COVID Webinar Series: Transcript of session with Matt Willis, MD, MPH

Dr. Matt Willis, Marin County Public Health Officer
Recorded Wednesday, June 10th
His session is available for viewing online.  This is a transcript of the Q & A:

KRIS REBILLOT: Health officers across the country are aware of the protests around the murder of George Floyd and in support of the Black Lives Matter movement. What is your take on it?  Advice for folks who want to get out there.

MATT WILLIS:  Yeah.  I mean, this has been a challenge for us as public health officers to manage this confluence of the COVID-19 pandemic with social movement. Those of us that have been doing public health recognize that racial injustice and systemic racism have been fueling so much of what we fight in public health for all our careers. And so when a movement steps forward to say that’s the topic, that’s what we want to change, there’s a lot of reluctance on the public health side to say that shouldn’t happen. But at the same time, at this particular point in time, given that the epidemic is with… you know, the virus is circulating and in our environment, there’s a concern that these gatherings, as important as they are, might increase risk of transmission of the virus.

But to get to that… you know, the question of the purpose, I think one of the reasons that we offered a position of support, actually, is that we know that what… the change that these protesters are seeking are also public health, and maybe even a more systemic and sustainable and permanent benefit. You know, we are seeing change in ways that I don’t think we’ve seen before around this particular topic. In Marin County, you know, where I live, we have… we are the most affluent county in the state of California and have some of the longest life expectancy, but even just from my experience here, working in the community clinics before I became a health officer, there was a 15-year difference, we see a 15-year difference in life expectancy between a community like Ross, which is one of our most affluent, you know, almost all-white community, a wonderful community near where I live, and then, you know, Marin City, which is a primarily African-American community just miles away, 15 years shorter life expectancy. And that’s the… that’s the data. Those are the numbers. And I think it’s up to us to determine what… attribute meaning to that, and decide whether or not that’s acceptable. And I think we…

KRIS:  Do you have any advice for folks who want to get out there and have their voices heard?

MATT:  Yeah, so, you know, we’ve… we’re really clear… you know, we actually released… you know, we’ve been releasing guidelines for different sectors to come online in the shelter-in-place and we released guidelines for safe protesting, and it’s, essentially, what we’ve been saying all along, which is, you know, we know the virus is transmitted through aerosolized droplets generally about six feet distance. So if we’re able to practice those physical distancing principles and covering our face, especially since the protests are happening out-of-doors, the risks can be minimized. And so that’s the first thing, is, you know, ensuring that we’re covering our faces, we’re practicing physical distancing. If there is someone who is, you know… just the mechanics of this is if someone is screaming or yelling, or singing… you know, we know that those are, obviously, behaviors that go along with protesting… there’s also evidence that the virus is more… you know, more transmitted, more virus particles are transmitted through those behaviors. And if someone nearby is doing that and they’re not wearing a mask, it’s probably worth stepping away from that person, or offering a gentle reminder that a mask would be… would protect everyone.

We’re also offering testing in Marin, for anyone who has participated in a protest, for COVID-19. And it’s important if anyone does want to get tested that it should be no sooner than seven days after they may have participated in an event where they might have been concerned of exposure. If you get tested, you know, before that, it’s likely to be negative, and it may or may not actually represent the lack of infection because of the time it takes for the virus to assemble enough to actually be present in the nasal passages for the test. So we’re offering free tested for anyone who may have participated in a protest seven days after or after that.

KRIS:  Cases are going up, but hospitalizations are staying stable. What does that tell you?

MATT:  Yeah, our numbers now, we have 620 cases, total, across the country, 17 deaths. We’ve tested almost 17,000 people now. We’re doing a lot more testing.  427 of our cases have recovered, and I’m one of those numbers. And we now have a new category. It’s San Quentin, because we’re seeing an outbreak in San Quentin Prison, as well. So we’re counting those cases separately from… and there’s been 15 cases in San Quentin. So that’s kind of Marin County by the numbers currently.  What was the second part of your question?

KRIS:  Cases are going up, but hospitalizations are staying stable.

MATT:  Yes, right.  Yeah, yeah, that’s important. So we’re… we are doing a lot more testing, as I said, and we’re detecting a lot more cases through testing, especially in areas where we know with more targeted testing in communities who are particularly vulnerable, especially our lower-income immigrant communities who have been out on the frontlines as essential workers from the start, seeing high rates of positivity in those communities.  What we’re looking at most carefully in terms of our decisions around opening the shelter-in-place is our hospitalization rates, because that’s a way of controlling for bias that might be introduced. If you’re doing more testing, you’ll get more cases, but a proportion of people who become infected will become ill enough to be hospitalized.  So, in some ways, the hospitalization rate is a more precise indicator of actual burden in the community, and, fortunately, you know, we’re a relatively small county, 260,000 total residents. We’re had between one and six people in the hospital, bouncing around in that range for probably the last six weeks. And we’re still in that range, but I’m watching that number very carefully.

