Dr. Jason Smith, chief medical officer at U of L Health

Dr. Jason Smith, chief medical officer at U of L Health

LOUISVILLE, Ky. (WDRB) -- On Monday, less than 24 hours after Kentucky posted a record number of positive COVID-19 patients, Dr. Jason Smith, chief medical officer at U of L Health, addressed a number of questions about the recent spread of the disease.

He covered topics such as the death rate, the effect an increase in testing might have on the number of positive tests and the effectiveness of masks.

Below is a transcript of his answers verbatim (some of the questions have been rephrased for clarity). 

QUESTION: Can you provide an overview of what you're seeing in terms of the number of COVID-19 patients in Louisville, as well as the number of patients admitted to U of L Health?

SMITH:  I'm sure you've seen over the course of the last, really, three days and definitely the weekend, we've been seeing a pretty significant increase in the number of COVID-positive patients that are coming back through the multiple different testing portals throughout the state, and the city of Louisville.

We continue to monitor that situation and continue to monitor the overall admissions to the hospital systems. We've seen a slight increase — just a few patients — but in general, we are running about the same number as the total admissions that we have been, really, over the past month or so. No significant difference — if anything, maybe a slight decrease — in the number of patients admitted to ICU beds during that same period of time.

So from what we're seeing, it's been an increased number of positives without a lot of change in our overall hospital admissions, which is a good thing right now.

QUESTION: Can you explain the difference between the number of positive cases, verses the positivity rate?

SMITH: Sure. So, one of the things that is different, particularly when you start looking at positivity rates, is the number of tests that are currently available throughout the states and throughout the cities.

If you go back to, say, March of this year, when we first started the testing of patients, we would run about a 15 percent -- at times -- positive rate, simply at times because we had much fewer tests available to us, and we were only testing high-risk symptomatic individuals. 

Now we have overall expanded the number and types of tests we are doing. We are testing more asymptomatic individuals. We are also testing more people in and out of the communities, and we are identifying those patients either earlier, or in different age demographics, which leads to an increased number of overall positive cases, with maybe a slight increase in our rate that we had been running previously, but much lower than it had been, even back in March when we were seeing a really high in the number of positive cases.

QUESTION: Are you ramping up staffing in anticipation of a surge?

SMITH: We continue to assess staffing daily. We are actually increasing some of the available beds that we have at Jewish Hospital and opening up some of the units that had previously been closed, in order to have both ICU capabilities as well as the normal hospital bed capabilities during this time. 

We won't be bringing staff in until we actually have patients in the beds, but we do have those capabilities with our surge staffing plans to make sure that we do have the people at bedside if needed if we do admit those patients.

QUESTION: Do you expect to see a rise in cases in the coming weeks given there is a delay in the incubation of the virus?

SMITH: I would anticipate we continue to see an increase overall in the next few weeks.

If you look across the state of Kentucky, there are multiple counties now which have seen a lot of increase over the past, really, seven days. I think that was pretty indicative of the report that was put out by the governor's office yesterday regarding the total number of positive tests that we saw. 

That will continue, particularly as we see, really, over the next few weeks, that kind of come to fruition. As more and more people are exposed, it will have significant growth of the overall positive cases.

QUESTION: What accounts for the increase in cases and why are you not seeing an increase in hospitalizations?

SMITH: So the overall increase in cases are probably related to an underlying spread of the infection across the community, is the bottom line.

We are seeing more and more transmission of this disease in and around the community as people begin to travel, people begin to interact more, are in groups more -- and I think that is leading to those overall positive numbers.

Why are we not seeing an increase in hospitalizations? What we are seeing right now is an increase in positive cases in younger patients. So patients in their 20s, 30s and 40s are coming back more positive than patients in their 60s and 70s that we had previously seen. This is probably because -- again -- they are out and about and doing more -- are exposed to the disease more -- and while we have had some cases of being hospitalized in them, they have a much lower risk of needing hospital care for this disease than patients who are older.

QUESTION: Do you anticipate, if the number of cases continues to rise, that U of L will tighten restrictions on things such as visitation, elective surgeries, etc.?

