Coronavirus (COVID-19): Press Conference with Paul Biddinger, 05/26/20




You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Dr. Paul Biddinger, vice chair for emergency preparedness in the Department of Emergency Medicine at Massachusetts General Hospital and medical director for Emergency Preparedness at the Hospital and Partners Health Care. This call was recorded at 11:00 a.m. Eastern Time on Tuesday, May 26.


Transcript


PAUL BIDDINGER: Good morning to everyone. Nice to virtually connect with you all again. So across the Mass General Brigham Health Care System, we saw our peak of hospitalizations in the third week of April, roughly April 22nd and 23rd, depending on whether or not you count the overall numbers of admissions or intensive care unit admissions, the peaks were within one day of one another. But since that time, we have been seeing really a linear decrease in the number of patients across all of our hospitals. The pace of decrease is somewhat slower than the pace of ramp up, which is actually consistent with what we’ve seen in other areas of the globe that were hit earlier than us, notably Italy. But thankfully, the number is coming down.


And at present, we still have about 300 patients across Mass General Brigham hospitals who are still in the hospital with about one hundred of those patients still in the intensive care unit. It is taking a while for those intensive care unit numbers in particular to come down. Many of the patients with critical illness from COVID have very long lengths of stay in the intensive care unit. And therefore those numbers are trending down more slowly than the overall number of patients in the hospital. We are still seeing some new patients with COVID, but that rate of presentations is decreasing. We’re seeing increasing rates of presentations of patients with other illnesses in our emergency departments. Specifically, general care, medical kinds of issues.


And as well, we have submitted our form for recovery, the attestation form to the state that is required as part of the governor’s recovery plan last week and are starting to see patients booking appointments for care that is urgent and meets the state’s definition, such as pediatric well child visits, vaccination visits and screening procedures for patients at high risk and others. And this comes in the background of an increased overall volume of no longer deferrable procedures. So what that means is that at the beginning of the shutdown, there were some medical procedures covered by the governor’s order that were elective at the time that were deferrable. And the more time passed, there were a number of patients who could no longer defer that care. And so that volume has been increasing as well. Overall, we are cautiously optimistic that we will be able to continue to increase volume.


Obviously, the state guidance requires us to make sure we have surge capacity in case there were to be another wave of illness. And everyone is cautious given the fact that we are gradually reopening parts of the Commonwealth. We ourselves are monitoring emergency department presentations of patients with COVID, hospital admissions and ICU admissions of patients with COVID as some of our earliest indicators in the health care system that there could be another surge. And so far, we have not seen any evidence of that. But of course, it’s early.


We definitely are encouraged by the cautious approach and we are certainly very much eager to be able to deliver health care for everyone who needs it. There is, as most all of you are aware, there’s a body of evidence that shows that a number of people have deferred health care longer than they should. And what we really want to do is prevent any additional adverse consequences from illness if people have been staying away from the health care system. So I’ll stop there and happy to answer questions.


MODERATOR: Great. Thank you, Dr. Biddinger. Looks like our first question.


Q: Thank you, Paul. First, I want to clear something up. If the G in your name hard or soft?


PAUL BIDDINGER:  It’s actually silent, I say. Biddinger.


Q: Biddinger. Okay.


MODERATOR: My apologies then.


PAUL BIDDINGER: Everyone pronounces it differently. It’s not something that bothers me, so it’s all good.


Q: It just matters for radio, that’s all. Okay. And so you’ve been talking about, we’re looking forward and you’re talking about the current state of affairs. But I’d like to ask you to just very briefly look back and talk about, you know, there’s a lot of very depressing analysis about how poorly America has done in general handling this pandemic. Can you give a bit of a glass half full analysis about, even if it’s just local, about what we have done well, what we’ve learned from this bout with the virus and what you expect us to do better next time?


PAUL BIDDINGER: Yes, I think, you know, obviously the pandemic is a tragedy and there’s no way to to deny that. But there have been good things that have come out of this. I think on a global scale, the pace of sharing of scientific information is unlike anything we’ve ever seen. The fact that new lessons are learned, reviewed, published, shared, acted on within days to weeks is absolutely extraordinary.


