 Good morning. It is eight o'clock and we'll go ahead and get started with the Moran Ice Center grand rounds first of all Welcome everyone joining us. This is an extraordinary grand rounds. I'll be willing to say it's going to be one of our best One of the beautiful things about being in academics is the the wealth of specialists the wealth of knowledge on a college campus and today we're going to Take a take a visit around to Experts on ethics epidemiology and economics and covid's effects on each of these So our first presenter and speaker will be Dr. Rich Nelson He is a PhD as a research associate professor in the Division of Epidemiology at the University of Utah School of Medicine and a health And a research health scientist at the VA Salt Lake City healthcare system. He's an economist An associate director of the health economics Core and the Center for Clinical and Translational Service at the University of Utah Rich Nelson is also one of the the great people on earth. He much like Griffon Jardine and Ned Flanders He's someone who's unflappable and his happiness and ability to bring joy to those around him That's an honor to have him I'll later Introduce more in detail or our other speakers. Dr. Alan Nakashima an internal medicine specialist And then of course, Dr. J Jacobson who we all at Moran know. Well, I'll give just a brief bio for both of them Just before their presentations. So with that rich will turn it to you For a visit into some of the economics underlying covid-19 Great, thanks Jeff, I'm going to share my screen here I Just make sure this works Hey, are you seeing that now? It's up. Okay. Great. Well, thank you for the introduction One of my life goals is to be like Griffin Jardine, so if I can achieve that that's a life well-lived But thanks for the invitation Jeff to present today today and thank you to Moran for having me I just want to start off by by first thanking all of you in the medical community for all you're doing to keep us safe to keep your patients safe and These are our difficult and trying times, so thank you for all you're doing There are so many questions that we have right now Things are that this is these are unprecedented times we're living in and There are all sorts of questions that we as individuals have but but as leaders and and decision-makers have right now So how do we think about these? The these tough decisions we have to make So I'm going to talk today about the field of economics and how some of the tools in this field can help us in Kind of navigating these these different times, so Remember what economics is from your your Microecon 101 class from from college. Here's a quick definition So economics is the study of how we use scarce resources in order to fulfill our wants, which sometimes can be unlimited And so because we can't get everything that we want we have to choose So to put it succinctly economics is the study of choices So economics has also been called the dismal science. This is a phrase that was coined back in the mid 19th century by Thomas Carlisle And it it's more applicable today, unfortunately than ever This is the quote from Joshua Gans who is an economist at the University of Toronto He said in a book about the economics in in about economics in the age of 19 He said everything is awful virus is awful immediate choices are awful The future may even more awful. So dismal indeed So this is a painting by the Dutch artist Peter Bruegel from 1568 called the blind leading the blind and this kind of sums up a lot of what we're feeling right now We're in untreated territory This is a new virus its effects are unknown And and we're kind of all trying to figure out our way through this what I like about this painting is that These individuals are having a tough time obviously making it through life, but they're all helping each other So I see us as a community and as a as a society having kind of bonded together in unity through this and Despite our lack of Clarity on what we're seeing. I hope that we can all stay United in our to try to get through this So when when Jeff and originally asked me to speak a few weeks ago I started making a list of all the potential topics I could talk about related to economics and in this pandemic and this is a An incomplete list and they're certainly playing with their interesting ones that we could talk about But I figured I would I would start off and talk just talk about the big one. So The huge question that we all had to ask a few weeks ago and are currently asking right now is was it worth it to shut the economy down for 19 We've seen a lot of politicians asking this question. There are protesters who are are questioning this we ourselves I I ask myself this same question all the time. Is it worth it to do what we're doing? So to Get some clarity on that what we really need to do is to compare the consequences of alternate universes The one that we're currently living in where we have shut the economy down and some alternate version of that universe Where we didn't shut the economy down. This is not unlike one of my favorite movies Spider-man into the spider-verse Where we're comparing the world that Miles Morales lives in to the world that Peter B Parker lives in And what's a little bit challenging is that we're we're still want the movie hasn't ended yet We're still in this movie and we were not sure how it ends yet, but We can draw on some past experiences So you may have all seen this figure from which came from a study from a few years ago Looking at the death rates during 1918 During the flu pandemic that year So the the solid line here is is Philadelphia and the dotted line is in Lewis So Philadelphia if you remember had a big parade to honor soldiers coming back from the Great War Whereas St. Louis had much stricter social distancing guidance they Restricted gatherings to less than fewer than 20 people they shut down schools and churches and as you can see there They're dead. It was much lower than it was in Philadelphia. So we can use this experience to kind of Get some insight into how this might affect us The shutting down the economy closing restaurants closing national parks Cancelling the NBC season that there are real and substantial costs associated with his action So, how do we know this is the right thing to do? So we can what we can do is we can look at these two different scenarios We can call one the shutdown will call the other one life as usual and we can examine the benefits of each of these strategies so the benefits might be in terms of of of individual lives and the years of life that could be saved by Going with the shutdown strategy compared with our life as usual strategy So we can compare those benefits with each other between the two strategies. We'll call that the net benefits And then we can look at the costs associated with these two strategies as well. So those costs could be expenditures for for healthcare those costs could be GDP lost due to decrease in economic activity And so what we we weigh the benefits of these two strategies against each other And we weigh the cost of these strategies against each other And then we can kind of combine those net benefits and the net costs into kind of a nested scale almost Where we we compare the net benefits with the net cost to see Which was greater and that helps us to know Whether we've made a good decision or which decision we should make dr. Jacobson one question came in Was the area under the curve the same for both cities and that's from dr. Olson That's a good question. It was not the There was a net increase in in in deaths and in Affiliate obviously compared to to St. Louis. Good question though So So if we save lives by social distancing and flattening the curve, how do we value the lives that we save? So and how do we compare that to the cost of shutting down the economy? This is as you can imagine. This is not this is not an easy Question to grapple with so there are a number of ways that we could value Lights that would be saved one way would be to place a dollar value in terms of the The Amount of productivity that that person might have throughout their lifetime measured by their earnings We could look to how others have have Valued life. So juries will award monetary values in in cases of wrongful death The 911 commission had had to think through this when when Deciding on a dollar amount for compensation for victims of that disaster What the federal government has used and has done this for for many decades now is something called the value of a statistical life Or the vsl So rather than trying to estimate how much the life is worth which is as you can imagine is very hard The value of statistical life methodology kind of comes at it from a different angle It's calculated by estimating how much we'd be willing to pay to decrease our risk of death An amount that Federal agencies use these days for the vsl is on the order of 10 million dollars or so So a Study has come out from some economists at the University of Chicago that has Has made this calculation in in for for COVID-19. So so similar to what we saw for Philadelphia and st. Louis We have a red curve, which is life as usual and the blue curve, which is the shutdown or or social