73 - COVID-19 and Influenza (Dr. Clete Younger)

With COVID-19 still affecting our daily lives and influenza season approaching quickly, Dr. Clete Younger, physician at UnityPoint Clinic Family Medicine - Medical District, joins Dr. Arnold to discuss the latest information.

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Transcript

Dr. Arnold:

This is LiveWell Talk on COVID-19 and influenza. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. With COVID-19 forcing us to wear masks, practice social distancing, stores limiting visitors, church services not in full attendance, the flu season approaching quickly, we invited Dr. Clete Younger, UnityPoint Clinic family medicine physician, to share information and update. Welcome.

Dr. Younger:

Thank you.

Dr. Arnold:

Let's talk about the current situation with COVID-19. What are you seeing Clete, out in the clinic?

Dr. Younger:

So I think, you know, what we're seeing right now is we're learning a lot so we can treat it better. And now we're starting to see, now that we have such extensive testing, we're really getting a better idea of, you know, how extensive it is in our community. But also that, you know, a lot of people that get this, actually don't get sick. And that's one of the things that's making it so challenging. As we've tested more across the United States, we found that now somewhere around 80 plus percent of people are completely asymptomatic with it, which makes it very challenging then to contain it and explains why in the United States, we're having such a challenge containing it. Because a lot of people aren't sick. And if you don't know that you're sick, you're not going to be able to prevent the spread to somebody else. The fact that people don't get sick also then lowers people's calculation of risk. So they're willing to take more risks, because they're not getting sick from this. The United States is also a very unique country in that we very much value our liberties and freedoms and the combination of a virus that doesn't make a lot of people sick. And the fact that we don't want to be restricted in what we're doing as far as our activities, that cultural and viral comp combination has led to the fact where the United States is now carrying most of the burden of cases across the world.

 Now that's where we're at right now, because I think, you know, United States was early in adopting this reopening type strategy. It's going to be really interesting to see how other countries are able to manage this. Because while other countries that have locked down their populations more in the beginning have been much more successful with continuing the virus. South Korea would be an example. I mean, their case count is so much smaller than ours considering their population size. The challenge is going to be: is that sustainable? Is this something that's really going to be able to happen long-term? So one very interesting thing about the influenza season last year and where we're at with coronavirus, is last year in the '19/'20 flu season, the most common cause of death from influenza was influenza A, and it was strain H1N1. And we all remember H1N1 from 11 years ago when that suddenly appeared and became a very big deal right away, because we didn't have a vaccination for it right away. And that disproportionately affected pregnant women and children. And there was a pretty significant death rate associated with that. We were fortunate with H1N1 that we already had flu vaccinations, so we could easily manufacturer a vaccination to include H1N1. Here's the thing, we vaccinated for H1N1 for 10 years. The most common cause of flu deaths last year was the strain of H1N1. So even a virus that we've been vaccinating for for 10 years is still having a significant burden on death, year-to-year in this country and around the world. So the idea that coronavirus is going to suddenly go away when a vaccination's, developed is not true. It's going to be something we are going to have to deal with on a probably seasonal or constant basis going forward, just like we are with H1N1. We've accepted that that's there. Coronavirus is going to be there too.

Dr. Arnold:

I think what a more likely scenario is that much like SARS1, it just kind of fades over time. I don't think it'll be seasonal.

Dr. Younger:

It'll be interesting to see. We don't know. You know, I think that's the thing. You know, H1N1 is interesting just because it's still here and it hasn't gone away, even with vaccination. Now, will coronavirus behave like that or not? It's tough to know.

Dr. Arnold:

I mean, it's kind of a pet peeve when people try to compare the two, because they're not, they're two different viruses.

Dr. Younger:

Yes.

