Leading Tampa medical specialists hold town hall on COVID-19

The Hillsborough County Medical Association (HCMA) recently held a virtual Town Hall for physicians featuring expert panelists Dr. John Sinnott and Dr. Douglas Holt to talk about what's new and what's next with COVID-19. HCMA President Dr. Michael Cromer moderated the May 27 event, summarized below by retired OB/GYN Dr. Bruce Shephard.

Dr. Cromer: This Town Hall meeting is titled "From 'What If?' to 'What now?' '' Our panelists are Dr. John Sinnott, Chairman of the Department of Internal Medicine at USF College of Medicine as well as an epidemiologist for Tampa General Hospital, and Dr. Douglas Holt, the Health Officer for the Florida Department of Health in Hillsborough County and Professor of Medicine at USF College of Medicine.

To begin I would like to ask each panelist how your life has changed in the past three months.

Dr. Sinnott: I was minding my own business running a department of medicine, thinking I had left most of my infectious disease days behind. While in Asia over New Year's, on January 2, I heard about this odd virus in China and immediately became concerned about SARS. By the end of January, I knew we were going to have problems. Ever since, it’s been extraordinarily busy with planning, preparation, and really has changed what I do a lot. We had been focused on research and now we’re focused on taking care of critically ill patients.

Dr. Holt: I call it “BC” -- before COVID. I was leading a Health Department of 400 dedicated professionals who are really trying to give everybody the opportunity to live healthier. Much of what we do involves a long-term vision to influence a community toward better health. As I recall, it was a Friday night and I thought I was going to have a quiet evening when I received a call from a state epidemiologist who said we had just had one of the first COVID cases in the state. Since then it’s been minute-by-minute, hour-by-hour. It’s full, it’s exhausting, and at times exhilarating.
Dr. Cromer: Dr. Holt, I believe it has been your staff and department that’s set up free testing around our county. How did that come about?

Dr. Holt: It’s been a completely collaborative effort. Our [Hillborough] County has done the sites, the hospitals have stepped up with the staff, we’ve had support from the City [of Tampa]. It’s really been a community effort.

Dr. Cromer: How does this pandemic compare to others in the past?

Dr. Sinnott: There was a massive pandemic in the 1880s, but there was not good record keeping. But the result of that pandemic was that people started keeping records. It started in Germany, went to Great Britain, and then the U.S. The first well-documented pandemic, the Spanish Flu of 1918, arrived in the spring, originating at a pig farm in Kansas while WWI was in full swing and they were busy sending troops off. The doctor who wrote the original account said he was seeing 10 patients a day at first but soon 200 patients a day. He noted at least a fourth of them died in the prime of life. Because of a lack of knowledge and communications, they shipped the soldiers off to different ports from which the virus was rapidly transported to Europe. In the war, neither the U.S. or Germany reported our cases and it wasn’t until neutral Spain reported their own severe losses of a quarter of their population that the epidemic was recognized and got the name Spanish Flu. Something like 50-100 million people died, the greatest pandemic to date, with many suffering long-term effects like encephalitis and Parkinson’s Disease.

Dr. Holt: In more recent times, we’ve dealt with Swine Flu, S1N1, West Nile, Zika, and others. These were not pandemics, but rather outbreaks in localized populations. HIV was a pandemic but had much narrower risk factors for which we now have effective diagnosis and treatment. This is completely beyond anything I have experienced in my career. Looking back, the Spanish Flu does tell us some things that we’re clearly seeing: Personal space matters. Crowded places are dangerous. And if you get mixed messages and you don’t follow policy directions, there are consequences.

Dr. Cromer: Dr. Sinnott, you have been to the lab in China where this virus has been studied. What are your thoughts on its origin?