distancing And so, uh, yeah, dr. Olson's question The very end of the curve between these two is is larger for for life as usual than it is for The shutdown and so the the the net increase in in in deaths The shutdown or compared to life as usual and the shutdown These economists have attached that vsl dollar amount to that and have seen have have found that The the monetary benefit of those lives save is roughly eight trillion dollars And as you can see that that That varies by age. It's larger for for those of older age Given that the virus affects them more severely So eight trillion dollars is the the the net benefit of of shutting down the economy compared to life as usual So how does that compare to the net cost? We actually that's a good question I don't know. I don't really know that at this point. I've seen estimates Uh in The ballpark of of one and a half to two trillion dollars for the u.s economy might be I saw something the other day that There might be a four trillion dollar loss in in global GDP We're not we're not sure how much this is but but what we know is the eight trillion dollars in terms of benefits is a lot So here are some quotes from some well known and highly regarded economists In the popular press recently about this exact calculation The should we do this or not? So kit viscusi Kind of pioneered the the value of statistical life methodology in the 80s And he said that this eight trillion dollar figure is such a large number that it dominates whatever economic costs We are incurring right now Justin wolford at the university of michigan had a similar Thought he said it's it's useful to adopt the cost-benefit frame But the moment you do that the outcomes are so overwhelming that you don't need to fill in the details to know what to do So, uh, essentially eight trillion dollars is so huge That we don't even need to know what the costs are to in order for the eight trillion dollars to win Uh, so it makes sense to shut everything down quickly because every every day and every week matters, um Rather than spending the time to figure out exactly how much the cost might be So the hard thing though is right now we're in this scenario where Shutdown outweighs life as usual But 99.9 percent of the time we're in this situation where where Shutting things down does not make sense uh, and so And eventually we'll get to that point But in between between now and then we're going to be in a very gray area where the scales are starting to tip And it starts to look more a little more even between shutdown and life as usual And that's where uh, it's going to be very difficult to make these these types of decisions Dr. Nelson, uh, dr. Olson has another question Again about the assumptions made in the study Out of chicago question is does the area under the curve not depend? If the or or not depend if the pandemic ends with herd immunity versus a short exit with the vaccine essentially the assumption of the The time horizon Yeah, no, that's that's a that's an excellent question Yeah, uh, so this was uh, I want to say that the the time horizon on this was relatively short. It might have been um through the fall Um, but but you're right that you know, we could think about short term immediate term and and long term for this I think this was relatively short term before a vaccine would be available um, uh and As far as the their assumptions on herd immunity I'm not I don't recall off the top of my head what they thought about that. Let me jump in if I may Randy's question is a really really important one. And of course, we don't have a final answer But there are some things to to consider um, some people have actually argued that Let's just take vaccine off the table If the issue is herd immunity Then the only question is you get there faster without social distancing, but you need to get there eventually So that's an argument about how many people are infected and the area under the curve for infected people may very much be the same The real question and again rich is talking about the cost of lives and particularly the cost of lives lost One of the things that seems to be true Is that if you don't do the protective measures and have a very acute spike in the curve There may actually be deaths that could otherwise be prevented The best example of that would be somebody whose life could be saved by use of a ventilator If the ventilator was not available think of that very steep curve that person would die The number of people infected might be the same But when you're separating mortality from infection There is an argument and it's an argument essentially about scarce resources That is you take advantage of those resources as long as you can Making them available to save the lives that could be saved by intervention Yeah, yeah, that's a great point. Jay. So, uh, I mean, it's it's the concept that we've talked about or that We've seen a lot now about uh, uh, fighting the curve and spreading it out be longer rather than than, uh, uh higher it during any one one time period. So we're that that preserves resources that can be used over a longer period of time that that that that Yep prevents deaths down the road that that could occur now because of of just a lack of resources. Yeah, great point Excellent. Um, so what what's challenging about this though as we move forward is that how and when we relax these these restrictions depends on a lot of things so, um There are differential impact impacts of of the virus and and of these policies on on different individuals So we know that the the virus affects people differently The the economic effects of the of the shutdown affects different sectors of the economy differently That there's lots of geographic variation And then when we talk about easing the restrictions, um, that can mean a lot of different things. So, I mean in this very simplistic scenario we've been talking about here the uh shutdown or no shutdown is is a dichotomous variable But in reality, it's probably a continuous variable where where there are, you know, different degrees of shutdown And so as you can tell things get start to get very complicated very quickly Uh, and then there's the so okay So we've decided that uh, at least in the aggregate that the benefits of social distancing restrictions and shutting down the economy outweigh the costs of doing it But that doesn't mean that there aren't costs. Uh, that there there are definitely costs and these Are being disproportionately borne by certain individuals in certain sectors of the economy Uh, so vulnerable populations, uh, central workers and their families The health care system and hospitals, uh, are are definitely being hit right now Uh, so you've probably all seen this figure. This is uh, the number of unemployment insurance claims by week Uh, since the the late 60s, you can kind of see spikes every once in a while where during times of recession So the third week in march, uh, uh, there were more than three million unemployment insurance claims, which was more than triple Any other time in the previous 50 years And the the following week, uh, there were twice as many An unemployment insurance claims as there had been the week before so in in two weeks There were 10 million people climbing for unemployment insurance, which is like a mind-bogglingly high number So in terms of hospitals, uh, so some colleagues of mine and I have, uh, looked at the effect of of restricting elected procedures on hospital profits So we've basically been been comparing the world where We have no elected procedures Versus life as usual and comparing the profits between the two at from a hospital's perspective And so here's some uh, some of the preliminary results from our analyses. Uh, the these bars show the Uh, the the net profit for hospitals during these times across different assumptions in terms of the incidence of infection And the admission rate and you can see that under some scenarios, we see positive profits, but under a lot of them Uh, hospitals are taking a hit from this and and this is what this is what a lot of hospitals are facing right now uh, so As we think about how and when to get back to normal, um, this economic valuation framework can can I think it can be useful. Um, so we've in just these kind of short Scenarios and examples that we've given here Um, we've seen that the this as applied to the economy as a whole Uh was deemed to be a good decision And and was one of the the justifications for doing this Um, but we've also seen that this decision hurts some very important players in the economy including hospitals. Um, so one useful Use of this of this framework is that it helps us to quantify How much individuals who are hurt by these policies are hurt by them? And that can help us develop new policies that help compensate Those who who who might suffer losses because of any policies that happened before? Uh, so unfortunately there are uh Many many challenges to that we're gonna have to face over the next Coming weeks coming months and and and maybe even years Um, and given that this is such an unprecedented time. Uh, we really don't have a playbook for this Um, so I mean in a sense. We're really kind of the the blind being led by only the slightly less blind