One example is what we call awake proning. Proning is when you position someone face down, belly down on the bed and actually improves their oxygenation and breathing. And it’s been done for years in some of the tertiary care intensive care units for patients who are on ventilators. But it was never really considered in patients who are breathing on their own as a way to stave off putting them on a ventilator. Lessons were learned about the effectiveness of awake proning in Italy and literally within one to two weeks we’re putting it to use here in Boston, which is just extraordinary. And there are lots of other lessons about treatment protocols that have been shared, reviewed, published that fast. And I think that’s really amazing.


I think the ability of the health care system to change has also really, really increased. We put telemedicine protocols, infection control protocols, operational protocols all into play within days to weeks, which would have normally taken months to years. You know, we rolled out systems of having iPads in patients’ rooms to help them communicate, telemedicine protocols to let our physicians speak with their patients at home. All of those things within a couple of days. Even our universal masking policy, where we started handing out thousands of masks every single day and restricting access to our hospitals happened on a Friday evening. And across many different hospitals, complete retooling of how people come and go from the hospital was turned on literally again within about a day. So the fact that the health care system moved faster is encouraging. Often times people use an analogy of a battleship that takes miles and miles to turn around, applies to health care. I think we’ve become a lot more like small, nimble ships that can move faster than we ever have before.


And last thing I’ll just say is that we’ve actually cooperated across the health care system in ways we never have either. As we were facing a potential surge where we were running out of intensive care unit beds, we set up a capacity committee across the entire city of Boston, co chaired by physician leaders from Mass General Brigham, as well as from the Beth Israel Lahey system. And all of the hospitals in the Boston area participated in daily calls – still participate, it’s still going on – to make sure that we have access to ICU beds available. We knew where there was capacity. We knew where there might be constrained capacity. And it really was an extraordinary example of collaboration among normally very competitive health care systems just to make sure the care was available.


Q: Thank you, beautiful.


MODERATOR: Next question.


Q: Hi, good morning. A couple of questions, if you don’t mind. Just first, following up on a couple of your colleagues at the School of Public Health, their comments to the Globe, just talking about their being still a very real possibility of a resurgence or a second wave. Do you concur with that assessment?


PAUL BIDDINGER: I think there’s always the risk of another wave. Unfortunately, of course, the virus hasn’t gone away and we don’t have any preventive measures. The science that we have available suggests that the number of infections in the community is not high enough to give us that herd immunity that I think everyone is pretty familiar with now that would decrease virus transmission. Really, what it is, it’s about making sure that we keep the opportunities for the virus to spread to be as few as possible. And I think there are a lot of measures in place that were not in place before, before the shutdown.


We have essentially a universal masking recommendation that went in public. People are wearing face coverings, which really does decrease disease transmission, we’ve now learned. People are more wary of social distancing. They’re much more aware of the need not to touch their face and to wash their hands. And definitely the opening society is going gradually. So certainly all of those things make me cautiously hopeful that we will not see a significant wave here in Massachusetts. Definitely, I think the fewer restrictions there are on opening, the greater the chance there is of a second wave, because, again, the virus is very much still out there and we need to remain cautious and vigilant. I think time will tell. But I think that the approach of going slowly and monitoring data such as monitoring new cases is definitely the right approach.


Q: So as we do see the reopening process start to unfold there, I mean, are there any sort of inherent threats that that does pose, though, as we go along the way?


PAUL BIDDINGER: Sure. I think the risk obviously is that more contact between people is potentially more opportunities for virus transmission. The hope is to make the pace of reopening appropriate for the decrease in the amount of virus in the community. If one line that’s going up, which is the opening, doesn’t outpace the line that’s going down, which is how much virus there is in the community, then I think we can avoid a major second wave. One of the greatest challenges with that is just how delayed the signal is between the action and the data.


What I mean by that is I mentioned that emergency department visits, diagnosis of new cases in hospitalized patients and ICU patients, those are really some of the most important indicators. But those lag typically by a week to two weeks after any sort of action happens at a societal level. So it’s a little bit like driving your car on the highway where you push on the gas or the brake, but it takes 20 or 30 seconds before the change gets into effect. Makes it really hard to drive when the delay between action and consequences is so significant. So just means we have to watch that data incredibly closely. It’s another argument for going slowly.