Dr. Arnold:

They act completely different. The analogy early on that COVID was similar to the flu, you know, we do not see 50 year old males with just a little diabetes or hypertension have acute respiratory distress syndrome with flu. We don't. So that, so it's different from that standpoint definitely. And the testing. And I think sometimes people hear the word cases, which it's really just a positive test, it's not really a case. You know, it's not being treated. As you pointed out, the asymptomatic, which puts a lot of strain on that. Maybe, I think you would have talked about this before, but you know, the social distancing we did in February/March almost just eliminated the flu.

Dr. Younger:

Yes.

Dr. Arnold:

So I think that proves right there social distancing works, quite honestly. And I think we'll have to continue that in the fall with influenza.

Dr. Younger:

And that is going to make influenza and RSV and other coronaviruses really interesting this year. Because we've seen, you know, with all the things we're doing now, a significant reduction in the amount of kids that are sick. Some of the pediatric offices, a lot less visits for ill kids, because they're not mixing with each other and we're doing these distancing and mass techniques. And the influenza issue we were dealing with in March, which in March was actually a bigger problem. In Iowa, for example, was influenza. And that just disappeared in 10 days because we started doing all this stuff.

Dr. Arnold:

Yeah. And I'd had those, I did have those numbers in one of my previous podcasts. It just went away.

Dr. Younger:

Yeah, it was very interesting. So it'll be interesting this fall, because we're still going to be doing masks and distancing. So the question is: what's going to be more impactful? Our distancing techniques in lowering the rates of influenza, or the reality that probably less people are going to get food vaccinations this year because they're afraid to go out and get them. And so that's what nobody really knows, because we're probably going to have less vaccinations because people won't go to HyVee and get them like they used to, or come to our clinics and get them like they used to. So how are you going to get those people vaccinated. Or, is the fact that we are still very restrictive with what we're doing as far as connections with each other, actually going to have a big impact on flu and we're not going to see nearly as many cases this year. And that may trickle down to things like RSV. You know, from a kid's standpoint, RSV is much more significant of a disease than coronavirus is. As far as the burden of, you know, on children and hospitalizations and ER visits. So are we going to see less of that because kids are mostly wearing masks in schools and some of those kids are virtual? So that's a big unknown that will be interesting epidemiologically to see as we go through the next 18 months.

Dr. Arnold:

I think we moved the goalpost a little bit. And this has been a frustration that I've had. When we started the social distancing and lockdown it was too slow. We had no immunity in the community and it was to slow that down, so it wouldn't have overwhelmed healthcare system. And we did it, it worked. And somewhere in there, we went from flatten the curve, so not everybody showed up on a Tuesday sick. And we made that happen, right? But then all of a sudden now I hear people say, well, you need to prevent cases. And you can't prevent mother nature. I mean, you can slow it down, but it'll come back. And I think that's been frustrating for me in articulating the measures that we need to take, because it's not about prevention. It's about timing. It's not a numbers issue, it's a timing issue. But that's, that's gotten lost in the messaging someplace.

Dr. Younger:

Yeah, I mean, we're definitely in a situation where, you know, in Iowa we're special in that we're not overwhelmed with COVID patients. We've learned a lot since March on how to take care of those patients and made our efforts to treat people that are very ill better. So now as somebody who gets COVID-19 in Iowa, if you get sick enough that you need to be in the hospital, one, there is capacity that exists. And two, we know a lot more than we did five months ago. So it's definitely a better place. We've definitely, I mean, the curve is pretty flat. If you look at Iowa, it's kind of like a big plateau right now.

Dr. Arnold:

Right.

Dr. Younger:

We're just kind of sitting at the same amount. The question will be when school opens, you know, does that change that at all? And I don't know if we know that yet. Just because I think the schools are going to react to cases in such a way that we're probably not going to see a big spike, because they're not going to let that happen in the school because they don't want that to happen. So we're probably going to sit at the same plateau for a period of time. And probably the question is, is there going to be a point where vaccination and the number of people that have gotten sick finally gets us to that herd immunity number of 60 or 70%. You know, once we've had enough people that have had it and we finally gotten vaccinations and distributed, where then we have a better kind of immunity.