um So, uh, we we can certainly talk about many of these challenges At this point, what if I what if I pause and and throw it over to to the next presenter? Is that sound good jay? Uh, that would be fine unless Jeff has some questions that have come in specifically for you that could be brief No, that's perfect. Why uh, why don't we go ahead and move on to our next presenter. Thank you, uh Dr. Nelson if we can have you hang on for any questions at the end Again, just for those of you that joined us a little, uh, late That's dr. Rich Nelson from the department of epidemiology. He's a phd researcher in medical healthcare economics Our next speaker is dr. Alan Nakashima. She's a program manager for the utah department of health and an internal medicine specialist She is actually a native utah grew up Went to high school at skyline the university of utah for undergrad She went on to a 30 year career in epidemiology at the cdc where she was a senior medical epidemiologist 10 years ago. She came here and she was the state epidemiologist And she began to transition to a part-time role And her part-time role currently is a 60 hour a week part-time job We are honored to have you dr. Nakashima and thank you Well, thank you. I'm very happy to be here as my slides come up You know, I spent almost 30 years in at the cdc and You know when I started that was actually the 1981 is when I started there and I Was uh, that was the first year of the AIDS epidemic Certainly a defining But then I never So, um, yeah Just I'm so sorry to interrupt the way the slides are scheduling and does also show your notes, which is fine There is also a way you could share without that Yeah, I don't need to show notes. How do I is that not? That goes back the other way. Let's see All right. How do I do that? Like escape, is that right? Yep. Go ahead and start with escape Okay Or end slide show at the top And then typically just from beginning should work. Although it may depend on you You're still seeing them. No, I don't need notes on there But some of these slides I borrowed from some other talks I've given so Well, well, is that all right? This is great. Let's continue on you Oh, I see that how do I get rid of this part? I see you should be able to Switch out of present review Okay So just If you hit play if you go ahead from the beginning again, uh, dr. Sophia fang Is said to click on the display settings at the top and that will switch the display Display settings go ahead and hit from beginning From beginning That's the problem. It's all it's a full screen from me. Oh, I see over here then display settings Okay And it says duplicate slide show One presenter view and slide show Okay There that work. That's it. Oh, perfect. Okay. That's great All right, uh, so I you know, this was a Interesting experience of for me Coming back to Utah. I was hoping that I was going to transition to retirement very soon and then this hit um, and uh It really has made me think about what public health is Really about and so I'm going to just share with you just From the perspective of a little bit about Ethics because Jay said that I should talk a little bit about ethics um But I want to talk about this very vulnerable population that's Our elderly population that's in long-term care facilities because um, I'm working to help care associate infections now and This was a natural fit on this epidemic kit that I would end up Working in this area My viewpoint is going to be very applied public health So, you know, this is so different than what was just presented because uh, there's no theory We have to get something done when something hits in applied public health. So that that will be our point of view so you I'll probably remember that Back in around february, uh, we started seeing you know, Seattle was the first Case in the united states that was detected Probably there were a lot more already in the east but So seattle had some of the first cases that we saw in The united states and then we saw these large outbreak that occurred in this nursing home And it resulted in a lot of deaths And uh, we all in public health as we watched this scenario layout were Very concerned that it's the epidemic ever came to our state What would we do with this situation to prevent this situation from happening? um, so I'm just going to show you a few slides from the new york epidemic because I think You know, we just heard about what could happen. This is an explosive epidemic where And we'll talk a little bit about timing because I think That shutdown here was probably not in time and There were consequences this explosive epidemic, but I want you to notice here and the two bars So this is the rates of cobit 19 cases per hundred thousand population And you can see by age group 65 to 74 year old group and the 75 years and older groups had very very high rates of Illness in new york city And even a more disproportionate Rate of deaths occurred in these populations that were elderly so You can see that in the younger age groups. We didn't see that many The death rates were pretty low, but When you get to the 65 and older death rates were very very high So this leads to a question You know, italy as many of you might recall had to make some really really difficult choices Because again, they had an explosive epidemic completely overwhelmed their healthcare system And so they had to make these choices about Who to prioritize their healthcare resources for very difficult decisions And so many of the elderly were basically not put on ventilators and Basically triage to what becomes palliative care and essentially Were left to die And we don't want to have those very difficult choices, but I think that This population is a population that will always bear the brunt of this epidemic So now I'm going to just switch quickly to what we're experiencing in utah So now I think in utah we did shut down in time, which was I think a difficult decision, but it made a big difference for us Our rates are very very low compared to new york You can see over here in the on the chart That that our case per 100,000 rates are just minuscule compared to what's going on in new york And actually the 65 and older age groups are not that they're not the highest Rates where we're actually seeing right now I'm gonna But I want to also point out that we've only had 45 deaths as of April 28th, but 22 of those or close to 50 percent have occurred in the long-term care settings and The mean age there is 73 years of age So long-term care setting what are their risk factors? Well, of course their age They often Have ventilator use or chronic conditions Such as diabetes lung disease or immunocompromised conditions And most importantly the living conditions in a long-term care facility I don't know if you have visited one recently But hygiene is very difficult to maintain and I did a lot of outbreak investigations for healthcare associated infections in these facilities And extremely difficult to control any kind of an outbreak in that setting because of the hygiene issues that are That these patients are experiencing Um, and then they also Have to share, you know, they're in close contact or sharing a lot of facilities and equipment Baiting equipment PT equipment even equipment to move them Uh, and then of course all the monitoring equipment blood pressure cuffs, etc. They're all being shared And then most importantly they really have no infection control For the most part it's it's pretty minimal certainly the The acute a long-term acute care facilities where ventilators are a little bit better But all of these facilities have a problem with infection control and personal protective equipment They often don't have any many nursing homes that we started If we went to at the beginning of this epidemic had essentially none on site Dr. Nakashima dr. Olson had a question and dr. Olson you are unmuted if you want to go ahead and ask that Yes, uh, so it's it's interesting that uh, you know, we look at those figures in regards to the age related But now that we're starting to get serology in a few places and realize the the huge number of likely asymptomatic cases Uh And and we look back at that we may find that each of those bars at each of the age range is pretty much the Same it's just that the younger ones had many more their asymptomatic cases Yeah, uh, I think that's probably true. Um We uh, uh, do know that um in long-term care facilities even though you wouldn't be surprised But you would also see a huge number of asymptomatic cases. So for example in a lot of our outbreaks Um, uh, I'll just give an example. We had one that had A 20 of 30 Residents in a facility that came down with a COVID-19 Uh, are tested positive but uh six of those actually had A symptomatic disease and actually, uh, most of those went on to die But the uh, other 14 actually had almost no symptoms. They they just Went right through this with nothing. So, um, there's something about this disease that we don't understand about How it selects people who really get Very ill may have to do with the immune system and the immune system response, but Um, uh, even among the elderly we're seeing a lot of asymptomatic illness Yeah, and I'll I'll respond about that risk factored later