KRIS:  What is the demographic of the folks who are having the most difficult time with COVID-19?

MATT: Absolutely. Yeah, we’re seeing that, you know, a smaller… and, fortunately, a smaller fraction of our older… so population above age 65 make up about 25% of our population as a whole, but only about 15% of our cases, but they’re about 30% of our hospitalizations. And all of our deaths, of our 17 deaths, are in people above age 65. So, you know, our local data really validates, mirrors, what we already know about this virus, is that it really… for people of older age or people who have more serious medical conditions are at higher risk for more serious outcomes, more likely to be hospitalized, and more likely to pass.

KRIS:  How do you decide what is safe in a community?

MATT:  Yeah. Well, the shelter-in-place, you know, we were among the first countries. We were part of the six-county coalition that was really the first in the nation to do the aggressive shelter-in-place policy. And that was because the Bay Area was really kind of the first… one of the first hotbeds of transmission across the United States, partly because of our relationship with the Pacific Rim and travel. Especially in the South Bay area, Santa Clara County was getting, you know, really rapid acceleration in cases, exponential growth. And Dr. Sara Cody, the health officer of Santa Clara pulled us together, the six health officers of those adjacent counties, to… ‘You know, we have a problem here. We need to act now and hours matter.’ Because she was just seeing more and more people rolling in and was concerned about her hospitals being overwhelmed.

So out of that relationship and that coalition, the first shelter-in-place was executed. And our thinking at that time was what sectors will we allow to remain open? And it was organized around what’s essential versus what’s non-essential. So essential, you know, these are the things people need to live. So food, access to healthcare, your pharmacy. You know, habitability, so your tools, you know, plumbing, certain things to keep the house going. You know, and there was this sort of dialogue around what do we deem as essential?

Six weeks later, we shifted to a risk-based strategy for our reopening. So that’s where we are now, which is the next sector to open as we move forward in two-week intervals based on the incubation period of the virus is based on the risk of that activity. So the first things we opened were outdoor activities, and now we’re moving towards more indoor activities. For example, indoor retail is going online this coming Friday. Indoor dining will come online soon thereafter. But up to this point, it’s been based on, you know, an establishment of risk. And, briefly, risk boils down to… if you’re thinking about it from a science standpoint or a virus standpoint, it’s the proximity of the encounter and the duration of the encounter. If you think about, you know, the number of virus particles that one needs to ingest in order to become infected, it’s about a thousand we think, and you can get that all at once. If someone coughs or sneezes on you and their face isn’t covered, or you can get that over a period of time if someone was just breathing. And so when we want to make sure that, you know, those activities like salons, where you have people in closer proximity, you know, hairdressing, which, obviously, I haven’t taken advantage of, where you’re closer together for a longer period of time, those are the businesses and the sectors that we bring online later.

KRIS:  When you talk about risk, how do you know about the risk of making a non-essential dental appointment or doctor’s appointment? What advice do you have for folks in that regard?

MATT:  Yeah, that’s just coming back online now. The state has allowed… you know, the State of California is setting the… some of the… there’s, you know, local jurisdiction rules and then there’s the state rules. The State of California is now allowing non-essential, or non-urgent or emergent healthcare. And that’s… you know, we… for all the reasons we do primary care in the first place, we know that mammography, colonoscopy, the regular checkup are important for long-term health. Those things have been delayed. You know, many people haven’t obtained those sorts of services. And the harm will start to accrue the longer we wait. And so the risk has really shifted towards now that we know that the clinics are able to practice safe practices and have the PPE they need, they’re scheduling fewer appointments so there’s fewer people in the waiting room. More of the processing. I’m here next to a clinic here in Marin, where they’re doing the intakes actually just at the doorway where people are out of doors because it’s a nice day and there’s less risk there. Those sorts of practices are making it safer for us to return to normal primary care relationships. And we’re working with dentists, as well.

KRIS:  How do you see school opening and keeping all students, including special ed students and staff safe? What’s happening with the schools here?

MATT:  This is a... yeah, I mean, the uncertainty over the future in terms of just where the epidemic will be… come when schools would reopen, I think is one of the most challenging aspects, in terms of planning. I just got off a call with our school superintendents and the trustees, and it’s challenging to say, well, we don’t really know yet how schools will open. You know, the options are, you know, completely distance experience if we’re really just getting hit very hard, some mix of distance learning and onsite learning, and then fully onsite. The principle that I think we’re applying, and it’s a little bit of an exception to what I articulated, as a purely risk-based decision-making process, the fact that we see that schools and education are essential for our young people, leads us to try and allow as much in-person learning in the classroom as we possibly can, from a point of view of also ensuring safety. So I’m working very closely with the Office of Education and the State of California. A lot of the relationship has come down to the local health officers to work with their local education leaders to determine whether the strategies that are going to work within that setting, with some very… you know, general parameters that we’ve been given. And, fortunately, here in Marin, we have a… you know, she is charging forward, planning and we share… you know, we’re both very clear, I think, that our goal is to optimize children being together in classrooms as the best learning environment for them developmentally, socially, neuro-developmentally, etc., and that’s the overarching principle. And then there’s a variety of, you know, specific strategies that we’ve been working to ensure that happens.