Dr. Arnold:

But one good news there is, they think the herd immunity number for this might be a lot lower than based upon New York. I mean, New York got slammed with the most deaths. But then once they were over that hump, they've done fairly well with it as far as new cases for being very limited. And it's just kind of wait and see right now. But I think that the take home point is, we have the capacity.

Dr. Younger:

Yeah. I mean, I feel as an Iowan, you know, or living in Cedar Rapids for example, very safe because our healthcare system is very good and very robust. And if somebody gets sick, we have the capacity to take care of them. Every day in my clinic, I have somebody tell me either if they get coronavirus, they'll die. And so then we have to reeducate on: actually, if you get coronavirus, you probably won't get sick. That's the tricky part. There's only a small proportion of those patients that get it, that actually get ill. And two, that if I get it and I go to the hospital, nobody's going to be able to take care of me. And I have to remind people, that's not the point that we're at. We're actually at a very good capacity. We know what we're doing. We have the ability to take care of sick people in our hospitals. And you shouldn't fear that we don't have the ability to do that if you get it.

Dr. Arnold:

Well, that goes back to that people—it'd be a whole other podcast about the media and the hype from it. But, you know, they equate cases with admissions. You know, I had patient tell me on the other day: oh my gosh, are you okay? Yeah, I'm fine. Well, you guys had 40 new cases. Maybe. I don't know, we had two admissions, you know, and out of that. And I think that is misleading at the minimum. Let's go back to stressing the importance of getting the flu shot. I think that people have trepidation with vaccinations to begin with. I mean, I'm a strong advocate for vaccinations. But as you know, there's a vocal minority of people that do not support that. What's your advice as far as getting the flu shot? You said there may be some logistic issues with patients not wanting to travel.

Dr. Younger:

Yeah. And we're trying to work through that. I think the thing about flu is so, you know, every year in the United States, between 40 and a 100 thousand people die from influenza. Right now, we're at 170,000 deaths of coronavirus. But in the last four years, more people have died from flu than coronavirus. So flu is still a big deal. In certain years, we can have 80 to a 100 thousand deaths of influenza if it's a bad year. So it is a very significant disease. If you look at the world in the '19/'20 flu season, there's been somewhere between 400 to 600 thousand deaths. And in the world right now we're at like 700 or 800 thousand deaths of coronavirus. So, I mean, it is still a very significant disease that we shouldn't ignore because coronavirus is the more prominent kind of news story right now.

 I think the things with the influenza vaccination that are significantly different are: We've done this for a long time. We know a lot about that vaccination. We know a lot about its safety. We give it to, you know, hundreds of millions of people across the world every year. So we have a lot of experience with it in its safety. And it treats a disease that does have a significant burden on our elderly population, people walking around, and kids, more so than even coronavirus does. The other thing that's interesting with flu vaccination is it really should be a seasonal commitment. One of the things we know about influenza vaccination, subsequent vaccinations actually work better than if you just get it intermittently.

Dr. Arnold:

Right.

Dr. Younger:

I'll have some patients that'll be like, well, I'm going to wait and see if it's a bad year and if it's bad year I'll get it. And if it's not a bad year, I won't. And the data actually says, if you get the flu shot every year, it's more effective than if you get it intermittently. So healthcare providers and people that are required to get it every year, actually a better immunity than the person that will get it once out of every three years.

Dr. Arnold:

It's interesting you say that. So early on during the COVID pandemic, you know, there's a lot of literature is coming out. I was reading about the Spanish flu. And so I remember at one time being told or reading that it really affected young people, military-aged people. Well one, it was world war. They were, you know, being demobilized or living in close quarters. But they also thought it was because it released a cytokine storm and they have these immune systems. And the older people actually did better than the younger people. Well going back, they think there is a, in around 1890, there was an influenza epidemic. And they think some of those people that lived through that had a little bit of immunity that spilled over into the Spanish flu that prevented them. So it's what you're saying is, you know, continually given it does have immunity year to year.