MODERATOR: Do you have a follow up?


Q: Just one more, if you don’t mind. So just moving forward now, would your emphasis to be along the lines of what the governor has been talking about, just kind of going to look what you’re just saying with the tracing and the testing, trying to yield those real time results?


PAUL BIDDINGER: Yeah, I think it’s really a combination of things. I think, again, going slowly and making sure that the testing data as well as the hospitalization data doesn’t suggest we’re going too fast is exactly the right approach. Again, testing can be swayed a bit by how many people we’re testing, which communities. So those numbers sometimes do and sometimes don’t reflect what is going on in the community in terms of disease prevalence. But overall, the number of hospitalizations, especially the number of ICU admissions, that really does reflect community prevalence pretty well.


So it’s really important data. I think, in terms of contact tracing and just overall more testing, that’s part of how we decrease the overall amount of disease in the community. So that’s sort of a direct intervention for how we decrease disease transmission with testing and contact tracing. So I think both are important. We should be as aggressive as possible with testing and contact tracing. We should be somewhat measured in how slowly we reopen just to make sure we don’t go too fast.


Q: And then just finally, is it is it your view just looking at the re-opening process going from phase the phase, is it reasonable to expect that would be a seamless transition or do you envision there being some set backs along the way?


PAUL BIDDINGER: I think this is unprecedented. We’ve never done anything like this before as a society, certainly not since the pandemic of 1918. So I think it’s probably inevitable there will be some lessons learned. There’s been so many lessons learned already along the way. My hope is, is that we’ll continue to be really flexible both in the health care system, but at a public health and policy level, that as new data comes in that says what either is safe or isn’t safe, that we act or we react quickly.


Q: Thank you very much, sir.


PAUL BIDDINGER: Thanks.


MODERATOR: Next question.


Q: Hi, Paul, thanks for. Thanks for doing this. I wanted to back up to some of the things you said earlier about the rapid pace of change in the health care system, things like everything from sharing scientific data to immediately getting masks on everybody. I wonder, as we look ahead, you know, clearly this pandemic has had a large effect on society broadly. What changes do you see being permanent?


PAUL BIDDINGER: I think probably the one that most obviously comes to mind is telemedicine. I think people have been working for years, probably really fair to say decades, on telemedicine, when it’s appropriate for patients not to have to come to the hospital, but they can see their doctor remotely. And the pandemic forced a lot of that on us. But both on the patient and on the provider side, there’s been a ton of satisfaction that that works. And, you know, you can understand as a patient when you don’t want to have to come into the hospital to park, to wait, to go through all of those processes, that it’s more convenient. And certainly, I think there are parts of telemedicine that are going to stay, just like technology’s changed so many other aspects of our lives.


I think there will be other parts of this is as well. I think health care systems, seeing now how fast they can change, will probably start trying to bake this into their leadership and organizational systems. You know, my world is one of disaster preparedness where we build systems to react quickly when there’s immediate threat in front of us. But I think there’s a lot that people are starting to think about that is applicable to normal operations where we’re not going to be in crisis mode all the time, but we are probably going to try and preserve those lessons of how we react and how we act quickly so that we’re more nimble organizations overall.


Q: Very good. Thank you.


MODERATOR: Next question.


Q: Thank you. Actually, just to build on Al’s question. So, what do you think will be easier next surge because of what was done this surge? And then going back to my original question, also, you talked about and I asked you to go positive and you did in terms of things that have gone right. But could you also highlight a couple of things that ‘we’re not going to do that again’?


PAUL BIDDINGER: So, I think probably I’ll start with that, because I think that that is really important. I think, you know, as we headed into the pandemic peak and of course, we’re still in the pandemic, but as we were heading towards the peak, we weren’t certain how big it was going to be and we weren’t really certain how we were going to do a lot of the things that were required of us, meaning surge to create all this new intensive care unit capacity, protect our patients, protect our staff, make sure we didn’t see excess disease transmission in hospitals specifically.


