Connell mug shot

Dr. Joan Connell

As the state begins easing restrictions on high-contact businesses, we visited again with North Dakota’s Field Doctor, Dr. Joan Connell, to talk about the latest scientific and medical developments in the COVID-19 fight. We also discussed proper mask-wearing and PPE use, as well as the persistent — and incorrect — myth that flu is more deadly than coronavirus.

Q: Many people on Facebook and social media are looking at the low number of cases from COVID-19 so far, and suggesting all the measures the state took was overkill. Did we go overboard?

A: Absolutely not. The fact that North Dakotans were so responsible with the lockdown is what helped our cases. If you look at what happened in New York, where they were not able to respond as quickly and early and effectively in the process of the pandemic, that is a tragedy that we were lucky to avoid.

Models are estimating that 36,000 deaths could have been prevented if New York would have locked down just a few days earlier.

Social distancing and good hygiene remain the most effective methods for decreasing morbidity and mortality from COVID-19. Without continued adherence to the (CDC) recommendations, we could find ourselves in (New York’s) position.

We are still having positives every day, so it is still in the environment, and we need to be aware of that.

It is possible it may not be as prevalent in the summer, but as long as there is some number of cases, it is likely it will ramp back up in the fall and winter.

It’s also possible it will be a consistent rate that isn’t affected by the season of the year. We’re going to learn that over this summer, and that will be great to learn that.

Q: There are a lot of comparisons between COVID-19 and the flu. The gist of many is that this hasn’t been as bad as the flu. Do you agree?

A: Let’s see, influenza deaths in North Dakota for the season, and this starts back to the 31st week of 2019 through the 21st week of 2020. We have had way more time for the flu, and we’ve had 21 influenza deaths in North Dakota and 549 hospitalizations. Looking at the COVID-19 deaths, there have been 52. Way more in 2.5 months than we’ve had in 7.5 months from the flu.

So this myth that influenza is more deadly — just look at what happened in New York. Influenza didn’t result in New York having to store the bodies of influenza patients because there were so many fatalities. COVID-19 did.

Q: North Dakota has lifted restrictions on its high-contact business, as long as they agree to certain protocols. It has also just issued guidelines for large gatherings such as weddings. Given that COVID-19 is so deadly for vulnerable populations, is it really safe for us to reopen now?

A: I think when we think about staying healthy during COVID-19, we think about reducing our risk for getting coronavirus and other disease processes. But we also need to think about physical health. That includes eating healthy, exercising regularly, and some of that also crosses over into emotional health, which involves staying connected, and then there are mindfulness techniques, which crosses over into spiritual health, too, having a relationship with your higher power. All of that kind of blends together for health, and you cannot have any one piece of that and ignore the rest.

So when we talk about protecting yourself from COVID-19, nothing has changed. I’m looking at the CDC update as of April 24, and it still says avoid close contacts. It says stay at least 6 feet from others, do not gather in groups, avoid mass gatherings. But, what happens is, when we think about emotional health, we have this financial piece tied to that. If we are living out on the street, that threatens our physical and our emotional health. So we have to have our financial health in there as well.

So, for the most part, if we can go back to work, we need to earn a living, because when we work, that gives people a lot of emotional health as well.

You still want to do all the bottom-line things that we’ve been talking about. Avoid close contact, keep your hands off your face, and use good hand hygiene. You want to do that as much as possible while getting things done that you need to do.

If you need to work, go to work, but be as conscious of these practices as you possibly can.

Q: We’ve seen a drop-off in the number of people wearing masks while out and about. Meanwhile, places like Bethel Lutheran Nursing Rehabilitation Center were early adopters when it comes to mask-wearing. They have credited masks with stopping the spread of two asymptomatic coronavirus cases in their facility. What advice do you have for us on properly wearing masks?

A: You would want to wear a mask when you are out and about socially, particularly in those instances where there might be periods of time where you are closer than 6 feet away from someone. Like in the grocery store, where you have to walk by someone quickly, one going one direction and the other going the opposite direction. For that brief moment, it would be nice if you have your mask on in case you sneeze at that given moment, to protect the other person from your secretions.

Of course, if you have any signs of illness, which could be a cough, runny nose, simple things like that, you should be staying home No. 1. But if you didn’t realize you had it and all of a sudden have the urge to cough or sneeze, it would be really nice if you had a mask on. There are some people who are experiencing COVID without a sore throat, cough, runny nose — without any symptoms at all. They can still have a high viral load, however, so when they are breathing or talking or if there are a lot of them in close spaces for prolonged periods of time with others, they are still contagious.