Dr. Younger:

So the other interesting case happened about five years ago. So what we had with influenza, the dominant strain of influenza for two years in a row was the same. And that does not happen very often, but that happened five or six years ago. And what was interesting about that year is it gave people a chance to do research on that. And what we found is the people that had been vaccinated the season prior, still had immunity a season and a half later. So this idea that, Oh, I should only get the flu vaccination in October so it will protect me in January, February, March, there's actually not evidence to support that. And actually based on the evidence that we have from those two seasons that occurred back to back, your immunity from a single flu shot can last years. So really what we want people to do is get the flu shot early. It's going to last the whole season, and it's probably going to last into the next season. And that's important on stacking those flu vaccinations by getting them each year. You're protecting yourself for multiple years, going forward with the strains that are given during that particular flu vaccination. So that was an interesting case study too, that we didn't know how long it lasted. Now we do, it's better to get it early. It's better to get it every year. You're going to do better with influenza if you do that.

Dr. Arnold:

Have you ever read of how they determine the makeup of the vaccine each year?

Dr. Younger:

I mean, I know some of the details about using the winter in the southern hemisphere.

Dr. Arnold:

Yeah! It's like six scientists in Sydney, Australia. From all over the world, six of these experts, sit in a room and kind of just negotiate, based upon the data, what they think it's going to be. And it's not computer models. It's just good old-fashioned scientists brainstorming out, which I thought that was kind of interesting. What are the best steps for treatment of COVID-19 on these patients that have mild symptoms but don't require hospitalization? What are you recommending?

Dr. Younger:

So what we're talking to patients first about is, try to not get other people sick. So number one, particularly your family and anybody that's in your family that's higher risk. People need to rest. They need to try to reduce stress. Because we spend probably half the time, with positive cases, trying to calm anxiety about it. Because again, people think they get coronavirus and they're going to die. So reeducating people and just understanding that if you get coronavirus, you're not, that's not a death sentence. You're probably going to get through this fine. But things like rest, fluids, and Tylenol are the key. Not putting your body under undue strain is a good thing, so that you can recover. And understanding that, you know, some people have symptoms for a couple of days and he gets better. But sometimes this lasts for about a week, or a little bit longer.

 I think the things that we're teaching people that it's different with coronavirus and other viruses, people think of bronchitis as being this cough that lasts four to six weeks. And I can't tell you how many people that have told me they had COVID in February or January because they had this terrible cough and it lasted for a month and a half. That's actually not what coronavirus does. It can cause a headache, cough, sore throat, muscle aches, but it doesn't cause the prolonged cough that other viruses do in the upper airway. Coronavirus is bad down low, but not necessarily up high. So if you have a cough with coronavirus, it's probably gone, or almost always gone, at day ten. So educating people that cough isn't really what they need to be as worried about, because that part's going to get better. What they need to do is stay hydrated, keep their temperature under control, and really monitor for increasing respiratory problems. So breathing problems, shortness of breath. Because those are the people, if they get worse, typically about a week later after the infection, those are the people we really want to keep an eye on as far as keeping them healthy. But it is nice to know that it's not a typical bronchitis thing where you're going to have a cough for a month. That's just not what coronavirus does.

Dr. Arnold:

Yeah, and that post-viral bronchial asthma that people get, that cough, is so hard to treat. Because it just kind of gets better on its own. I always say you want to be the last doctor that saw him.

Dr. Younger:

Yep.

Dr. Arnold:

Because they'll go to five different physicians and you see them last and then they just get better on their own.

Dr. Younger:

No matter what you do.

Dr. Arnold:

They're like, man, Arnold's brilliant. I went and I saw Younger, he didn't know what the hell he was doing. But man, Arnold cured me right away. And when you're the first one to see it, you're like: Oh my gosh, this is not going to get better.

Dr. Younger:

Yeah. So it is unique that way. And so it presents a little bit differently and then we have to manage it a little bit differently. So we definitely learned a lot in the last five to six months.