Dr. Sinnott: That laboratory was designed with the assistance of the U.S. and operated to American standards. One of the pathogens they specifically work with is coronavirus, which is the number two threat to world stability from infectious disease after the influenza virus. China had wonderful flu facilities so they wanted corona facilities. This was not a biologic weapons laboratory. The idea that it escaped from there doesn’t make sense to me. This lab is at least 50 miles south of Wuhan and it’s a crummy road. So how that leads to 14 men getting sick at a wet market doesn’t make any sense. There is no evidence whatsoever that this virus was biologically engineered. There’s no evidence it was grown in a lab. There’s no RNA sequence that corresponds to this. It’s unique.

Dr. Cromer: What are your opinions as to how we, nationally as well as in Florida, have managed COVID-19?

Dr. Holt: Clearly there are some things we have done well and there have been some things we haven’t done well. With testing, we did not do well. We came up with a complicated test and persisted to make it work. It’s very good, accurate, but a challenge to administer compared to some of the others the world has used. Now we’re doing the opposite, sort of rushing to put a lot of tests that haven’t really been validated out there for people to use to get tested and that’s creating, I think, some confusion.

I think we’re really a nation at war in the sense that each state has had to fight its own battle without coordinated leadership from the federal government.

Locally, I think we’ve done very well partly because we’ve had good relationships between our medical community and our health departments. The hospitals, too, have put their competitiveness aside and stepped up. I was just on a call today with all the area hospitals to discuss how we can meet the challenges in long-term care facilities. Our public leaders have also stepped up and initiated some early social distancing practices. But the challenge I think we all face is so much politicization around it. But there are many other parts of the country that are much more extreme so I’m proud so far of what we have done as far as a community in responding. But the fight’s not over.

Dr. Cromer: Dr. Sinnott, what are some of the practical things we can do as citizens to protect ourselves?

Dr. Sinnott: Number one, just like the early days of HIV, we need to consider everyone potentially contagious. People can look fine, but spread this virus by talking, coughing, or sneezing. No matter what you read, it is airborne for anywhere from 30 minutes to three hours. The facemask protects to some extent but the surgical masks often used really protect other people. It’s almost a social obligation to protect others by wearing a mask.

Second, there is literature showing that people who have low vitamin D levels do not do well with this virus. So probably 4,000 units a day is what most people in infectious diseases would recommend. They would suggest also that high-touch surfaces are going to require the use of hand sanitizer and alcohol wipes almost religiously.

Ninety-five percent of cases I treat don’t know where they got it. The other 5% probably got it by touching something. It’s not a hardy virus but it loves to spread indoors, person-to-person.

Dr. Holt: And I would add good hand-washing, of course. It really comes down to situational awareness. Know where you are going, know when to take those extra precautions, maybe know where you shouldn’t go.

Dr. Cromer: Why is it that this virus appears to have a particularly high mortality rate?

Dr. Sinnott: In the same way that HIV presented us with a unique and not previously recognized illness, we find ourselves with the same thing now. We now know there are two disease processes going on. One involves an inflammation of the endothelium -- the blood vessel lining -- causing either blood clots or bleeding and we’re not sure why some do one and some do the other. Second, and this usually happens later as your body begins to respond with the adaptive immune system, you run the risk of "cytokine storm,'' a catastrophic immune over-response that can cause kidney and pulmonary failure.

Dr. Cromer: Given this multi-system presentation, what are your opinions on the various treatments being studied for COVID-19?

Dr. Sinnott: No one really has the right drug. And there’s an old saying in medicine: “When there’s not one treatment, there are many” and everything under the sun has been tried. Remdesivir has been the most successful so far. It shortens time on the ventilator from 18 days on the average to 13 days. This is the key reason we run out of ventilators because the average stay on a vent is 3.4 days. Now all of a sudden someone was on it six times as long. That ties up everything. Remdesivir helps with that and we’ve used it extensively. With another treatment, plasma infusions (plasmapheresis) from patients that have recovered, the results are more subtle and we don’t see as clear cut of a response. 

Dr. Cromer: Dr. Sinnott, what kind of research are you doing at USF?