KRIS:  How do you keep gaggles of kids in school, going out for recess and then keeping them safe, keeping the teachers safe, keeping the staff safe?

MATT:  Yeah, I mean, this is really a… you know, a challenge in how innovative our leaders can be because schools will look different. And I think those that just say, ‘Well, you know, we’re only satisfied if we can do it the way we used to.’ That’s off the table. It’s… you know, we’re going to have more distance between children in the classroom. Right now, the CDC says six feet, you know, based on what I said about the distance that the particles float. You know, that distance between four feet and six feet is probably a relatively low number of particles. You know, the majority are in that three to four feet, you know, up to four feet. So it’s possible, you know, at each incremental step where we’re able to offer a little more freedom, that corresponds to more children who can be in that same classroom together. One of the challenges I’m hearing is that if we really stick to six feet, it’s going to be fewer kids in the classroom and we’re going to have to do two separate shifts. And I’m just articulating the challenges. You know, one of the… the problem with separate shifts is if you have kids coming in Monday, Wednesday, Friday in cohorts of 12, then what did that Tuesday, Thursday, what are they doing on those other days? And are they also having social interactions outside of that setting where we might actually have more cohorting if we’re actually able to do like 20 kids in a classroom at once where you can do it five days a week. So these are some of the calculus that we’re having to work out.

One of the main principles is trying to limit the mixing between students. And so, you know, we’ve been doing now stable cohorts of 12 kids with the same adults, and that from an infectious disease standpoint, limits the risk of transmission beyond a certain group if any of the children are infected. So that’s… and then based on age, so, you know, younger children, smaller cohorts. And when you get to the high school age, because the behavior can be different, they can cover their faces more reliably, they understand the principles of social distancing, we hope… I have an adolescent boy. I’m not so sure that’s a safe assumption… but, you know, so we might not need to do the cohorting when it comes to high school and middle school, but for younger kids really trying to make sure that there’s that nest, that cocoon around them of a certain number of kids and we’re negotiating what that number would be.

KRIS:  The actual details are going to be worked out over the remainder of the summer before school starts, right?

MATT:  Right. And we’re still waiting for guidance from California Department of Public Health in terms of, you know, what are the… what are the rules of the game, you know, what are the guardrails for this, and then where do we have freedom to move within that?

KRIS:  What’s the status of testing? What’s our capacity? And where are we with antibody testing?

MATT:  Yeah, so there’s two kinds of testing. There’s the PCR testing. That’s the detection of the virus, itself. Usually, it’s a nasal swab looking for the presence of the virus in your nasal passages. That’s what I say… you know, we’ve had almost 17,000 people tested in Marin, and all of our cases, confirmed cases, are through that kind of testing. And that basically is positive for around a two-week interval when you’re actively infected. Some people remain positive for a longer period. Some small fraction unclear whether or not that actually represents an ongoing infection where they’re contagious to others. But that’s the PCR test. That’s, I think, the most important tool available to us right now is really just getting… and this has been a national story of this epidemic, has been the lack of testing capacity. We’ve been doing everything we can at the local level to reach our goal of 500 tests per day. That’s our goal for the county, which corresponds to about 200 tests per 100,000 residents. And we’re about at that goal right now, and the surge in cases we’re seeing is actually, you know, partly attributable to how much success we add in testing.

The reason we need to test is that this is a virus that many people are asymptomatic or the symptoms may be subtle, but they are infectious to others around them. For example, people who are in high-risk settings, like skilled nursing facilities, staff, etc., if the risk to people they may transmit the virus to is high, we need to make sure those people are tested. So that’s one of our primary strategies is that PCR testing, just to detect cases so we can do the contact investigation, isolate people, etc.

Antibody testing, a totally separate type of testing. That’s looking for the presence of your body’s immune response to having been infected with the virus. Your body has, you know, a library of… you know, a memory of every disease you’ve ever been exposed to for which your body mounted a response, very specific antibodies that we can look for in your system. So when you get vaccinated against measles, mumps, rubella, chickenpox, whatever it is, you have little antibodies that are specific to that particular disease. And we can… so we can look for COVID-19 antibodies through the antibody test.