Dr. Arnold:

Now, I think that the myalgias with influenza is always so overwhelming. It's kind of just a unique thing to that where you see people so devastatingly weak and prostrated. Are you seeing that with coronavirus?

Dr. Younger:

We are. What I've seen more actually is apathy towards eating and activity. So it's kind of more of a fatigue than a muscle ache. And now I've dealt most of the COVID patients that I've taken care of, a hundred or so directly, have been in the nursing home setting. And really in that population particularly, appetite loss is significant. And that's one of the things we've had to battle with is keeping people hydrated, because they just don't want to eat or drink anything for a week. And they'll tell you that they're achy and don't feel good. But I agree, it's different than the myalgia associated with influenza. They're definitely different. Unfortunately, we sometimes see that apathy towards eating lasts for weeks, up to a couple months before it's come back. You know, one of the biggest outbreaks that I dealt with back in April, we're finally seeing the patients that were sick then that had that appetite loss, finally come back now here in August. And it's taken two to three months to get to that point. In the people that had the bad appetite loss at the beginning, it persisted for quite a while and they just didn't feel good. They were just apathetic to wanting to do anything or eating. Different than influenza, where once you get people through the myalgia part of it, that part's gone. And then you don't have to worry about that anymore.

Dr. Arnold:

I mean, you could almost walk in a room when you make hospital rounds and say: Oh, that person has influenza. Just by the way they're postured in the bed and they just look sick. Let's just kind of wrap up with the last question here. But so at what point, I think you kind of hit on it, but let's just go over it again. What point—I got exposed to COVID, I'm not feeling too bad, I don't want to go get tested because I'm not feeling bad, I'm isolating myself. But at what point do I say: I better call Dr. Younger?

Dr. Younger:

So I think the first part you said was a good point. If you have minor symptoms that you can manage and you've had an exposure, you don't need to be tested. We are, you know, struggling with the burden of testing and we need to be able to have testing for people when we needed an urgent situations. For people who have exposure and minor symptoms: sore throat, cough, maybe a headache, maybe some muscle aches, and they had a covert exposure, they should presume they have it. They should treat themselves with Tylenol and fluids and isolate themselves and take care of themselves. And not necessarily get testing because that puts you out in the community. And if your symptoms are mild, testing isn't going to change anything that we do with treatment.

Dr. Arnold:

Right.

Dr. Younger:

What people need to watch for is progressive shortness of breath, or not being able to breathe, or feeling like they can't get a breath. Those people need to be evaluated. The people that struggle with coronavirus or when they get to day seven or eight or nine, and we've seen this as a phenomenon with this particular virus, is that it causes inflammation and damage deep in the lungs. And people then can't get oxygen into their bloodstream as efficiently, that makes them feel short of breath. But those are the patients we worry about getting a lot sicker, when they get that deep damage associated with coronavirus. So somebody who is sick at the beginning, but then it's mild and goes away, you're going to be okay. Somebody gets sick at the beginning with a sore throat, headache, fever, and they're doing okay, then at a week they really start to feel short of breath. They need to seek care right away. That's a person we need to evaluate. Because that's a person, with early intervention we can make a better difference in how they're doing later. So day one and day two, that's not where the big deal is. In influenza, sometimes that can be, when they're the sickest at day one or day two. It's the people with symptoms still at about a week, and with shortness of breath, those people need to speak with a physician about what to do next.

Dr. Arnold:

I think another point just to post-exposure, because I've seen this happen. A patient get exposed on Monday, they go to the doctor on Tuesday and want to be tested. Which you know, it has to be at least 48 hours. I recommend 72 post exposure. Clete, this is really great information. Once again, that was Dr. Clete Younger joining me today to discuss about COVID and influenza, and I'm sure there will be more to follow as the season unfolds. For more information, visit UnityPoint.org. Thank you for listening to LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcasts. We're available on Apple Podcasts, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.