You are at risk for getting COVID-19 based on your exposure to the virus and the time you were exposed to the virus. So if it is a giant exposure like a sneeze, that can be a momentary exposure and you are at risk for getting it. If someone is sitting quietly, if that asymptomatic person is sitting there quietly breathing, we are estimating it takes at least 15 minutes of exposure to that person.

Q: Some people have suggested that cloth masks won’t really do any good. They can’t block microscopic viral particles from coming into the mask wearer, for example. What’s the real point of a cloth mask?

A: A good experiment to do to see how effective cloth masks are at blocking secretion droplets from you is to sneeze in a room where you can see the sunlight streaming in. You can see your secretion droplets with a mask and without, and you can see when you use a mask there are fewer droplets in the air, even though the mask is only cloth.

One thing we worry about with the cloth mask is the sides of the mask, because they don’t adhere to your face. So when I have my mask on, I still cough or sneeze into my elbow. That is a really good way, a kind of double protection. I try to cover up those sides with my arm and forearm.

Q: What about other PPE, such as gloves at the grocery store? Should we really change gloves each time we pick up a new vegetable as some healthcare workers on social media suggest?

A: Changing gloves between each vegetable is not practical, and it would be bad for the environment.

I’m OK with gloves I guess if people are remembering that it’s not a substitute for good hand hygiene. You still have to wash your hands afterwards.

But to me, taking gloves on and off sounds risky. You can be diligent with that, and it can work out well, but you’d still have to wash your hands anyway.

I really think to me that it all comes down more to the basic things we learned at the start of this. Wash your hands often, and don’t touch your face. And just because you have gloves on doesn’t mean it’s OK to touch your face.

We also have to remain mindful of what we are doing. When you pick up produce from the grocery store, for example, don’t take a big whiff. That’s awfully easy to forget by the way — I found myself sniffing a candle the other day and was like oh no, what am I doing. So yeah, you really have to look at your environment and think it’s possible someone could have just sneezed where you are walking, where you are touching.

But don’t develop an anxiety attack over it. Just a healthy fear.

To me that means, whether we wear gloves or not, we will wash the produce when we get home. Wash your hands, disinfect your phone, and so on.

Q: Wash the vegetables? With dish soap?

A: I think it just depends. Me personally, I just rinse my fruit and vegetables off with water. That might be taking a little bit of a risk, but I don’t want to spend all my time washing fruit. When I’m done, though, I wash my hands, and I guess that’s the thing.

If you want to use a mild soap, it doesn’t take much to kill the virus. Just rinse them off, put them in a little bit of soapy water, and then dry them off.

Q: We’ve heard a lot about young people and COVID-19 that suggests the disease isn’t serious for them, but Dr. (Anthony) Fauci recently mentioned a troubling syndrome that’s being seen in some children with coronavirus. Could you tell us about that please?

A: This is a rare thing we are seeing in the pediatric patients, most of them less than 18. We have seen it in the U.S., and it’s has been reported in Europe. The reports of these patients are they become critically ill if they acquire this, and it looks like Kawasaki’s Disease or Toxic Shock Syndrome.

Both of those are kind of caused by the immune system going haywire. I want to stress this is something rare. If your child tests positive for COVID-19, this would be very rare. It would be a complication of that, but the risk is not zero. it is possible.

Treatments for it are primarily supportive care and often includes intensive care. We don’t know if there are milder versions of this that have just not been reported because no one made the connection.

Q: Does the summer necessarily mean we will get a coronavirus reprieve?

A: Wouldn’t it be neat if it was harder to catch coronavirus in the summer than winter?

That’s something we will be looking for. There are different ways to model this, but if you have coronavirus and can spread it to three others typically, so in the summer, if you catch people with coronavirus with the same exposure to the same number of people and they are only spreading it to one other during the summer, then that would tend to suggest there may be a seasonal component to this.

Q: Let’s talk about something else that’s the hallmark of summer. Pool parties. Summer is the season for that, and the pool is full of COVID-killing chlorine, of course. But does that necessarily mean it’s safe to invite the neighborhood for a pool party?

A: If you could be socially distant while swimming, it might be a good thing. The other thing we know is the virus is sensitive to ultraviolet light. I think it could be great, but I think that social distancing will still apply, even in a pool.

Q: There’s been a lot of talk about a resurgence of COVID-19 in the fall or winter. With the Spanish flu, there was a second, more deadly round. What should we expect with COVID-19 in this regard?

A: We have a sort of wait-and-see attitude with this. But given that the prevalence of coronavirus is pretty low, most people probably haven’t seen it, so it is likely at some point that more people are going to get sick. That is almost a certainty.

We don’t know if antibodies are going to be protective, nor do we know for how long they might be protective, if they are.

And again, if there is a seasonal component to this, like there is for influenza, RSV, and many other viruses, then we would expect more cases in the fall and winter.