The two challenges with antibody testing is that (a) we don’t know what it means to have antibodies against COVID-19. So this is my situation. I was infected, recovered, I had anybody testing twice now, and it’s been positive. But what science cannot tell me yet is what that means in terms of… does that confer true immunity? In other words, am I protected against being infected again with COVID-19 or not? And so I think until we answer that question, the value of antibody testing, just categorically isn’t clear until we actually know how to interpret the results. Secondly, the tests, themselves, lack accuracy in many cases, especially when there’s low prevalence of false positive rate. Even a very small false positive rate will lead to the majority of people who test positive actually being false positives if you have a low incidence in your community. So the interpretation of the results is really challenging, which is why the CDC and California Department of Public Health are not currently recommending antibody testing at the individual level to determine someone’s immune status or infection status, but in some cases might recommend that it can be used for populations as a whole to determine kind of what the historical prevalence of the disease was in that population across the board, because the false positives and the false negatives sort of wash out when you’re testing thousands of people at once.

KRIS:  How would they test in a larger population? What would that look like?

MATT:  So there was an operation like this in Bolinas, California, a few weeks ago where they tested 1,800 people over a three-day period. It was a grassroots effort partnered with UCSF, one of the research facilities here in the city, and, basically, did a lot of canvassing, free testing. And they did the PCR test and then the antibody test for everyone. And that’s… so that’s one mechanism, is through sort of a research design where you’re trying to get an entire community at once.

Right now, where I sit in the Canal area of San Rafael, we’re seeing lots of incidents of PCR positivity, even an outbreak, really, in this community. We’re considering whether or not we should just try and determine how close to herd immunity, how close to that 80% or… you know, 80- to 90% of people who’ve been infected and rendered immune to it…you know, and that’s how we define herd immunity… how close are we in in this community where we’ve seen a lot of prevalence over the last few weeks? So that’s… antibody testing at the community level would be a way of answering that kind of question.

KRIS:  You are in an area that has a lot of dense populations of folks who are Latino, Hispanic. That’s the main cause for concern, as far as you’re concerned. Can you talk about that?

MATT:  Yeah, I think it’s part of the California story, really. You know, there’s an over-representation of people who have been out on the front lines as our essential workers in terms of our cases. You know, in Marin County, our Latinx community makes up maybe 20% of the total, 15% of the total, but they’re, you know, about… almost 70% now of the total cases, and in the last two weeks, it’s almost been 90% of the cases are people in that community. And, again, it relates to exposure. Being… you know, leaving home every day to work. You know, much lower… you know, less ability to work from home. And then being reliant on daily income, working, even, you know, compelled in some ways, just to make ends meet to work if you’re having symptoms. And then it’s less easy to isolate once you’ve been diagnosed, because many of these people live in units with five to 10 in one unit in order to sort of pool rent so that they can afford... obviously, the cost of housing here is high. So the risk of transmission within the household is also accelerated. So that’s one of the main drivers of… and the conditions, sort of the preconditions in our community that are fueling this epidemic locally. And we’re having to work, you know, fast and working really in close concert with our community-based organizations here in the Canal and other areas like this to ensure that we have the bilingual, bicultural competence to reach this community in an informed way to offer the messaging and the support, and navigate people through the choices that they’re facing once they’ve been diagnosed.

KRIS:  Given that there are these hot spots within communities, do you have any sense of how this thing is going to end? What’s it going to take? I mean, I just read in the paper that New Zealand now says they have zero cases. What’s it going to take to really bring COVID-19 under control?

MATT:  Yeah. Well, it helps to be an island.

KRIS:  Right.

MATT:  You know, and… we’ll see… I mean, it will be interesting to see if New Zealand is able to pull that off. It’s a good start, but, you know, at a certain point, commerce is going to come back in, which is all… I mean, that’s the story for all of us. You know, it’s one thing to sort of hunker down, but that’s… you know, two years before a vaccine, we’re compelled to begin to reopen amidst a virus that’s with us.

So I think, you know, what we’re looking at... I’ve just been seeing some of the modeling that’s been offered for the state of California... is surges in cases. You know, these conversations that are happening now feel a lot like the conversations that were happening in early March, where people are looking at models where they’re seeing a rapid rise, they’re seeing hospitalization. You know, you see… on your graph, you see the line that corresponds to the number of hospital beds you have, and then you see the line that corresponds to the number of cases and the people being hospital, and they cross. So you’re… that was kind of the experience we were having in early March that led to the first shelter-in-place. We’re seeing similar curves now being projected for… in California, later July and August, even, which, you know, people have been talking about the fall surge. That seems to have, actually, in the modeling now kind of crept more into the summer. And we’re… you know, I think the reason that we’re still moving forward, despite that is (a) that, you know, the economic harm and other harms as the shelter-in-place extends starts to eclipse the potential harms of transmission, and those are challenging decisions to make in terms of a balance.

But we’ve also had a lot of time to prepare. So our hospitals are now fully prepared for surge. We have set up alternate care sites that are ready and waiting to go. We have 50 beds that are empty right now and unstaffed, but, you know, all the equipment is there. So we’ve done the preparation we need. We have the testing capacity. We have the contact tracing capacity. And, now, it’s up to us from a behavioral standpoint… I mean, I think the policies that prevented interactions was one part of this in phase one. It’s now going to be behaviors. It’s going to be up to us to prevent that surge that’s being anticipated, in our everyday behavior. And so that’s, I think, one of the most important points. And I feel discouraged when I look out and see people not wearing masks and interacting in ways, because I fear that the reopening decisions to make into the shelter-in-place are leading to a false sense of security, or a sense that the coast is clear, it must be safe, and other behaviors, are actually… they’re actually less vigilant. When, in fact, the exact opposite needs to be what we’re… happening. We need to be even more vigilant.