because we've got some interesting actually Irrelated information that I doubt anybody here's heard. So we'll give that in later. Okay All right, so um because we saw that the situation in uh, Seattle, um We started very early in Utah to try to prepare our long-term care facilities for what was going to come um and uh, we started putting out guidances and A lot of tools for educating these long-term care facilities that had never done any infection control on things like, uh developing visitor policies Uh closing all their doors walking everything, uh making sure that uh, everybody who came into the facility checked into the front Uh front door and uh got registered Um And only people that absolutely needed to be into that facility would come in Uh, we also asked people not to uh, if you were in an independent living or assisted living situation Um, but you not leave the facility, uh unless it was an essential A visit to a physician or something like that um So that the uh Infection would not enter the facility We learned a lot about that at the beginning Uh, and as time has progressed for example, uh about two and a half or three weeks ago now We implemented a um 100 percent Uh PPE use uh with patient contact recommendation, uh, it's actually um I think closer and closer, uh to This policy is what I think is it's going to happen, uh nationally But we didn't see these recommendations come out But we put them in about three weeks ago because We found that in our outbreaks, uh, many of the uh outbreaks are started by pre-symptomatic or asymptomatic healthcare workers Uh, and we weren't going to be able to prevent any of these unless Every contact with a patient Had some kind of masking face shield And good hand hygiene So we actually, um put that in place about three weeks ago and as I said, we put a lot of materials Righted now before we even had the first case to prepare our facilities for this epidemic And then we also once the epidemic hit, uh, we have really worked on responding very rapidly to, um, COVID-19 events in this population And learning how to stop transmission And then, uh, we've actually evolved over the last three weeks on learning a lot about what we should do and what we shouldn't do Okay, so, uh, I'm going to talk to you just a little bit about how we respond to outbreaks at the, um Department, uh, I don't have a huge staff. We have about, um Seven people that actually work on these outbreaks In long-term care Usually the request for a, uh, response comes from a facility Um That has a concern it could be just a person that they're concerned about an exposure Uh, to COVID-19 and uh, they're concerned about what they should do about that They may have a known case of COVID-19 and healthcare worker or other staff. We're actually seeing a lot of ancillary staff like Food service and health keepers that are also bringing the infection into the facility Uh, so when we see that, um We, uh Begin with an infection control consultation because they often just want us to Uh, actually look at what they're doing and seeing if we think, uh, their, um Uh, current policies and procedures are are, uh, good enough to protect them from this infection But once we get a concern from the facility, uh, there's another way that we can actually hear about, uh, Situations and that's through our regular surveillance system Now we have an electronic surveillance system in Utah, which is actually, uh quite good. Um, all of the, um, laboratories, uh report electronically Into this system. So as soon as there's a positive COVID-19 Test, uh, then it usually gets rooted very quickly to this surveillance system And if that has, uh, been reported from a healthcare, uh, long-term care setting Then those are automatically, uh, routed to this mailbox, uh, hai at Utah.gov Which we man, uh, every, we're looking at that constantly. Um, and we, um Uh, will respond to those, uh reports as they come in So what do we do when we get a, um, um A call from one of these facilities? Well, uh, we're, and I'm going to just summarize this pretty quickly because of, um, Um, time, but, uh, we, um, First begin with an assessment of the situation, a typical, uh, epidemiologic, uh, assessment of person, place, and time, what's going on in the facility Uh, then we'll do what's called an infection control, uh, assessment of risk survey. This is, uh, A group of surveys that started with the Ebola, uh, epidemic Um, and it, it, these, um, but we have now focused this assessment. We adapted the, um, Ebola, uh, what we call ICAR, uh, onto, uh, COVID-19. So we ask a lot about, uh, their, um, Visitor policies, their ways of, um, Using PPE and their availability of PPE, those kinds of questions That are really focused on what they need to have for COVID-19 And then, uh, after we look at the situation, we actually immediately, uh, start making recommendations for what they should do in terms of cohorting, uh, infection control and use of, uh, protective equipment We also start, uh, contact tracing, uh, so we kind of, um, We actually have a whole team separate from the, uh, our regular team that now, we have now stood up to just do The contact tracing, because as you can imagine, there could be quite a few contacts to any one of these, um, cases that start Sometimes I get, like, depending on the individual, it could be 100 people or more Uh, and then this next, uh, thing that we do, which, uh, we couldn't do initially because, uh, one of the things that has happened is, you know, by watching the news, there's the availability of testing has been extremely Very evolved throughout this, uh, epidemic and in Utah, um, as recently as a month ago, we had very, uh, scarce testing In spite of what the politicians are saying, uh, we couldn't do the testing that we wanted to do, so, um, on the first outbreak That was a sizable outbreak. I struggled for half an hour on the phone just to get seven, um, uh, swabs to get to patients that I thought absolutely needed to be tested And, uh, it took me another 24 hours to get enough, uh, swabs to, um, test the entire facility, uh, residents and staff Um, but we're at a very different place today, and so now we are able to do these point prevalence surveys Um, using a mobile team and, uh, that's really changed the game Uh, we can go in there and, um, we test all the residents and all the staff, uh, within a day after we hear about it If we think it needs to get done And then, uh, the turnaround time on testing is about, uh, 24 hours, so we'll get the test results back And that can inform our cohorting decisions, uh, and recommendations to the facility Uh, we also stood up, um, And this has been, uh, an amazing struggle for us to stand up COVID-only facilities You can't imagine the number of issues that occur around, uh, standing up one of these facilities Um, uh, we think that, uh, for certain types of facilities, it would be great if we could, uh, send everybody to, um, A COVID-only facility because their ability to do infection control on site is so poor But in reality, um, uh, these are actually very difficult to stand up, and we actually, uh, mostly use the one that we have for hospitalization Uh, so the hospitalization, uh, hospitalized patients can be sent to these facilities as they're, uh, recovering from COVID-19 When they don't have to be, uh, in the acute care hospital any longer Uh, so, um, only a few patients from long-term care have actually been sent to these facilities And they've had to mostly manage their, um, own outbreaks on site And finally, we follow up, uh, these facilities that are having a, uh, problem for a long time, uh, usually at least a month And as it resolves, uh, we also have to provide them with, uh, support, and again, another point prevalent survey on, um, When they're ready to, uh, return to status of not having any COVID cases on their, uh, in their facility Um, so this is, uh, mobile testing, I mean, I, I, that was misspelled there, but it's unit, uh, these are units that, uh, we have several of them now That go out and do mobile testing, so this would be for the healthcare workers and do it, uh, in a drive-through manner But for the, uh, facility itself, uh, this individual will go into the facility and, uh, swap patients for us And again, that's been a game changer for us In fact, this is what the Centers for Disease Control is probably going to come and visit us in a week or so Because they want to see how we do this because, um, they think this has really been helpful Now, ultimately, now, I've been advised that we should be testing every nursing home in the, uh, state every day, but we can't do that, obviously There are more than 400 of these facilities in Utah, but, um, we are thinking about, uh, using points, uh, It's a point of care test that they do become available, uh, that would be great if we could at least test healthcare workers, uh, say once a week or something like that Um, and so at least, you know, that's on the horizon, if we get enough point of care testing available, we might be able to do that And, uh, hopefully they said that by doing it once a week, uh, maybe 25% of, uh, of these outbreaks could be prevented Dr. Nakashima, we have a question from Dr. Judith Warner in the department. How many