SMITH: It is always part of our plan, depending on the number of patients and cases that we do have admitted to the hospital, to begin to revisit those things. We would like to have a staged approach, if at all possible, to identify where the greatest risks are and make sure that we can fulfill the healthcare needs of all of our patients. But that is something that we do look at.

As of for right now, we assess this actually every two days, and say, 'Is there something we need to do or have the admission numbers change that we need to begin lock down our facilities a little bit more to protect staff and families, or do we need to change our overall ability to render care in an elective setting?'

And as of yet, we have not had to do either one of those.

QUESTION: The governor mentioned cases in kids under 5. How would you know if your kids have it? What do parents need to know about this, as far as prevention and risks and things like that?

SMITH: So, we know that you can have this disease in children. It's much less common than it is in people that are older, or even into their 20s, 30s and 40s.

One of the things that you need to look for is kids that have signs or symptoms of a cold and/or a flu-like illness: fever, agitation, cough. Typically, you won't have a lot of sneezing with this disease. And that can be the first signs that they may have been infected or may have carried this disease.

We also know that, at least from the early-on evidence, that they typically have a much more mild course of the illness than adults do. I'm not quite sure why that is just yet. Again, this is a new virus and a new illness but it does seem to be the case. It's one of the things that you just have to look out for, and be wary moreso that they could then spread that to someone who would be more susceptible to the virus than they themselves.

QUESTIONS: What is the long-term impact for COVID-19 patients, even after recovery? What are the psychological effects for patients?

SMITH: Yeah, that's a bit difficult to answer and say right now. I know it seems like we have been going through this for ever now, but it's just been a few months. So we are just beginning to understand what some of the long-term consequences are for patients that have been affected by COVID or may have been in the hospital for a prolonged period of time. We don't know what impact it would have to their health or their psychological well being following this.

One of the things I remind everyone is that anyone who has been in the hospital for a long period of time -- weeks for example -- or has been in the ICU during that period of time, there is always some long-term debility that that carries with it. It may be something minor, but it may be something significant, and that's one of the things that I think more research needs to be done. We need to follow patients who are admitted to the hospital, in particular, more carefully as we move through this overall course of this disease.

QUESTION: Some critics have said that the number of positive cases are inflated. What do you say to that? On another point, are these positive numbers under-reported, given that some people don't get tested, and they just quarantine for 14 days if they have symptoms, or asymptomatic people don't get tested because they have no symptoms? If under-reported, what percent higher do you think positive cases are?

SMITH: Yeah. So I will tell you that I would err that these numbers are probably lower than I would actually see that across the state and across the city.

And that pretty much holds true for most of the diseases that we look at -- things like influenza reporting and stuff that we do every year, we know that we under-report those overall numbers. And it's simply for the reasons that you stated: people identify symptoms. They self-quarantine. They don't have a reason or feel poorly enough to go get a test, so they just assume they have it. And we never capture those patients. 

I will say that now, we have a much better idea of what is going on with the number of cases that we are looking at, because we are only counting the true positives. I think early on in the disease process, one of the things was we didn't have enough testing, so we actually looked at people who were very suspicious for this disease and had findings of this disease that we weren't able to test and we were considering them positive. Now we don't have to do that. We have much better availability for tests.

So those numbers are probably true. I don't think they are over-reporting anything. If anything they are probably under-reporting the overall prevalence of the disease within the community.

QUESTION: Do you expect the death rate to increase?

SMITH: I don't know yet. That's one of the things that we need to keep an eye on.

At least in the current outbreak that we're seeing, this is a younger patient demographic. So they're much less likely to suffer severe complications from developing COVID. It's not that it can't happen -- and that's one of the things I want to remind people: we do have young people in the hospital with this disease right now. However, much less likely than someone who is in their 60s or older.

I think one of the things we have to be prepared for, is as we see more people get this disease, it is simply a matter of time before we infect someone who is more susceptible to this disease -- either because of a chronic medical condition or because of their age.

And when we do see that, I do anticipate the mortality from the disease to increase. That being said, we've not seen that yet in this current outbreak.

QUESTION: Eileen [a reporter] is asking for you to describe the scene in the ICU and the area of the hospital right now with COVID-19 patients, verses the scene at the height of the occupancy during this pandemic.

SMITH: So the units themselves actually don't look much different than what they looked like during the height of occupancy.