KRIS:  I’m getting questions about personal activity. People are concerned about going back to the gyms. Do you think it’s safe to go back to those facilities and places where they have opened up? What’s your advice around those venues?

MATT:  Yeah, I mean, I think as we open up more in the shelter-in-place, personal choice becomes more important, because we have, in some ways, deprived... you know, earlier, a simple way of thinking of this, people were sort of deprived of the choice to make… you know, to do too many things, just because it was illegal, outside of essential activities. By allowing those things to occur, the responsibilities will shift to the individual. So I really hope that people recognize that, you know, a gym opening up or a hair salon opening up doesn’t mean it’s safe to do that. It means that you are free to do that. And it’s a more mature regard, in some ways, but, you know, certainly, if someone is at risk… you know, if you’re in one of those groups where you might be at increased risk if you were infected, avoiding that, despite it being available, is probably a good idea. If you live with someone who is in one of those risk categories, say, you know, if your parents are living with you and they’re older, that’s another. But, yeah, I think gyms are an example of, yes, we have processes, protocols, procedures in place, they will be wiping the surfaces down, and those are really important. But there is a certain amount of intrinsic risk associated with some of these things that I think people need to take into account in their own decision-making.

KRIS:  Should everybody over 75 get tested?

MATT:  Yeah, I mean, we’re prioritizing testing for older adults in our... you know, we have free testing in multiple sites in Marin, and people can just go on and register to be tested, a self-registration, and they’re given a time to come through. I think one of my concerns is that there would be a… you know, if people are otherwise really effectively sheltering at home and have been isolated, there’s not a lot of need to get tested. In fact, the act of testing might actually bring them out in ways they wouldn’t have come out before. But if someone has had any potential exposures, we would recommend, especially someone in that age group, to go ahead and take advantage of the offer for testing, or they can get tested through their physician.

KRIS:  What do you think about outdoor church gatherings now, social distancing inside the sanctuary with 50 people?

MATT:  Yeah, we’ve move forward with... you know, the state allows now church services. Again, not a… you know, one of those exceptions to the risk-based decision-making. This was based partly on the... somewhat the sort of First Amendment, you know, constitutional rights to gather and worship, but, also, just recognizing the social value for so many to be able to practice their faith. It’s not… you know, it’s one of those things that I think it’s not a great idea. If you’re really just thinking about it from a pure infectious disease standpoint, being indoors… I mean, I think the state guidelines are that, you know, you have to have six feet distance, but you can have up to 100 people inside. Especially given the demographic characteristics of so many of the people who are attending church, you know, this is not something that we have recommended here in Marin. We have allowed faith-based gatherings to occur in Marin as of last week outdoors. And that’s one of the most… I think, one of the underappreciated principles of this, is that there’s very little... you know, when we look at outbreaks that have occurred in the United States, you know, many of them have been described now, and we’re getting more and more information about them, almost all of them relate to people who were together indoors, and the transmission is traced to some sort of indoor gathering. And it makes sense, because if you’re breathing out into the air and you’re in a well-ventilated outdoor space, (a) the capacity for physical distancing is greater, and (b) the particles disperse so much more quickly, especially if we’re covering our face. So we thought that was a safe way to approach that question of can people begin to worship together, is by doing it out of doors, in Marin.

KRIS:  What happens when somebody tests positive for COVID-19? Are there processes that kick in if somebody is diagnosed with COVID-19?

MATT:  Yeah, so, you know, we’ve had about 620 cases, and we know all of them, each and every one, because we… the processes is that, you know, they’re all… these are laboratory-confirmed cases. So the laboratory is in the equation always, and we have relationships with the labs. Most of it’s just a direct electronic feed from the laboratory into a database that we see. And so when a case flips positive at the lab level, we’re notified as public health. And we have a team of now about 50 contact tracers and it’s their job to be looking for these, and we have a goal of reaching every single person who has been detected as a case within 24 hours and isolating them. And we’re at about 80%, you know, at that. So we’re doing well, but we could do even better.