long-term care facility outbreaks have there been and what qualifies as an outbreak? One person more? Okay, so, uh, an outbreak for us is, uh, yeah, one or two people, at least two people in a facility We, uh, have had over 100 of these requests, but we, uh, but of these only about, uh, 40% have actually had one or more, uh, case because as I said, they'll often, uh, call us a facility or call us and ask for consultation More as a preventive measure or when they're, they have a concern like somebody who was exposed and then they never develop a case Um, then we've only had about, uh, five or six really large outbreaks. By that, I mean, uh, five, six or, uh, 30 cases, something like that Um, the rest of the outbreaks are usually, uh, we, uh, able to enter a transmission and they're usually stopped at a much, uh, you know, like, maybe two or three cases And Dr. Nakashima, we'll hold any more questions just so we can get to Jay here at the conclusion of your talk Okay All right, and this is the COVID only facility. It's a city creek facility. Um, uh, we have learned a ton from this facility. As I said, like we've had to develop SLPs from who can be admitted to this facility Uh, what is a proper discharge criteria because many of the facilities where these people have come from, um, don't want to take them back, uh, even though, um, they are now asymptomatic for many, many days Uh, so, um, especially if they remain PCR positive, they're very reluctant to take them back and so, um, we've had to work on a lot of criteria for those facilities Um, so lessons learned, we've had many. I, I, I laugh at this because, uh, even having gone through the HIV epidemic, I spent 30 years at CDC working on many aspects of HIV. This one has been tough Um, even though I've been, I saw a lot of things in HIV I thought, you know, were very difficult Uh, especially the first one there, politics versus science and public health decision making Uh, everyone appears to be an expert, but the experts here, and it has been really a challenge Uh, but I think the one thing that has helped, um, me with this work is keeping your eye on the ball. I think as, as young public health people, I think they often get discouraged when they see what's happening on the Uh, decision making scene when politics precedence over science, but we have to in public health, especially applied public health, we have to keep doing our work and eventually things will work out, but it is a tough situation Um, preparedness. So, you know, so when I first came here, we worked a lot on Developing an infectious disease emergency response plan Uh, and it was great that we did that and we learned how to stand up our incident command system and all of this and we've done all kinds of tabletab exercises and also use the system for many other smaller outbreaks, like measles or hepatitis A outbreaks that we've had in the department But nothing really can prepare us for the reality that we are currently seeing and it, you realize that Uh, no matter how much we prepare, I think it's a reality is very different than that Um, another lesson is extraordinary importance of timing. You know, we really struggled with the timing of our shutdown in Utah Uh, as we were working on that, so many people were opposed to doing that. I think we did it at the right time Because we certainly haven't seen any kind of explosive epidemic like we've seen back east Uh, we were on exponential curves all we were on that curve and we managed to flatten it out Um, as a previous speaker told us about but Timing is really important if we, I mean I'm sure that New York wish they had done it two weeks ahead of where they did at least two or three weeks ahead of where they did because it really makes a difference in what happens in the healthcare system I think that public health versus personal liberty is really an important lesson learned. There's real influences of culture on the choices we make. I think in Utah people have been extremely cooperative. They've been great in terms of wearing masks, self-isolation, staying at home, especially elderly people have really done a good job with that And I think that, I think they've done better than even the, you know, government has asked them to do I don't know how long that can last but I think, you know, people constantly are looking to what's going on in South Korea or I worked in Taiwan for four years Their cultures are very different. They are uniform cultures and they are much more willing to make the choice of limiting their personal liberties for the public's help And that will have to come, you know, I think wait and see how the American public will take this in the next, in the future because I think that how long can we do this? I think that we might have a little reprieve here in the summer but if we don't have a vaccine this is going to come back in the fall and we'll be able to make those choices Dr. Nakashima, we are just running out of time. I'm so sorry to interrupt. I actually asked Jay to go ahead and put his slides up and on behalf of the Moran Ice Center, thank you for that absolutely extraordinary Okay, and then I want to just end with this because I do think that we have to remember that, you know, for the elderly, this is a horrible time for them. They feel so lonely But they need to be alone and protect their own health. Okay, thank you. Thank you. Thank you. It's an honor to introduce Dr. J Jacobson, someone well known to all of us at Moran. He's the emeritus professor of internal medicine and division of medical ethics and infectious disease specialist by training. His bio on the University of Utah website ends with the following and I quote, I am also interested in the ethical issues that arise in the context of infectious diseases and quote with that, Dr. Jacobson we're glad you have an interest in this. Thank you so kindly Jeff. And I'm going to race through this because I want to get Randy's comments on as well, but I'll just let the participants know it's possible to stay on a little bit after the normal closing time, and I'll be available to I'm going to expand this beyond coven 19 to remind us of what the real questions are in this epidemic, but in many other epidemics that we currently are experiencing and that we will in the future. It's obvious everybody dies and when we talk about saving lives no lives are saved forever, but it's fair to say that some lives may be extended. It's also important to know that a life can be saved by either treatment or prevention, or the reduction of a risk to life, and a life saved by somebody that we know clinicians are very aware of this right someone who is an intensivist absolutely knows the person and the family of that person when there is a life extended because of intervention in an ICU. A life saved may be just an unidentified statistical construct. For example, those of us that are advocates for vaccine. Think about the numbers statistically for example of how many children in a large population might have their lives saved because of measles. We know that child and we never meet them. The child that has been vaccinated against measles doesn't develop it, and there's no way that we know that child or their families so that's an abstraction and really important because I think we're all much more sensitive to the concerns about saving the life of the person we know or who is physically in front of us than an unknown individual. A life saver may be an individual that could be a Boy Scout that does CPR and save somebody who's recovered from drowning. It could be a group of people who act collectively an organization and agency government company, a device, or even a sign, for example, something that says thin ice might actually save more than one life by its very presence. One of Miss Richard has said every life saved has a cost and usually a benefit, but the cost and the benefits don't always accrue to the same entity. Let me make that point one more time. For example, when we vaccinate a population of children against chickenpox. Most children may be prevented from getting chickenpox, but they're not getting chickenpox might save the life of an immune compromised adult. So the costs and benefits don't always accrue to the same individual, and sometimes not at the same time, something that we do for young people may actually save their life after they reach the age of 60 or 70. And the costs and benefits are rarely equal. And as I think Richard pointed out, they're very hard or impossible to calculate. A really important example of that is something that's premised on, for example, years of life remaining would value a life very differently at say age 85 or at age one. That's something very important and we'll come back to that. The biggest job is it to save lives. Even the Greeks began to talk about duties of station, one that you might not think about, but it's obviously a great example is someone who's employed as a lifeguard has a duty to save or extend lives of people at risk in the surf or in a pool or a lake. Passerby might be a better swimmer and might choose to intervene to do that, but it's not their duty. Other duties of course would be firefighters, policemen and certainly physicians. We tend to think