And what we’ve learned is that we are really good at preventing disease transmission, that we know how to take care of COVID patients safely, and we know what the personal protective equipment is for our nurses, for our respiratory therapists, for our physicians, for others. And we know how to configure the care space. So when we were heading into this, we basically pulled back to the core minimum of what we thought we could do as a health care system.


And that meant canceling an awful lot of elective and ambulatory procedures, visits, others, in order to to make sure that we created as much COVID capacity as we could. I think if we see significant additional surges of COVID, we hopefully don’t need to pullback in all of these areas to the same degree. I think we know how to deliver ambulatory care safely in the setting of COVID now. And I think it’s really important for patients to see their doctors, obviously, especially pediatric patients, for vaccines and, well, child visits. But really so much, you know, patients with heart failure, patients with diabetes, they need to see their doctors regularly. And I don’t think we’ll have to pull back to the same degree if we see another another surge.


I think also, you know, we do have effective infection control programs in place now. So we know that putting masks on all of our staff, all our visitors, all our patients, really helps to decrease disease transmission. We know how to clean, how to operate health care facilities. And really, health care facilities are very safe places to receive care now. And people should have a lot of reassurance that based on all of the lessons we’ve been learning over the last couple of months, we know how to deliver care both to patients with COVID and in patients without COVID.


Q: Thank you. What about closing down earlier, which it seems has made a huge difference. Just a matter of days can make a great big difference in various localities, right?


PAUL BIDDINGER: Yeah, absolutely. And I think there are two things about that. You know, hindsight, of course, is 20/20. And knowing what was ahead of us, I think everyone would love to have closed down earlier because that’s why we do it, is to prevent disease transmission. I think if you can picture the epidemic curves that we’ve all seen, they’re kind of slowly rising at the beginning for the first several days to weeks before they really accelerate and become very steep. And that’s the challenge, is knowing whether the curve really will accelerate and become so steep or not. I think it will be the challenge still going forward for looking for additional waves is that we’re not going to see a big, steep rise in cases early because that’s not how the disease transmission works. It means we have to look for very subtle signals in the data so that if indeed we have to slow the pace of opening or in fact go backwards, we have to pay attention to relatively small numbers. By the time we see big numbers, the decision will be too late.


Q: And so last question and just concretely about Mass General Brigham. So what’s that signal that you’ll be looking for in the weeks to come? How small is, like what is it concretely?


PAUL BIDDINGER: So it’s a couple of things. We still even now are comparing ourselves to those that went ahead of us, meaning mostly the northern Italian experience. But as I might’ve mentioned before, we have a health care systems engineering modeling group that looks at data from China, from elsewhere in Europe, elsewhere in the world, but really a focused a lot on the Italian experience, both both because of relevance as well as the quality of data that we have to use. And we have been decreasing on a pace similar to theirs.


I think if we were to fall off of that line, if we were to slow down or look like we’re increasing, clearly that’s a problem. There are in pockets of Italy, pockets of the globe, areas where cases have started to rise again. And what we do is, again, just try and look at the shape of that curve so that if it looks like we’re starting to look like a place that had a resurgence that we identified early. I can’t give you a number in terms of exact numbers of cases or percentages, but it’s really how we compare to those that are weeks to month ahead of us. And so far, thankfully, we’re not seeing anything that looks like that.


Q: Thank you.


MODERATOR: Just real quickly, I’m going to kind of connect a few things here. So Carey is asking about the stuff that went well and stuff that didn’t go well. And I have a question for you. What don’t we know that you wish we did know about the pandemic?


PAUL BIDDINGER: I think one of the most fundamental questions we don’t know yet is whether prior infection gives you immunity. There is so much talk about serology, about the blood tests and whether you have immunoglobulin or antibody against the virus. It is intuitive to us that prior infection will give you immunity. But we don’t know that. And therefore, the guidance that we give to people who’ve been previously infected or who might have positive serology, that that guidance is really on hold until we have a better sense of what that means.