What could result in a more deadly situation, No. 1, is if we decide not to social distance and just let the chips fall where they may.

The No. 2 thing is, if the immune system actually responded to the second hit of the virus in a more deadly way. So if the immune system actually went haywire, which is kind of what seems to be happening with Kawasaki or Toxic Shock kids.

No. 3, if the virus mutates and becomes either more infectious or more deadly.

Q: Do we see signs that COVID-19 patients are developing immunity? That will be a key component of a successful vaccine. How is that looking?

A: People are hopeful that the success we’ve seen with using convalescent plasma on people with COVID-19 suggests immunity developing from antibodies that are having a protective response. What we don’t know is if those antibodies are going to be able to reproduce with more exposure to the virus, or how long the initial set of antibodies you had are going to last.

We are hopeful that there is immunity, but the only way we will know for sure is what we see happening once people start getting sick a second time. Will those who had it before get it again? That is just going to take time.

Q: What’s the status on treatments for COVID-19?

North Dakota was given 50 doses of Remdesivir, which was made available under emergency use authorization. With that FDA guidance, there are some strict requirements, so those are being taken into consideration. The physician advisory group that is working with the Department of Health was also asked to come up with some criteria for patient eligibility.

Remdesivir is not a cure for COVID-19, but it may shorten the recovery time. We initially studied it for the Ebola virus, so we understand what many of the adverse effects are. It can be a little hard on the liver, and there are patients who can be allergic to it. Sometimes with the infusion patients can have a drop in blood pressure.

When you use medication under emergency authorization like this, you also have to report any adverse effects, so that data will be studied as well.

Hydroxychloroquine is another potential medication being used in North Dakota, and we are just kind of waiting to see on that. For in vitro studies (in a petri dish or test tube), when you look at the cells in culture, it looks like it has some activity, so we are waiting for the outcomes in actual patients.

For the convalescent plasma, we need more donors to get the relevant immunoglobulins from them, and make that it’s own package to give to patients. I know that Biolife in Bismarck is collecting plasma for that purpose, and it will go to Georgia where they will develop the hyper immune product that will be given to patients involved in a multi-center trial. I’m not aware of any North Dakota institutions involved in that trial.

We also need convalescent plasma so we can order it for use in our patients, so it is more immediately available.

Q: What about serologic testing? When are likely to see a viable test?

A: The big challenge with serologic testing is when you don’t have a high prevalence of the disease, which luckily, we don’t right now because of our social distancing, that throws off the utility of the serologic test because it dramatically increases the rate of false positives.

We also don’t yet know if getting it and having antibodies means it’s protective, or whether it will make you susceptible to getting sicker with the next exposure to the virus.

We see that sort of thing with dengue fever. The first time someone is infected with it, they are usually only mildly ill. The next time, however, it can be fatal.

We are really hoping that is not the case with coronavirus. It would be unusual as far as viruses go for this to be the case. But for those reasons, this idea that we just want to get it and get it over with — I don’t really feel that way. I don’t want to get it until I know that it will be protective.

The severe inflammatory response in children is also worrisome, and makes me want to keep my kids practicing good social distancing and not throw them out into the COVID jungle just yet.

Q: What about other health issues right now?

A: My sister asks this question a lot as well. So I think that when we go out in the world or stay at home, we need to think about our decisions as a risk-benefit analysis.

Dental services are one example where the visit is longer than 15 minutes, and you have to be within 6 feet of each other, so it’s a really good one to talk about this.

If you have a big history of oral hygiene problems, if you have cavities or gingivitis, the benefits of getting your preventative dental services will likely outweigh the risks of you getting COVID.

If you never had a cavity, and you don’t have gingivitis, maybe you can call your dentist and see how long they think it would be to wait before your preventive care visit. Just talk with your provider about it.

For well checks, a lot of that has to do with talking. We screen for all sorts of things by asking questions.

In my practice, we are using telehealth with both an audio and a visual component.

For sports physicals, we do as much as we can via telehealth. They come in for weight, measurement, and to get vital signs taken and to get immunized. Our goal is to get the patient out of the office within 15 minutes.

So I encourage people to call their care providers and see if some or all of their check can be done via telehealth.

Sometimes, you absolutely need a live visit. And if so, that is probably because the benefit of the live visit is worth the risk of coronavirus.

It’s also really important at this time to stay up on immunizations. We don’t want measles outbreaks and kids getting serious bacterial illnesses because their parents are worried about coronavirus.

Those don’t have to be a significant exposure for coronavirus if you work this out with your provider, and if your health system is diligent in having a priority of minimizing exposure risks.

We are also going to need a high rate of influenza vaccine this fall. I’m very concerned about what coronavirus and influenza in the same person at the same time looks like, and I don’t think it would be good.

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