that one has a duty to save one's own life, but of course people exercise sometimes terrible judgment and risk those lives. But if they encounter somebody with a duty of station, for example, if they're in the water and can't swim, we hope there's a lifeguard whose duty it is to extend that life. Similarly, these duties are shared by families. There's no stronger advocate for the life of someone than a mother advocating for the life of her child. We think about it as our tribe, our community, our neighbor, and particularly in some parts of the world, government. But an excellent question might be which government entity is really responsible for saving lives. I think our country's experience demonstrates that more vividly than I could have ever imagined. I think Salt Lake City is a really wonderful example of a city that took leadership and responsibility for this as did our county. In some states, governors have been initial responders and leaders, and one could imagine and has seen in other countries of national leaders taking on this role. For physicians, it's again complicated. If a physician doesn't have the skill to save a patient with a particular disease, I don't think they have the obligation to do that. The next question, of course, is which patients are physicians obliged to save? And that's where really this issue or this epidemic has become most concerning. That is, if a patient is acutely and severely ill, and we have more of them than we can care for, which of those are we obliged to take care of? I wanted to just share quickly with you the fact that this is the first epidemic that we have ever seen this kind of radical economic separation response. Interestingly enough, there are much milder measures that could have been taken many years ago or in any year to deal with other epidemics. A really good example is the fact that in every year we have between 12,000 and 60,000 deaths from influenza, and the World Health Organization estimates over half a million of those every year. For that disease, we know how to test, we generally have masks available, there is a treatment, there is vaccine, and we could quarantine or isolate. What I will tell you is that we don't have any mandates that require protection or these measures for influenza. We have recommendations. Interestingly enough, healthcare workers are a high risk group for this because of their contact with influenza patients. They also potentially transmit this disease to patients who don't have it. That's a paradox, right? Healthcare workers infecting patients, something that could be avoided. While it's recommended and required in some facilities that healthcare workers be vaccinated, practice is only 2 to 60%. That's well below the level of herd immunity that generally means that almost everyone is protected. Public acceptance of the vaccine, again in our country it's not required, is only about 50%. And the vaccines are not particularly effective in the elderly, which again with this disease are the highest risk. Think about the fact that we don't mandate preventing this preventable disease. We don't insist on treating all people are making it available, and we don't require infected individuals to be quarantined. Those are choices that we make and we make those every year. Another dramatic example is essentially an epidemic of drunk driving fatalities. There are 30 deaths a day and 10,000 deaths a year in our country. There are ways of preventing this kind of death, and we don't take that, right? Testing for alcohol levels with random testing and roadblocks is a very discouraging technique against drunk driving. Ticketing with real consequences like loss of license would work. Social norms as exist in Europe have really accomplished this. And of course, severe punishments for people who drive even once while intoxicated, let alone multiple times. This just shows you that the United States has about a third of deaths in automobile accidents due to drunk driving. If you scan down quickly, you'll see all the countries that are a fraction of that. The United Kingdom half of that rate and Germany about a fourth of that rate. Those are causes of death that we don't intercede with that require much, much less aggressive interventions. I think I'll make this the last example is opiate deaths. Another epidemic in the United States, the blue bar graph on the right, shows you that rising epidemic. So in Germany about 1300 cases in 2007 and approximately the same number nine years later that year 2016 63,000 Americans died. But there's almost as much opioid prescribed to individuals in Germany as there is in the United States. So once again just to emphasize that by rates now not by numbers in 2016. The death rate in Germany from drug induced overdose was 21 per million in the US, it was almost 10 times that or 200 per million. The difference is how that other country responds with harm reduction. Things like shared needles that prevent infection the availability of a uniform product, the availability of treatments for overdose like naloxone and obviously drug treatment facilities where willing people who are addicted are readily admitted and secured until some progress is made against addiction. I'm going to just skip the deaths that we have from uninsured patients. Again, preventable deaths that are prevented in most other countries. Let's see for this epidemic. These are critical questions. Dr. Nakashima mentioned that testing is now becoming available, but access to testing is tremendously important. And we haven't fully answered the question of whether this should be something available to literally everyone. And in fact, taking place in selected sites like nursing home facilities. In this country, the question of who pays is always a question this epidemic has brought to add to the forefront with much of the cost of both preventing and treating coven 19 addressed at the federal level. But the HCW is obligation to treat communicable infectious disease, except to say even firefighters are not obliged to go into a burning building if they don't have the equipment they need to protect themselves. A healthcare worker with adequate protective equipment is certainly obliged to treat someone if they have the skill set to do that. But it's really an unanswered question as to whether or not we should require healthcare workers to do this when we're not prepared to protect them. How are scarce resources allocated? As you know, in our country, we've allocated in some peculiar ways. In most healthcare facilities, we treat the sickest patients first. In the US traditionally, we treated the sickest patients first if they could pay. Now we live under a mandate which says if people are emergently ill, they must be treated, but there's often no compensation for that. So that even works against treating the sickest first. In an acute crisis like the COVID crisis, if it exceeded our capacity, the response would be instead of the sickest first, the response would be to treat those with the best opportunity to survive first. And Dr. Nakashima mentioned in Italy, the physicians used age as a surrogate for most likely to survive. In the US, we tend to use a quantitative measure called the SOFA score, the organ failure predictive score, to select people independent of age. So I just realized that an older, healthy individual may have a better chance of survival and a lower SOFA score than a young person who's chronically ill would say a respiratory or even respiratory failure prior to becoming sick with COVID. Hey, this is a quick transition to get Randy on board one moment. Let's see. A quick look for you to see, and I'd be glad to share this later as well, that we don't exclude people from acute care or ventilator care, unless they have the conditions in that little gray box to the right. And particularly if they've already indicated that their preferences for non intervention, no cardiac resuscitation and no ventilator care. And actually, and you know about this physician 33 year old ophthalmologist who warned his colleagues on December 31 about the corona outbreak before it was officially recognized that warning circulated widely. He was admonished by his government for spreading rumors and had to sign a promise to desist. He however returned to work, saw a patient in his office for open angle glaucoma contracted COVID from her on January 8 and worried about infecting his family. One child and a pregnant wife he remained in a hotel to isolate himself where he grew sicker and was hospitalized from his hospital bed he published his experience on social media on January 31. And he went on sadly to die on February 7. He became a hero in China galvanized protest for free speech, and his death sparked a wave of public morning. He was exonerated by his government on March 19 and honored as a martyr with 12 other physicians. And with that I hope Randy can share some perspectives from an ophthalmologist in the United States. So a few things for us to think about from the I stand point is that a lot of you may not realize that in the from the Chinese experience that the number one group of providers to die were ENT physicians because they tend to aerosolize the you know inside the cases in the head