So we find out about the case through the laboratory. We’ll call that person. You know, all the contact information is offered when they’re tested, so we have that information to call them back. If we can’t, we’ll go through the clinician who may have ordered the test. And then we walk them through what’s… you know, the contact investigation. So the first goal is to ensure that they are well, you know, we’ll determine what their status is, and if they need medical care, we can facilitate that. And then, secondly, to ensure that they’re isolated from others around them. Then we begin a process of determining who they had close contact with. And so this is a thorough interview, going back for their period of infectivity. Usually, it’s about two or three days… if they have symptoms, we’re looking at two or three days before they develop symptoms. So this is a… you know, a memory game with the case to say, ‘Where were you when? Who did you have close contact with?’ And then we reach out to those individuals that they had close contact with to ensure that they are quarantined, themselves. We use the term ‘isolation’ for cases, the term ‘quarantine’ for people who have been exposed. And those that are quarantined based on exposure, are then tested, themselves. And if any of them become positive, that cycle begins again, until we’ve hopefully sort of interrupted a chain of transmission.

KRIS:  There is one drug that shows some promise against COVID-19. It’s called Remdesivir. Do we have it in the County? How’s that being handled?

MATT:  Yeah, this is a… you know, there’s been scarcity in so many areas of COVID-19, whether it was testing, you know, contact tracing, the app. I mean, but now we’re… the new scarcity is the treatment. There is an effective treatment, and we do have Remdesivir here in Marin in an allocation. So there’s a per capita allocation to counties that’s coming down through the state, I think is starting at the CDC. And for us, that was, I think, 22 doses. And so we’re… we worked with our… we have three hospitals in Marin, and we got the infectious disease specialists together and say, ‘Okay guys, you know, this is what we got. How do we want to allocate this? What’s the most logical and fair way for patients to ensure... you know, that need it, that they get it?’ And what we came up with is just a little commission that would consider cases, have a brief discussion, and no matter which hospital it was in, and make a decision that this is a case based on their severity, based on other clinical symptoms that are not so severe that they will probably pass anyway. There’s different criteria there that are considered, and then the drug is allocated through that process to that hospital. And we’ve done… I think we’ve had two patients, so far, since that allocation arrived, where we’ve actually used that, and both have survived.

KRIS:  And there will be more coming down the pipe, one would hope, right?

MATT:  Yes. Yes. And we keep submitting the requests. More is better.

KRIS:  What is the situation in nursing homes, assisted livings, senior communities?

MATT:  Yeah, I mean, this has been one of the... you know, the other big… so we have the… you know, the challenge of clusters at the community level in our low income communities, and then the other, I think, just categorical hardest challenge for us is our older elder care facilities, both skilled nursing facilities and residential care facilities for the elderly, which we have about 68, total, facilities like that in the county. We have a mobile testing unit that is… you know, each day, morning and afternoon, is visiting one or another of these facilities to do testing of staff and residents. There’s, at any given time, between five and 10 different facilities that have at least one staff member who has tested positive. Again, this is part of the consequences of aggressive testing is that you see cases where they exist. And then there’s a lot of follow-up, especially if that case is someone who has been working in a skilled nursing facility, because we end up often testing the entire… all the residents. And through that process, we’re able to sort of intervene as early as possible if we’re seeing any transmission there. And that’s been a really effective strategy, but we’re needing to expand that capacity. So earlier this week, I issued an order, Health Officer Order, requiring that those facilities actually develop the internal capacity to test both staff and residents, and that they need to test all their staff by the end of July. And the process will be testing a quarter of the staff every week in a rolling fashion. Because what we found is that when we have outbreaks in these facilities, it’s invariably someone among the staff who is bringing it into the facility and may not have symptoms. And so the symptom checks and temperature checks and other things we’re putting in place may not be adequate, are not adequate in the absence of testing. That’s kind of the current strategy is to… and then there’s a lot of technical assistance, obviously, in terms of just helping them make sure that they have the proper infection control procedures, have the adequate PPE. We’re supplying them all with PPE, and still, unfortunately, limiting visitation from the outside. I know that’s a really hard thing for a lot of families, that they’re not able to visit, but because we have so much prevalence in the community and the vulnerability is so high, we’re still preventing those kinds of visits.

KRIS:  There is talk about redesigning nursing homes. There’s talk about kind of creating pods where people are more contained, or you have the same cohort of people that are interacting. Are there plans to do that?

MATT:  Well, we have, you know, many versions of that now when we have cases where we’re having to move people around. So they’re sort of taking advantage of sort of the architecture to sequester categories of people. And, yes, we haven’t, you know, formally entered into conversations with our skilled nursing facilities around how they would actually... I mean, I think this is something that is sort of a… you know, a longer-term lesson of COVID-19, in terms of just how we organize care for people at the end of their life or in their last years, because there’s… like so many things, you know, COVID-19 has sort of, you know, pressure-tested this system, and we’ve seen cracks all over, especially with just the way that these facilities are organized, and the care that they’re able to offer. And so I would hope that that would be just among those things that we’ll be starting to do differently in the coming years, based on what we’ve learned from this epidemic.

KRIS:  Pneumonia shots, flu vaccines helpful?