I think the difference is a comfortable nature that the staff has in caring and dealing with these patients right now. One of the things we've learned is that if we have the proper PPE gear, we are able to protect our staff, to protect the people caring for the patients, and we do have the availability to give that gear to the people who need it right now.

Early on in this process, when supply chains were disrupted, we didn't really know how the disease was spread very well. It was a very different environment or a very different feeling within the ICU -- as opposed the actual layout or number of patients or things like that.

We do have a fewer number of patients than we had at the height of this. Probably about half the number of patients, currently. 

I think the more concerning thing is that, even though we kind of really saw that number of total cases decrease, we never saw a complete resolution of inpatients being treated for the disease, and so my worry is that it's still out there and it's still underlying, kind of, everything going on. And we need to keep an eye on it.

QUESTION: Can you speak to what medical staff has learned about this virus over the last few months and has made it easier to treat patients?

SMITH: So what have we learned over the last few months?

First of all, I think it's the understanding and the reliance on our personal protective equipment. Early on in the disease process, again, we didn't really know how this disease was spread well. If we think back to the end of February and beginning of March, we had some scattered data coming out of China on what was going on, but now that the world is at a much better understanding of how the disease is spread and how we can protect our healthcare workers, as long as we have that equipment, we feel pretty confident that we're going to feel safe in that regard, and can provide a good level of care. 

Also, we know that from a supportive nature of care, some things work better than others as far as treating this disease, and we know that there are some strategies of how we can manage the ventilator to make the patients more comfortable and try and get the best possible resolution if they do require ventilation during that time. 

Aside from that, this is one of those diseases that just requires a lot of time and energy to support the person. We don't have a cure, nor do we have a real treatment for this yet. So right now, I think, it's just a matter of putting the energy and time into making sure that they have the best outcome as possible. 

So from that answer, it's not easier, I think. It's just a better understanding of what is going on.

QUESTION: What would you say to people who see this increase as a sign that masks don't work? That is a common comment we are getting on our news articles.

SMITH: If we had greater, or around 95 percent mask utilization within the population when they were in and around other people, I would say that that may be a valid concern. But as of right now, we have not seen the prevalence of use of masks within the community — or within community groups — that would really show a significant reduction in the overall spread of this disease.

Use of masks is one of those things that, if a lot of people are doing it, we can see a really significant reduction in the spread of the disease because we limit the infectious agents that are produced by someone who is sick from this, whether they know it or not. 

Without it, even one person — for example, going to the grocery store and not wearing a mask — can contaminate 20 or 30 people who come through and are wearing their mask because it gets on their hands and they then touch food or their face or their car or something else, that then allows it to spread to the people within their family. 

So you have to have a strong utilization of masks to understand that it's going to have an impact on the spread of this virus.

QUESTION: Paul Miles is asking if we have any new information about the immunity of people who have contracted COVID.

SMITH: We don't right now. Again, that's one of the projects that was ongoing.

I think we were encouraged by the information that came out earlier about the vaccine and how one of the first trials for the vaccine has shown to have a really strong immune response, which was fantastic. That's really the first step in trying to identify some vaccination to limit the spread of this disease.

Other than that, we haven't really identified a strong correlation between the immune response or the timing of the immune response following infection.

QUESTION: Would you please characterize the COVID patients currently treated in your system? Can you break down the age ranges of U of L's COVID patients?

SMITH: I can give some general information. U of L Health has always had a slightly younger demographic of patients than some of the other surrounding health care organizations. So we still see a larger predominance of patients in their 30s and 40s. It then has a bit of a nadir, and then we start to see a significant increase in the patients over the age of 65.

Part of that is because of our testing that we're doing in and around the community — particularly in the nursing homes — that are identifying that older group of patients early on. It also is indicative of the testing that we're doing in the community, trying to get out into some of the neighborhoods to test people who are concerned who may or may not have access to some of the healthcare opportunities that others do. So that gives us a little bit younger demographic.

For us, it's not been a huge change from what we've seen previously. I think the difference is that if you look across the city, it's a much younger cohort than many of the other health care organizations around the city are seeing, more in line with what we have been seeing all along.

