gentlemen much obliged for you taking timeto talk about this resurgence of cova 19. We're seeing it out of control across the country. I was just looking at some news items before hosting this call. And I am seeing hospitals in Ohio and Montana and Indiana. That air overwhelmed there. Transfer delays and diversions going on. What are you saying at your respective hospitals? I guess I could start with you, Dr Wall. Are you seeing an overrun of kobane patients there? A duke or you and see at U N. C. Okay. Yeah. You know, things have been pretty study, I think here in Chapel Hill. E. Think both for duking, UNC. We're in situations where, um it doesn't necessarily reflect what's going on locally because we get a lot of transfers from outside hospitals who need the special services at our tertiary care facilities. So it's not. It's not really taking the temperature of the local pandemic, but mawr statewide. So we've all always maintained a fairly consistent census on always sort of at the tipping point of our I see you. You know, not yet having to open up a second. I see you. But just about there. I don't know how it is over it. Do. But I suspect Similar. Yeah. What does it look like there at Duke? Yeah, it's pretty similar for us here. I mean, I think if I look back to our senses since September, we kind of hit our low point coming out of the summer when in fact, things were much easier. And across our system, we probably at that point had sort of 20 to 30 people. Throughout October, it was sort of 50 toe 50 55. Just the last week. We've actually had quite a considerable jump, which I think has mirrored, in fact, as David said, What's happened in the state. And we're sort of now up into the 75 to 80 range, um, for admissions. And I think we're in the same sort of boats starting toe plan again to say, Hey, what does it mean? Toe open up another. I see award. What does it mean to space patients in different ways? We re extended our general floor ward for covert patients as well in sort of early preparation. For what I like to say, I think it's gonna get busier before it gets quieter again and at Wake met. What are you seeing there now? Yeah, bro. And I think Dr Will's comments reflect a similar experience for us. We had, ah, sort of bottoming out there in the September. The early fall time frame and summer was was our peak year across the Wake Med campuses. We're back up to about 80% of our peak, and it really has been a consistent rise in the last few weeks, both in positivity rate. Azzawi test folks who are symptomatic as well is just community background. So folks are asymptomatic and you're having a procedure done and get a test and are surprisingly positive. Is there a real risk that you'll run out of room at any of your hospitals? If we get this flood of patients with Coburn? I think I think for us it may be less and I'll be interested to hear what my colleagues you say. It may be less of a physical spice or less of a ventilator, less of, ah, like less of a room capacity and much more of a staffing issue. Um, you know, this is relevant. Relevant increase for staph infection asked offer in the community like everyone else who we care for. And, you know, sometimes having capacity is not just about having a bit. It's about having nursing staff, physicians, everyone else who it needs to be associated with that bed. Uh, that will be, I think, our capacity question that keeps coming up. We're a long way from that at the moment, but that's that's probably the type point rather than bed space. When people are admitted to the hospital, clearly it's serious seriously enough for them to be hospitalized. But what does it look like the treatment look like for most code patients? Are they on ventilators? Are they in I C U. What does it? What does the experience look like? Most patients don't don't require ventilation, and we've seen an I C U utilization rate more recently in about the 20 to 30% range. Recognizing that my two colleagues are infectious diseases docks that I think they might be able to better speak to the substantial advancements that we've made, both in anti virus treatment as well as other treatments. Yeah, I agree. I think that, you know, it's it's less than 50% of our folks who are in an I C u setting we do as Cam mentioned, have ah co vid ward for people who don't require intensive care. Eso that that's about half at least or 60% of our impatient census. And then even among the people in the I c u. Not everyone is on a ventilator, as Chris mentioned, So really, it starts to come down to maybe 30% of everyone in the hospital, maybe on a ventilator. If you start looking at other types of mechanical interventions like high flow oxygen, the numbers go up. So yeah, these air sick people And generally I think what we try to do is keep the people who are not in I see you from having to be in an I C u Mhm. Yeah, that's that's pretty similar for us to I think, you know, broadly. A third, a third, a third, a third, maybe in I c. U. Needing very seriously. Levels of mechanical ventilatory support a third, some level of oxygen support That's less than that, Be it on award or in a I see you in a third who are you know, either in the hospital for some other reason and incidentally, picked up as being covered positive as a community, rates go up or or have enough flu like symptoms, but they're not sort of oxygen dependant. Um, yeah, right. No. Yeah. Yeah. And I think Brian, what you're trying to get at is I think we do have some tools that maybe four or five months ago we didn't have. I would say we basically just have mallets and maybe some saws and not something like a laser. So we have some crude, very blunt tools that we're using right now. As you mentioned Dixon, methadone, Randy Severe Industrial probably has some modest effects. Were prone ing people like crazy, which I think has really helped as well. S o. I think we're seeing some fruits of this kitchen sink approach, but I wouldn't say I think Jackson medicines really has probably made a difference. But yeah, we really don't have the therapeutics that one would imagine. We would need to really get people better. Really, It's true. It's very limited. What? What tools we have right now is, but it's better than it was. David's right there. It's better than it was, but better than it was for hospitalized patients is not a 0% mortality rate we're still seeing across the nation easily. One in 10 hostile fertilized patients dying from co vid. So this remains an incredibly serious condition for the folks who get very sick from it. One thing I hear over and over from people who are, shall we say less than concerned. Not all that concerned about the virus. They They say the virus impacts those with compromised immune systems, those who have underlying health conditions. They're the ones we need to really worry about people who are in advanced years, the elderly. But are you seeing Patients Cove in patients who are young, middle aged two who don't really have any substantial underlying health issues? I mean, is it just impacting? Is is it as I hear so often, just impacting those who are who have other health concerns? Brian, I'm happy toe briefly. Speak