Dr. Sinnott: At Tampa General right now we are involved in probably 14 different studies including one on how to best prevent infection in health care workers, another on how to treat people that test positive but are not sick, and a variety of ICU therapies. So, we’re still looking. I think the great hope is the unique RNA polymerase that this virus has and I suspect that long before a vaccine, somebody’s going to use a platform similar to the therapy we use for hepatitis C by using an anti-RNA polymerase compound. I hold out much greater hope for that actually than a vaccine partly because the public is very skeptical about vaccines. Plus, in the American mind, people like to take pills. Developing a vaccine is a very complex process but may offer a solution in the longer term.

Dr. Cromer: Having been involved in pharmaceutical research, do you have any idea of a timeline for an effective treatment for this virus?

Dr. Sinnott: I would imagine that by next spring we’ll have some idea of an oral agent or perhaps a medication that can be given by injection or intravenously, and in two years probably a more definitive therapeutic medication. 

Dr. Cromer: Dr. Holt, what are your recommendations around testing, starting first with the diagnostic PCR test?

Dr. Holt: In the diagnostic world, the PCR is a very good test if collected and processed properly. This is a deep nasopharyngeal swab test where you’re looking not for the virus, but the RNA. It’s processed by machines in state-of-the-art labs that hospitals routinely use in our community. But there have been reports of labs running tests without the quality standards, particularly some of the drive-through places.

False-negative PCR tests in people who actually have COVID-19 generally are because they were collected too early in their illness or the collection process was not adequate. This can also happen if the test is too late in the illness and it’s already moved down into the lungs.

There is also a newer rapid test, a nasal swab PCR test with results in 5-15 minutes, that was designed to be used in point-of-care settings for symptomatic people, not for screening. You’ll see a higher number of false negatives in this rapid test so negatives should be followed up with a confirmatory nasopharyngeal swab.

Dr. Sinnott: A negative PCR test is not definitive. As noted by Dr. Holt, it could be due to sampling error, too early in the illness, and so forth, but with a positive PCR, if done correctly, we have to assume it is quite accurate. I look at a positive PCR test as the fingerprint at a crime scene. The next step after identifying people who test positive is trickier. We have to culture live virus which is sort of the holy grail of diagnosis. With a second type of diagnostic test, antigen testing, there are many problems with contaminants and it doesn’t appear useful at this time. Long-term, there’s a third type of testing, antibody testing, which will tell you exposure to the virus, its prevalence, but, in our current state of knowledge, not whether you’re immune or not. But it still would be valuable information. We may have had twice as many cases as we think which would tell us if the disease is milder. I don’t think that will be the case but it would be a delightful finding.

Dr. Cromer: Should there be widespread PCR testing for COVID of asymptomatic people in the general public?

Dr. Holt: Right now, we’re doing it in the long-term care facilities and that’s a population we need to know. The testing of asymptomatic people in the general public provides some value in getting an estimate of how much virus is out there. It’s not an ideal test to use that for and we don’t have enough labs for population screening at present since a more urgent need is to test symptomatic people.

A positive PCR test in an asymptomatic individual for me is a challenge only because I don’t know when they were infected and these tests can stay positive for six weeks. We’re using what we’ve got but we need better tests to measure the viral circulation in the population.

Dr. Cromer: It seems the U.S. has a disproportionate percentage of numbers of COVID cases as well as deaths. Why is that?

Dr. Sinnott: It is becoming clear that there are two strains of this virus. One is the original Wuhan strain, strain A, the other is a strain that mutated on its way to Milan and found its way to Italy, Spain, and New York City. This strain B replicates about 270 times faster than strain A and may account for these massive outbreaks on the U.S. east coast.

Dr. Holt: This virus was in the U.S. for a lot longer than we knew. New York City represented a disproportional amount of the infections that we’ve had; and in a congested environment that is highly conducive to spread.

Dr. Cromer: What are your thoughts on Florida’s reopening and our likelihood of having a new wave of cases in the coming months?

Dr. Holt: The 14-day trajectory is based on the incubation period of the virus. Simplistically, you can think of it as a wildfire where a downward trend means containment. But with still having an upward slope of cases in Florida, we’re not even out of the first wave. History would suggest with the influenza virus that we’ll have a 3-6 month lull and then the second wave has the potential to be significantly larger than what we’ve dealt with. But we can influence that if we continue to adopt situational awareness and the sensibility with which we live our lives to at least minimize that second wave.

