if it's like that. Oh, thank you for that. That's very important. So let me, let me, let me go to one last question before at a time. And that is about kupuna specifically. So you have them in their apartments, you know, you told them to stay at home or they're quarantined for some reason, but they're really not on the street. Now it becomes necessary for them to go on the street or at least the question is raised. The question is raised, for example, to go to the doctor's office. The question is raised and on a non coronavirus issue, some other issue who knows what or to go shopping or to get something that they consider essential. What's your advice to them about a handling a trip like that going outside like that? What should they do and be what's your advice when they want somebody to come into the house, maybe for cleaning who knows what, someone who's not part of the immediate family? In other words, what's your advice as to engaging with others for a vulnerable, you know, kupuna? Well, I think that's an excellent question. And the my advice is to have as little contact with other people as possible. And in other words, if you can get someone to do your grocery shopping for you, like a family member, that would be better. There should still be six feet between you. Maybe your family member can drop the groceries off at the porch. You know, I would not at this point in time until things have calmed down more. And we've got this virus under control. I would not have regular maid service, cleaning services, that kind of thing. I would do everything I can to do it myself. If you insist on it, then I would make sure that they wear a mask and that you wear a mask as well. And anything they touch, you know, they better be cleaning with Clorox or another compound that can kill coronavirus. And then, you know, if they actually and they should wear gloves, but if they and if they touch anything without their gloves or, you know, even, you know, have them take their shoes off and leave them outside, you know, they'll take them inside. It's coronavirus is really tricky. And there was a study done that showed that coronavirus, even if the protective clothing is sort of, how shall I say, shaken around, then you can put coronavirus particles in the air, you know, patients rooms, there's been coronavirus on the out, you know, that has seeped through the vents in one study. One study in China, there was a lot, there's a facility where this kupuna was completely by herself hadn't gone anywhere and had had very little contact and no sick contacts. And they thought, well, maybe it's getting into the vent ventilation system. And so they studied and there was coronavirus particles in the ventilation system. So we're talking about, you know, there's a lot of stuff we really, really don't know, you know, about the virus and taking as much precaution as possible is really the way to go. Wash your hands frequently. I go outside to exercise and when I come back, it's like a decontamination zone, you know, all the clothes go into a plastic bag, my shoes are outside. I spray everything with basically as a propo alcohol mixture, about 70%. Then I go straight to the shower. And I do that with my kids. It's all very reasonable. Well, I think we were still learning. So everybody has to get the message. And we all have to be careful just like that. I hope we can visit back with you later, because we'll learn more and you'll see more and we can compare notes going forward. I really appreciate you coming on the show and sharing this with us. Oh, absolutely. It's my pleasure, Jay. And I look forward to our next show. Everyone stay safe. Stay safe. Aloha.