If indeed it turns out that being infected gives you immunity, then we really want to know how long it gives you immunity for. Immunity is not always lifelong. Sometimes it’s only for a year or two. And so I think we really need to know that because that really affects how we think about populations and the overall ability of a population to withstand further waves. Last thing I’d just say is we really, really are looking for more guidance on treatment. As I said before, there’s an amazing amount of scientific sharing of knowledge right now, but sometimes it just takes time to properly learn lessons. If you try and share data too early, before the case numbers, before the analysis, before the outcomes are really known, you can end up making bad decisions clinically. So we just needed some time to let these clinical trials pan out, to analyze the data, to share the lessons. But certainly all of us are eager to learn what is the best clinical care for COVID patients that saves the most lives.


MODERATOR: Thank you. Next question.


Q: I hope you haven’t covered this already, but I was just wondering if you could – I was trying to do a story today on the, now that we’re all reopening again, could we just talk about the likelihood of a second wave. I mean, people are excited to be back out. And I think a lot of people may not be thinking about it, but what is the likelihood of a second wave? When is it likely to happen? And for those maybe who may not know the Spanish flu in 1918, my understanding, there was a second wave that was even larger than the first wave. So maybe you could hit on some of those points, please.


PAUL BIDDINGER:  Sure. Yeah. No, thanks. I we do. We did talk a little bit. I’m happy to to revisit because I think a couple more things we can can talk about. You know, one of the things that that was postulated about the second wave of the Spanish flu was that there was genetic change in the virus that both changed how it was transmitted from person to person, as well as the degree of illness that it caused. And so one of the things that’s been more reassuring today is that there has not been that kind of genetic alteration to the virus noted by anyone who’s studying it. So certainly we’re on guard for that possibility. Viruses mutate. That’s what they do. They change always. But in terms of a large second wave caused by a different virus that causes worse illness, so far we have not seen that.


You know, I absolutely understand why everyone’s eager to get back to normal. I feel the same way in myself, of course. But I think the point is probably more important. People sometimes think about waves like snow storms, like once the storm has passed, you can kind of go outside and play for a while until the next one comes back. And that’s really not the way that pandemics work. The virus is still out there and it’s still snowing, if I can probably overuse that analogy. The point is that we have to decrease the opportunity for the virus to be transmitted from person to person. So just because we’re seeing improvement does not mean that the threat has gone away. We have to be vigilant. We have to learn the lessons we’ve already learned about masking, about distance, about decreased numbers of interactions with other people. And even though people want to go back to the way it was before we had COVID, that’s just not possible right now.


And so what we have to do is accept the reality that the way we interact with one another has to be changed for quite some time. We can interact together more safely and more if we do it slowly, and if we rush too quickly or if we think that the first wave is passing and therefore it’s safe until the next wave comes, that’s really not the right way to look at it. The right way is to say we’re decreasing. We ourselves are decreasing that first wave and we need to keep acting that way or at least persist with some of our behavior modifications so that we don’t see that major second wave, because a lot of that, frankly, is under our control and not so much the virus.


Q: And if I could follow up, just so again, what what is the likelihood that we could have a second wave? When would it be? And even if we did everything correctly, could we still be vulnerable to a second wave based on what happens, for example, in other states?


PAUL BIDDINGER: Yes. So all of our behavior affects one another, and I think as we are learning more and more about how the first wave of COVID spread across the country, the risk of travel shows how interconnected we are. So I think definitely if there are increasing numbers in other states and there are a number of states in the United States that actually have increasing numbers right now, that that could potentially affect us here in New England, no question.


I think when a second wave could happen is really, there several cases in which that could play out. It could happen sooner if we reopen too fast and people start interacting with one another without masks, without appropriate distance in too significant numbers. But I think we’ll face another challenge in the fall as well when we probably have more people going to school, more people traveling potentially for college and kids maybe back in elementary or secondary school.


And then ultimately, as it gets cold, as we’re all indoors, more together in common spaces. So unfortunately, there are several challenges ahead in terms of either the pace of reopening or real logistical concerns that will happen in the fall and winter. So I think the chance of a second wave is pretty significant. Hopefully we’ll keep that wave small. And the way we’ll do it is by looking at the data available to us about the fact that we’re not decreasing, but we’re increasing and then we take the appropriate action across the whole commonwealth.


Q: Thank you.


MODERATOR: Are you all set?