QUESTION: If there is a surge at U of L Hospital of COVID-19 patients, is there any concern you have of a protocol or lack of resource at the hospital that would make the surge difficult to support (not enough ventilators, PPE, etc.) or do you feel completely prepared?

SMITH: I don't think you can feel completely prepared for anything like this.

I will tell you that I don't have any concerns around ventilators, or beds, or personal protective equipment like I did early on in this. We have been able to identify and get more of this equipment.

I think if things kind of get out of control like they did early on in New York, or they may be kind of getting kind of in Texas and Florida, there are always concerns. When we start seeing 90 to 100 percent capacity in a hospital, even in the best of circumstances, that makes caring for everyone in that facility difficult.

I think the one thing that, from our standpoint, that we really have to keep a close eye on is our own staff. We are aggressive about identifying and testing those individuals.

My biggest worry is what has been seen in lots of other healthcare areas, is that when this is spread through the community, as we are currently seeing, our healthcare workers are part of that community. And they may be spread, they may be off work for a period of time. And if that is the case, that is my biggest concern, is that any pandemic like this will affect our own staff and the hospitals to a similar effect that it will affect the community. And we need to keep them in a regiment of testing and protecting them as much as possible so we can maintain our ability to care for individuals who come in.

QUESTION: I know there are different COVID-19 tests, but what is the margin of error for a false positive and false negative overall.

SMITH: So the biggest margin of error that we currently have is related to the specimen collection. Right now the test — or the Gold Standard test — that we use is the nasopharyngeal swab, and looking for, or actually identifying pieces or parts of the virus DNA. One of the things that we know is if we get a good sample, that test is very sensitive and specific for the disease to greater than 97 percent on both of them. 

So the test itself is excellent. That's why the technique for collecting the specimen is so important. If we get a good sample, we can say that we have done everything we can to get the best results of the test. 

And it's important that we get the right type of sample and making sure that we do get — if someone is having symptoms, we do identify the back of the nose as the area we want to culture and make sure that we get that sample, we get it to the lab as quickly as possible, to get those tests run and isolated.

QUESTION: What do you think we'll see going forward from here with numbers? How long do you think positive cases will go up? When do you think they'll level off? Is there anything else you want to add on what you think we'll see from here given your expertise?

SMITH: So I think the numbers are going to go up, particularly in the next week or so. 

I don't see, again, the mask utilization to affect that. I don't see the overall quarantine, or isolation, or social distancing that we have had previously in order to kind of stop this surge. So I think that's going to be the case moving forward.

Now what that will mean to the health care system, I don't know just yet. Again, my concern is that, as the numbers increase across the community, it will eventually see an increased number of admissions to the healthcare organization. I think that's just logical. I think that's going to be the case. So that's something, again, in the next week or two, that we are going to have to keep a very close eye on on what we need to do to deal with it.

QUESTION: Is it known how many people test positive are symptomatic?

SMITH: Right now we don't know that information. I've heard a lot of different numbers put out. From our current information, we don't have that to provide to the people who ask from a U of L Health standpoint. And in fact, I'm not sure that we have that from our overall healthcare organization standpoint. So I think it's the case -- I've heard anywhere from 10% to 40%. Again, it's very early in the disease process and it's hard to understand what that looks like.

QUESTION: Gov. Beshear calls this a wake-up call. What's your message to the community as the numbers rise?

SMITH: I would agree with Gov. Beshear that this is probably a wake-up call. 

Again, I think that if we don't start to have some significant buy-in from the community that we need to do something to curtail the spread, that there will be further quarantines that have to be put in place. And what those will be, I don't know. But I think in order for us to maintain our ability to go out into the community and do things, we have to take responsibility for those actions. And if we don't, I think we're going to get back into a situation that we saw early on in April when things were starting to be shut down.

QUESTION: If we don't take any action from here on out and continue as we are, what is Kentucky looking like?

SMITH: So I think if you look at the most recent information provided by public health officials at the state level, we have passed both Indiana and Ohio for number of cases per hundred thousand of population. That is on its way to being very similar to what you're seeing in Texas and in Florida, and my worry is is that's the type of outbreak you're going to see running around our facilities and our state if we don't start to try to have some things to curtail the spread of this infection across the Commonwealth.

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