and the rest and in their surgical procedures but very close to them were ophthalmologists. So we were the second most likely to get the disease and die and this this this gentleman is a perfect example of that obviously. So the feeding is the sitlamp exam is a dangerous thing to do you're sitting right in the face we know that even asymptomatic in breathing and particularly in talking can spread this disease so that's why we rapidly put those face shields up. On all of our sitlamps and why I think we've been pushing hard to see that we're taking extra precautions. The other thing that's interesting from this overall, or a lot of our unknowns and and the important part it's playing is how this moves forward. Some of you didn't see it on the chat side but a serology is going to tell us how many people you know we're actually infected. Sadly, a lot of the serology that has been approved in a rush by the FDA is is has so many false positives and false negatives. I don't know how good it's going to be. I can tell you that directly from Peter Jensen that a rep has tested the myriad of different ones that are out there there are two that have an extremely old false positive and false negative and they have an interesting way and I could go into detail and want to hear about how they do that. But those are the ones we're using. But indeed if the good testing shows that the actual infection rate is 30 to 40 times what it is of the known infection. Then that means asymptomatic is extremely common and that has two impacts. Number one, the positive is, you know, we will be moving faster to herd immunity than we think we will. Number two is actually three is that the antibodies there, not not known for sure, but using them in, you know, taking the serum and using the antibody may be an important treatment for those that are very sick. In a social that number three, they may indeed have a certain level of immunity, which is unknown, but most people feel we're going to find out we're only going to know that if we know who those people are and then follow them and see what happens over time. So I think that that's going to be a very important and known for us as we move forward but there's been some good studies done in Italy and now there was one in Santa Clara County and one in New Rochelle, New York, all of which suggested that the actual asymptomatic overall disease rate was, you know, 30 even as 80 times higher than what we know. So I think that's going to be important part as we move forward. The other thing that I think is critical understand is that it is absolutely at least clear as I see what's happening elsewhere in the world. This is going to be waxing and waning, and it's going to wane when we get really serious about it when we're really concerned about it when we clamp down like we've done. As you watch that, and the state follows this, you can look the infectivity rate, which in its free wild state can be three times the flu or up to four. I mean, that's a huge multiplier if you've got a logarithmic projection to the power of four. And yet, you know, we've been able in Utah, it looks like a lot of the numbers to get it down below one, which means that it's going to be in a waning pattern moving on. Now we're ready to loosen up. So as we loosen up, if we do that too much, then it's going to wax again. And most people reviewing this think in the fall there's a good chance that this will come back, but I predict we'll see periods when we're concerned. The University Hospital is a period of concern right now. Our numbers have gone up a more fortunately IHC is not seeing it. And so maybe it's just a local blip for us, but where are we seeing this. We're seeing this huge blip coming out of our large clinical presence out in the redwood area. And our testing is an averaging elsewhere around 5% of tests for symptomatic people fewer symptomatic that a 5% positive. They had a day where it ran 22% positive in that area in a place in which we have a lot of refugees in a period in which we have a lot of crowding. We have a lot of difficulties in regards to the social distancing and the rest. So these are all things that are important for us to follow. So I predict that we will see and I love the fact that we you know we've got this this phase stating of we've essentially been in red we're moving into orange. Hopefully we'll have a period of time we're in yellow I doubt we'll be in green until we either get a vaccine or a good treatment, or herd immunity and hopefully it's going to be one of the other two, you know before a vaccine, but there there's a lot of good vaccines in place and likely a vaccine, you know could be a good exit that will eventually occur and I had that Jay as well. Besides you pointed out, I just wanted to point out that when you're looking at the area under the curve of her immunity is the is what we're looking for it's going to be the same area under the curve, but two reasons note one not to overwhelm the system, you're absolutely correct. Number two is it's buying us time to get a vaccine or an effective treatment in place during that period of time which I think is a very real possibility. So, what I'm working on hard everybody needs to know is what is exactly does it mean. If it's orange. We kind of have been given a bit of an orange on elective surgeries and so we put new processes in place, always with the concept of trying to be safe. We're going to be able to do some in regards to where the patients are, and hopefully move on but but don't think this is going to be static I think we're going to see a lot of changes and a lot of other things in place. And then I wanted to add the teaser part of it, you know, as Judith said, there is something very interesting so what does ophthalmology have to do with this overall. This thing persists in the tears and often it seems like the virus is persisting in the tears, you know, longer than it's persisting in the mucosa and mucous and sputum and things like that. So, so don't forget that this thing definitely and you can present with conjunctivitis so we have another risk factor that's specific for ophthalmologists. So the interesting thing about this disease is that those who are dying and going on ventilators and remember the New York experience if you are 70 or older, and you're on a ventilator. Does anybody know what the mortality rate is right now 97%. So, and overall it's been 88%. And the big problem they're finding with the ventilator at people that are at that level of sickness is is what they're calling a cytokine storm or over overwhelmingly strong immune reaction and the immune disease is causing problems and so increasingly places are using immunomodulators now and there was just a study out today on an immunomodulator that look promising a biological and even though they said not to use steroids in these at that level, they're starting to use steroids to see what they can do. So, the second thing is this is fascinating phenomenon of multi organ disease which appears to be a micro vascular thing. And so, a lot of the patients and who the lungs are hanging in there they're not doing great. People are dying from heart disease and they're dying from kidney failure and they're dying from other things. And the pathology that's coming out of it is a is a is a micro vascular problem that's ongoing associated with that is this this new symptom of the disease and I'm sure you're all aware of anosmia right the that one of the early symptoms can be a loss of taste or smell often that's the only thing that people experience. It's so specific that if somebody has or presents that and we should ask that that's that's that could that's the only symptom that may have that's likely to be the disease is this new thing called COVID toes. So, it turns out that if you ask there's a fair number of people that get these interesting lesions down on their toes. And it also looks like it's a it's a micro vascular change, very painful and take a while to resolve and be very difficult. Sometimes it's the only symptom. Sometimes it's a delayed symptom people are looking at it so knowing that our Center for Translational Medicine and realizing how that's similar to to some of the genetic risk for macular degeneration we just recently looked carefully for those people who are homozygous risk that chromosome months that's compliment factor H which we know is a is a unusual overreaction of the compliment system. In the body and it's to both disease presentation and it's over a lifetime causing Mac a generation. And because we have over 10,000 people thanks to everybody here who are genotyped. We've been able to find out your risk for getting bad lung disease if you're homozygous is five times than after the overall population is a relative risk of five, which is huge. And that's a common disease that's a common gene. If you're homozygous risk at chromosome 10, not as common but still a relatively common event that's out there, you're 15 times as likely. If you were to get this virus to end up on a ventilator. And if you're homozygous risk on one and 10, you're toast. So we're scrambling as rapidly as possible to get ventilator blood. And and looking even reaching out to places like Ireland where we