MATT:  Yes. Yes. Yes. That’s my answer, yes. I mean, now more than ever. Now more than ever, for sure, because, you know, the last thing you need is two problems. I mean, you know, as we know, influenza is a serious illness in itself. COVID-19, obviously, potentially fatal, especially for our older residents, you know, who are in that recommended group for the Pneumovax. You know, flu shot? I mean, we’re going to be... I think… I’m hoping that, you know, we’re going to have a lot more interest in our flu shot. You know, every year we’re out there, you know, on the pulpit, you know, trying to get people to come in and get their flu vaccine because we know it’s preventable. It’s just, you know, every year, the strains change a little bit, and you need to be re-vaccinated annually to be protected. We generally get, you know, maybe 60- to 80% of people choosing to get vaccinated. But I’m hoping that this year, based on the awareness of the risks of these sort of respiratory illnesses and the risk of being coinfected with both COVID-19 and flu, that we’ll have 100% vaccinations for flu and for the Pneumovax.

KRIS:  I want to talk about your experience with COVID-19. How do you think you got it, and what was your experience with this thing?

MATT:  Yeah. Yeah, I was… I don’t know where I was infected with COVID-19, and I think that’s part of my story. And what I can offer is that you can’t always assume that, you know, who the… that you would recognize risk, and that it’s in the environment. And we have to approach one another, you know, as if, you know, the person you’re with may be infected just when we’re out… this was… you know, I was… I was diagnosed on the 20th of March, and so this was, you know, just when we were starting to talk about physical… you know, distancing was kind of just coming into the… you know, the elbow bumps, people were laughing about not being able to shake hands anymore. It was kind of in those earlier… I say early days. This is just a few months ago, but it seems like a long time ago. And we were also not… you know, if you remember, we weren’t actually recommending facial coverings at that time, you know, in public just for routine use.

So I was, you know, part of this press conference that went along with the announcement of the shelter-in-place that the six counties came together for. It was a big event, and it was held in San Jose. So I traveled down there for the media event announcing the shelter-in-place. Ironically, you know, very packed room, one of the last events of its kind that were allowable, because just hours later, we prevented gatherings like that from occurring. And it was in a hotbed area. That was an area where there was… as I said, where there was exponential growth in cases, so… and then I developed symptoms five days after that event. So it’s possible that that’s where the exposure occurred.

And my symptoms were kind of classic. You know, I got a low-grade fever, a cough, kind of a dry cough, some tightness in my chest. My wife sort of called me out on that and said, you know, ‘You don’t look good.’ I said, ‘I’m fine.’ And she said, ‘You should probably get tested.’ And I was tested, and the next day the results came back. And then, you know, I had about two or three days of kind of mild symptoms. I thought I would fall into that category of people, you know, with just a mild course. And then at about day five, I really took a turn for the worse, and I ended up really kind of bedbound for almost 10 days at home, completely dependent on my wife to… you know, for… the only thing I was really doing was getting up to use the bathroom for that. It really felt like, you know, a truck had kind of, you know, run me over, and fevers every day. At one point I went to the emergency department because I was having more shortness of breath. I did have a pulse oximeter, which is the machine that measures your blood levels, and it dropped down to about 88%, which is kind of a low-ish range, and went to the ED at that point to get a chest x-ray and be evaluated. And, you know, over the course of that interval, you know, 10 days or so, I started… I didn’t need to come into the hospital. I was offered, you know, the chance to, but because I had good support at home, I was able to recuperate at home, and slowly made my way back.

The whole thing took about three weeks before I was really back to… at work, you know, a place where I could actually come in and work regularly. So it really kind of gave me a real respect for... I had underestimated this virus, and it gave me an appreciation of how severe it can be.

KRIS:  Are you fine now? There are talks  that there are some folks who have lingering symptoms or may have long-term disabilities.

MATT:  Yeah. I mean, I’ve got some funny little stuff… there’s a vasculitis that goes along with... it’s been described the COVID toes. I have with… my hands get blotchy sometimes, and it’s clearly like a reno-style sort of vasculitis. Typically, it’s an immune response to the… you know, the small blood vessels. There’s no discomfort associated with that, but it is new, and I attribute it to that infection.

And then others, just… you know, I still feel a little bit of tightness in my chest. I’ve been… for the last week or so, I’ve done some little bike rides with my ten-year-old, and that’s about the pace that feels right for me. But I feel fortunate.

KRIS:  I understand two of your kids got it, but your wife didn’t get it, right?

MATT:  Right. I mean, and if there’s anyone who was like, you know, massively exposed, it was my wife, but… because, you know, you’re transmitting the virus before you develop developed symptoms. But, yeah, she... two of my three kids were infected. One wasn’t. And my wife wasn’t. And that’s one of the odd characteristics of this. And then even of my two kids who were infected, one was antibody negative on the test and one was positive. And then the one that had been negative when we tested him again two weeks later, became positive. So just the immunologic puzzles, you know, manifest even in our own household.

KRIS:  What should people do who live alone or who don’t have support, who find themselves positive for COVID-19?