Q: Let’s see. So it sounds like we really have to – just it’s just to wrap up – without any kind of vaccine that sounds like we’re just have to live with the fact that this is going to be with us for a while until we get a vaccine that’s widely disseminated then.


PAUL BIDDINGER: That’s exactly right. And, you know, I know everyone is overusing the phrase new normal, but I think unfortunate. That’s exactly what it is, is we have to accept the fact that some of these actions, some of these restrictions are part of how we all keep each other safe. And exactly as you said, until we have a vaccine and frankly, until it is widely distributed and administered to large populations, we’re going to be vulnerable to further outbreaks of COVID.


Q: The very last question I’ll ask is, if there was another significant second wave, that would obviously lead to we’d have to go back to another lockdown situation or something.


PAUL BIDDINGER: Yes, I think, you know, I think it would be a modified version, I think, of what we’ve been through. As I mentioned, we’re learning an awful lot of lessons on the health care side. I think for second waves, we won’t hopefully have to shut down the health care system quite as extensively as we did the first time. I think the same will ultimately be true at the business and societal level. I think there’s going to be an awful lot of continued study very quickly to try and identify which public health measures were the most effective and really make sure that we prioritize and sustain those.


And then when there are other ways to reopen, when we realized how we can operate businesses or how we can operate other parts of society more safely, that we can can support them and not have to shut down to the same degree. So it’s my hope that in future waves, even if we do have to reintroduce some of the measures that we’ve had in the last several months, they won’t be quite as blanket across all of society. We’ll have figured out which are the ones that really work best.


Q: Thank you.


MODERATOR: Next question.


Q: Alright, this is my last question. What is the latest on the extent to which infection control measures in hospitals, in particular the universal masking, stemmed infection? And I think it’s key, like, to what extent can that be extrapolated to the public going back out again? Like, how safe can people feel because they’re wearing masks at this point?


PAUL BIDDINGER: Yeah, I think there are lots of people right now trying to work on quantifying that. I think as everyone is aware, it used to be the dogma of infection control that wearing masks in public didn’t really change disease transmission. But that was for diseases pre-COVID and now the phrase that is being used is universal source control, which means that we all wear masks to protect each other. And I think there’s still a lot of popular misconception that masks are primarily to protect ourselves. And they probably do offer a degree of protection, but it’s mostly that we wear masks so that if any one of us is infected, we don’t infect others are around us. It decreases where the droplets go.


And so part of it is that it really has to be a community, a societal effort. We have to all buy into this and do this together if we’re going to protect each other. We’re definitely trying to figure out exactly the degree to which masking decreases transmission, but the early signals definitely suggest it helps. Secondly, we really need to figure out what kind of masking is helpful. Right now, the guidance is that non-medical people where some degree of face covering, but not necessarily a surgical mask or a medical mask. And that’s, of course, meant to preserve availability supply for the health care setting. There is some study of which face coverings are more effective than others. And unfortunately, a cloth or improvised face masks are not as effective as medical masks. But I think we’re going to learn an awful lot about what is an effective face mask that hopefully will be built into products made for the public, and some recommendations about how, again, as a community, we can decrease disease transmission.


Q: And in Mass General Brigham, are there any latest numbers about it?


PAUL BIDDINGER:  I don’t. I’m sorry. I don’t, yeah, I don’t have numbers that I can share, but we’re definitely trying to look at it and see what see with the numbers and the trends show.


Q: Okay, thank you.


MODERATOR: So I think if there are no other questions, then I go ahead and wrap up the call. Dr. Biddinger, do you have any final thoughts you’d like to say?


PAUL BIDDINGER: I think, you know, it is important to appreciate how many lives have been severely disrupted by COVID and how significant those stories are. But there’s a lot of good that can come out of this, hopefully in the health care system. I honestly think COVID, as tragic as it has been for multiple communities, has also shown a spotlight on health inequality and our need to do better for many communities among us. And so, you know, one way that we can build and improve from what we’ve been through in COVID, it is to recognize those inequalities and to really put special focused effort into remedying them. So there is good that can come out of tragedy. And I hope both in society and the way the health care system works, but also the way we treat one another with access to health care, there’s opportunity. So hopefully a potential positive outlook here as well.


This concludes the May 26 press conference.


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