have a group or who has in New York is we don't have a lot of people on ventilators, fortunately for us here in the Salt Lake Utah area but but a third strategy for exit is being able to determine what these genetic risks are. So there are people then just like we know that patients over 70 who have systemic disease have very, very high risk in association and quarantine for them as much as possible makes a lot more sense. If we can indeed find some of these other risks we may be able to open up the call the the overall economy more to those who don't have those risks, and obviously those that do that they have to be extra extra careful so those are all things that I think are really exciting on the front that potentially couldn't can help us as we move forward. And beyond that we're going to just have to live as a new normal, this this fluctuating and varying disease that's going to wax and wane depending upon how society is handling, you know this this this cruel pandemic. Thank you Dr Olson. We've had several comments questions about testing and Dr Nelson noted you know this is not a binary situation to open the economy open society up it's it's much more of a continuum and so really to any of the speakers today as what is the role of the accuracy of testing false positives and antibody tests etc in deciding how we begin to open up our society be it from an ethical perspective or an economic perspective. Maybe Dr Nakashima could comment on that first and then there may be something to add let's see what she has to say. In the absence of that, I think Randy made some critical points. Sorry, I was on me. I think, you know, one of the things that we do in public health that you all have heard about a lot in the press is contact tracing. In Asia, for example, when they see a case, they'll find all the contacts and they'll immediately test all those people and then come back and retest again in a week or so. And they will base their quarantine on that and hopefully prevents further spread. Now they're quarantine. We don't we don't do this in the US where we have a big penalty. They think in Taiwan, I think it's like $7500 penalty if you get out of quarantine when you're not supposed to be. So, and your neighbors will actually rat on you because you know that's a cultural thing that they have there but I think that we may use testing for some of those things. I think we're looking closely at the populations that we're going to be testing to see if we can, you know, keep from having to keep everything closed but we could actually try to see how well chasing the epidemic towards during the next month or so when we open up and use contact tracing and see if we can use testing to help prevent disease. The comment about testing is that tests, of course, have the challenge of false positives, false negatives, specificity and sensitivity, but their performance is partly based on the prevalence of a disorder in the population. So the predictive value of a positive even in a test with 97% sensitivity is not as good when the disease is very rare say one or 2% as it is when it's much more common 25 or 30%. First of all, we're very lucky with a community like Arup to validate the various tests and Randy's absolutely right. The gates were too high early in this epidemic and we had a failure of a test developed by the CDC and a tremendous delay in getting other tests on board. Now the gates are down and so commercially validated tests which have not gone through FDA approval are out there, but I'm sure that they will shake out. So we will soon have more reliable tests even more importantly will be tests as Dr. Nakashima said that can be done at the point of care, whether that's a quick blood test or a saliva test with a result available in minutes to an hour. That's actually a really good idea and of course if that could also be available for serologic tests that are predictive. That would be really, really important for groups that need to meet where it would be conceivable to know in very short order. Is there anyone infected in the group who could be excluded or protected and are there people who appear to be immune and not vulnerable. So this is Randy. The important thing is that as you push specificity often you lose sensitivity and vice versa. So you've got to kind of find the middle ground but everybody here there's a lot of discussion about this. Arup is spending a lot of time and effort. They're the third largest reference lab in the United States. I think we forget about, you know, how important that's been and I push Peter on this all the time but he actually says there are two serology tests, the one that Al Vitale's talked about and then one other that you know is a newer one that that really are approaching that you know magical 99 on 99% on both, which I think are critical for us to, you know to be able to to rely more on it as far as the tests are concerned. One of our biggest concerns about that is obviously a false negative. We're testing more and more people for testing individuals and and there have been some tests out there that actually in Italy they had a study was 30% false negative rate. That's a little better than flipping it going but not much. The Abbott test sadly has a 15% false negative but the only ones that Arup have been allowed have have to have had a false negative rate no more than a couple of percent, but Jay makes a great point I mean even in a couple of percent of its if it's not very probably still going to get a lot of false negatives out there. A quick point to make about this epidemic and in all other new diseases we can operate with uncertainty. So a good example is that in health care now many people are suggesting is not Dr. Nakashima said in extended care facilities that all healthcare providers wear some protective equipment all of the time. The reason being that we know that people may be infected and asymptomatic and even people who are tested may be test negative early before their infection reaches the point where it's detectable. So that's actually a response to uncertainty and I think that on the clinical side a patient who's admitted with fever cough shortness of breath and an osmia for example or maybe the unusual toe lesions that Randy described. That's a presumptive positive that you would worry about even with a negative test. We have that practice for tuberculosis for example if an x-ray is suspicious but the test for tuberculosis is negative we remain suspicious and careful until that can be validated. So I think his points about ophthalmology are superb. I think given the fact that there are many asymptomatic infections you should presume that any patient that you have close contact with especially if you generate aerosols constitutes a risk. And it's possible that the standard may be a lower level of protection say a surgical mask and a face shield for that but someone who hasn't confirmed or highly likely infection would generate a requirement for an N95 mask and more protection. Yeah I want to point out that for Moran that the policy we put together is is that we want to lead Moran as COVID free as possible so whether they've tested negative or not if they have any symptoms that we don't want them to be seen. If we have to see them we've got one isolation area that's not in our clinic in the operating room. We're testing all people for surgery if there's any positivity but let me let me leave this because people wonder how good are universal precautions. So I got this from San Finlayson who happens to speak he's the chair of surgery who speaks fluent Mandarin and has kept contact with his Chinese colleagues. So the first round of providers at Wuhan we know it was absolutely devastating. Many many deaths a lot of ENT and ophthalmologists who died a quarter of the health care workers all got infected. And so they had to bring a second wave of providers in to try to help that they they had face masks they had standard surgical masks. They used full protection when they knew they were dealing with active diseases and the overall infection rate of that second group of 41,000 workers that came in was less than one percent. So these things do work and I think that's critical people people understand and this virus has many negatives but it is very susceptible to hand sanitation washing and such things like that. So let's not forget that this virus can hang around and so that means we have to be scrupulous about cleaning washing our hands. But we need not be a vector of any significance for this disease if we will follow all the guidelines we're trying to outline so that we make sure we're safe for our patients and for ourselves and for our staff. Well thank you Randy and again on behalf of the Moran Eye Center thank you Dr Jacobson Dr Nelson and Dr Nakashima is an extraordinary discussion a little around the world of covert feel free to contact me directly if anyone has any additional questions I'm happy to pass them on to any of our speakers. So make sure that you do sign up for CME through Megan Nelson through Megan Johnson I'm sorry if you do have any additional questions thank you again for sticking around with us today. Be safe and we'll see you all next week. Thanks Jeff. Thank you Jeff.