MATT:  It is, yeah. I think it’s one of the things that my own experience has sort of led me sort of in a more informed way to our community, which was we had been focusing on that, you know, 5% of people that might surge into the hospitals, and we were really looking at our ventilator capacity, ICU capacity. And, you know, my illness sort of reminded me of the obvious, which is the under that tip of that iceberg, there’s a lot of people who can be really sick, but at home, and with supports may not otherwise need to come into the hospital, but will need supports. You know, I kept thinking if I was, you know, one of the patients that I served in this community, how would I manage that? If I, say, was a single mom with kids. And so we’re… we’re doing a lot of… you know, a lot of work with our social services, public health, and then social services within Department of Public Health… or Department of Health and Human Services. And the social services people are doing a lot of work in terms of income replacement meals. We’re providing meals to people into their homes who may have COVID-19, recognizing that they may not have the capacity to prepare those meals, and we certainly don’t want them venturing out to get food. And I think it’s another lesson in the need for just mutual support within our communities. People were leaving meals on our doorstep, leaving cards. That went such a long way because, you know, my wife was trying to manage three of us in the household, and didn’t… really wasn’t able to prepare those meals. And just the... I don’t know, the neighborhood, just the way people came together to support us, I think, is something we’re all going to have to be kind of looking out for each other, especially if we see more cases.

KRIS:  Your wife must have a super immune system.

MATT:  Yes, she’s... we need to analyze her immune system to know what the secret is.

KRIS:  Older adults tend to have different symptoms for this disease, right?

MATT:  Well, there’s a lot of... yeah, the... we’ve been wrestling with this challenge of how do we protect our elders in COVID-19, our older adults? And… because, obviously, we have a principle of wanting to... we don’t want to be ageist in the response, and it can sound that way when we say, ‘Well, unless you’re… you know, you can come to work unless you’re age 65 or older.’ But the... you know, so this is an area where, I think, you know, looking to the science and then designing the social strategy to match that. And the science is that people, you know, above age 60, age 65... I mean, I’m 54, and, you know, I was even concerned because, you know, it’s just…  it’s a continuum, like by age that, you know, the younger you are, the better you do. And it’s not just... you know, because we always… we always know that, you know, people who are older can do worse with X… whatever it might be, because the immune system may be not as strong. But there’s something particular about COVID-19 beyond that that makes our elders more vulnerable. And, similarly, something particular in children that is almost protective. And this is a… this is, I think, a unique immunologic reality that we haven’t really figured out what are the correlates to that, in terms of our own physiology. But, unfortunately, it’s true, and you can’t even necessarily predict based on the fitness level of someone who may be 65, whether or not they would have a better or worse outcome. One of our first deaths here in Marin County, in fact, our first death, was a gentleman who was playing soccer on a regular basis in his mid-70s, and just, you know, had a very serious illness and he ended up passing.

So I think it’s… you know, we can’t pretend like it’s not that if you’re… you know, if you’re well, if you’re an active and well elder that it’s not… or, you know, a senior that it’s not… that you’re not at risk. And so I think it’s important when we talk about the social strategies and the shelter-in-place, you know, that there is a need to, I think for the next few months, at least, take special measures to ensure that people are successfully isolated from those that might otherwise infect them.

KRIS:  Can you speak about blood type and COVID-19?  There are some studies out that show that folks with Type-A blood are at an increased risk for having a poor outcome.

MATT:  Yeah.  Yeah, I don’t…. I don’t know. You know, that’s… that’s an area… there’s so much that’s still… you know, the science is evolving so quickly, and it guess that’s a… you know, a lesson to me, in we’ve said things that we’ve reversed, speaking as, you know, the health… as the industry, whatever, as healthcare and science. We have… there have been data that have suggested some things and then changed. And that’s part of, I think, the transparency and the honesty that we need to be offering our communities as we move forward with this. The rules around facial covering, for example, have changed. And hydroxy… another example, hydroxychloroquine, the medicine that doesn’t do any good at all, it turns out, and for a while it was recommended as something people should use. Ibuprofen. ‘Avoid ibuprofen.’ That was the message. When I was sick it was

‘Stay away from ibuprofen.’ That’s changed. So I think we need to take some of these… when we have these early… early suggestions of one thing or another, really, you know, let the dust settle a little bit around that before we get too excited about it.

KRIS:  As someone over 70, I did not plan on COVID-19 in my retirement plans. How long do you see sheltering-in-place and practicing safety?’ Will I still be wearing a mask a year from now?

MATT:  A year from now?  I would say that that’s the… the year is that 50-50 for me. The year is the flip a coin. I think it’s before the… before a year, I would say yes. But, yeah, let’s hope. Let’s hope.

KRIS:  Your final advice, what do you want us to do?

MATT:  I think it’s important to not mistake reopening with safety. And the things that we’ve been saying all along, and maybe sort of boring as a closer, but simple, but incredibly effective:  cover your face, maintain that distancing, and we can weather this together.

KRIS:  Thank you.