Dr. Cromer: Even with widespread testing, will we in Tampa be returning to a new normal in the future?

Dr. Sinnott: Humans by nature are social animals and this virus preys on that aspect of being human. I think of it as like 9/11 but much worse. There was a time before 9/11 and a time after 9/11 and they’re not the same in any way. This is going to change the way people look at infectious diseases. It’s going to make them much more cautious about ill individuals. The fact that it could recur suddenly is always a threat. There’s a threat it could mutate. And, also, there’s no guarantee given the unfettered randomness of the evolution of these viruses we won’t have a second virus totally unrelated to this development next week.

We had three national early warning systems a few years ago. One was a pandemic preparedness team. Another, the CDC had a 16 billion dollar budget in 2016 which this year was cut to $5 billion a year. So it’s no surprise they can’t get out a good test. There was a Predict Program, part of USAID, whose job was to identify new viral threats. They identified the Ebola virus in 2016. They helped identify the SARS outbreak. Dismantling these programs has left us vulnerable.
Dr. Holt: One thing to keep in mind going forward is that we know this virus is deadly especially for the elderly and for those with chronic medical conditions. In Hillsborough County, we have had only one COVID-19 death in an individual under the age of 55 and he had a chronic medical illness.

Dr. Sinnott: And taking that one step further, we know that similar viruses like SARS can have serious long-term morbidity. We know very little about long-term complications of COVID-19 but they could be very significant.
Dr. Cromer: What are the experts looking for to indicate we can return to standard universal precautions in our [physicians'] offices?

Dr. Holt: I think there’s going to be a modification for a while of what our standard universal precautions are. The heavy use of N95s in your offices adds an additional layer but everything else is more important leading up to that one piece of equipment.

Dr. Sinnott: If I were in private practice, say as an ophthalmologist, I would be sure there were alcohol hand wipes, have someone greet them at the door with a thermometer, alter the traffic flow in my office so that people were not meeting face-to-face, either my staff or the patients; they would go in one door and out another. I would provide or require the use of masks before entering the building.

Dr. Cromer: Drs. Sinnott and Holt, do you have any final message to our physician audience?

Dr. Sinnott: I would beg all of us as doctors, as role models for the community, to set the standard of wearing a mask in public. That’s our role to take care of people that may not know as much as we do. And that will reduce cases. We’re going to have, I feel, difficult times ahead. This disease is still doubling in St. Petersburg and Tampa every five weeks.

Dr. Holt:  Information and knowledge are key and as physicians, we should continue to model the behaviors to keep our patients safe. They deserve to be protected.

Dr. Cromer: I want to thank our two panelists for a most informative and insightful discussion on a topic impacting the health of our entire community.

Dr. John Sinnott is Chairman of the Department of Internal Medicine at USF, Morsani College of Medicine as well as an epidemiologist for Tampa General Hospital.
Dr. Douglas Holt is the Health Officer for the Florida Department of Health in Hillsborough County and Professor of Medicine at USF, Morsani College of Medicine.

Dr. Michael Cromer is President of the Hillsborough County Medical Association.

Summarized by Dr. Bruce Shephard, retired Tampa Obstetrician-Gynecologist and Affiliate Associate Professor, Department of Obstetrics and Gynecology, USF, Morsani College of Medicine.

To find the latest statistics on cases of COVID-19 in Florida and by county, follow this link to the state Data Dashboard.

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Read more articles by Dr. Bruce Shephard.

Dr. Bruce D. Shephard, a retired Obstetrician-Gynecologist and Affiliate Associate Professor, Department of Obstetrics and Gynecology, USF Morsani College of Medicine, is best known locally for delivering more than 7,350 babies. He now occasionally teaches and always practices good health, dabbles in writing, and raises monarch butterflies. He and his wife, Coleen, live in Tampa.