to that first, but again, you have to expert epidemiologists joining us as well. I think it's fair to say that there are, without question folks who have higher risk of severe disease, but we at Wake Med as I know Duke and UNC have have seen people who are much, much younger, with no risk factors who wind up with severe disease and who die. Andi. And when they would walk in with Covad, you said I wouldn't have put you in that higher risk category. Mhm, Yeah, we've looked at some of our national trials that we've been in and sort of looked at the average age of folks who are coming in, and in fact you surprised that it's in the sort of 50 to 60 rounds. So I agree completely, Chris, that if I had Thio throw a blanket over who's at risk, it's clearly people who are older than 65 or 75. It's clearly folks who have hard to control diabetes or other cardio respiratory illnesses or obese. But there are a reasonable number of people who still keep coming in every day for us who are in there, forties or fifties and who are otherwise quite healthy and and that you know. So for folks who feel that this is, you know, sort of just another flu is always the quote that we keep hearing. Um, that doesn't mean that when so many thousands of people get infected every day that a certain number of those people don't get critically ill and some of them die. And it doesn't equally mean that those folks in their twenties and thirties who, even if themselves, may do fine, don't inadvertently in fact, other people who will not. And so I have a really hard time with with that argument that people say that when I when I in fact 100,000 people a day or it's heck, it's up upward of 150. I think at the moment per day you will find a lot of people in that age bracket who don't fit the typical Hey, I'm 85 and yet still have very critical in life threatening complications to this. Yeah, I agree. I think most people just have toe, um, literally and figuratively look in the mirror because any one of us could get Cove in 19, and if we don't get sick, we can easily transmitted to someone else. The transmission rate now is beyond one, so every person with Cove in 19 is transmitting this to at least one plus other person. That's where we're at right now, And if you look in the mirror and you can honestly say that you're not overweight or obese, then yeah, you're probably going to do a little bit better. You might not be as risk, but the majority of people in this country cannot say that when looking in the mirror. So if you're overweight or obese, you do no matter what your age, No matter if you have diabetes or not, you do not want to get this virus, especially none of us want to get this again because we could transmit it to get sick. But the people we're seeing in our I C use who are really, really sick, they are generally not always, but they're generally big people. And that's who we have in this country, a lot of big people. So that's not to say I haven't seen a 35 year old who has, you know, ah b m I of 22. I have sucking breath way see that? But again, I think the obesity that we're seeing is really playing a big role into this is well, it just leaves me with the impression that you just don't know how your body will respond to this disease. Whether you're 35 year old healthy, b m I 22 or you know, a 70 year old who's a little overweight, it could have That's right, a dire It's a crap. That's the problem with this virus. If we did know for certainty that there's a special group that is at risk for severe disease and everyone else isn't, that would change everything. But it's the indiscriminate nature this we cannot say we've had, you know, as you've seen in the news, we've had 12 year olds, 18 year olds who died from this infection. We just don't know how someone's going to respond, and it's that mystery that's not knowing. That makes this really terrifying. And I think especially now that the numbers have gone up like Camp, said, Really scary. I think it's important for people to know there was more Cove in 19 circulating right now than there was when we went in tow lock down. There's more circulating right now than there was yesterday or last week. So really, we just have to be very mindful that this is the time where there's more risk of infection than probably any time. Up until this point here in the United States, I personally admitted people who run marathons who are colleagues of mine, and I've seen them sucking breath in in the e d scared for their life. Like I do not feel comfortable about this. Like so for people to say, Oh, you know, I'm only 30 40. I'm totally healthy. Like that may be true, but I can guarantee you I've seen people who look like you who have admitted to the hospital. Wow, that's very telling. Very telling. You mentioned, Dr Wall, you mentioned the lock down. Do you think we need to go back to the kind of lockdowns we had in March? Early April? At the outset of this, do we need to have these stringent stay at home efforts? I'm really impressed by some of the messaging we're getting from the incoming administration. I think they're striking the exact right tone. And to paraphrase, it's not a switch on and off switch where you go toe lock down. You don't goto lock down lock downs a tool, but so is dialing in restrictions that can help us stop the spread. So when we emerged from a lock down. It's really what we do after the lock down that really matters. And if we open up too soon, as we've seen, you know, in a natural experiment that's happened in different places across the world, if not in the United States, we could see that infection rates generally go up as restrictions were lifted. So I think dialing back without going to the fully Oscar, because again we could go toe lock down. But it's what happens after locked down that really matters, I think, for further transmission. So I, like some of the messages, is coming. I do think we have to roll back some of the phases that we've seen getting. You know, my colleagues will tell you this is a virus that transmits from somebody who is infected to someone who is susceptible, and as long as we have the proximity between somebody who's infected and someone who's not infected in susceptible, we're gonna have transmission, whether that's in a grade school or high school or campus or meat packing plant or, you know, ah hospital. You know we've got toe work on decreasing those transmission encounters, and it's just practical restaurants and bars are perfect setups because people don't have masks on when they're drinking and eating for those transmission encounters. So we know physically and biologically what we have to do. The harder part is implementing that in a complex society and economy. What do you want to impress upon people? I think I know the answer to this. But when it comes to wearing masks, there's still a lot of resistance toe wearing mass everywhere. What would you tell people who are loathed? Toe toe, where face covering This is one of the most dead easy things you can dio like of all of the strategies that we have up our sleeve for this, of all of the ways that we just talked about about, you know, locking back down or society reintroducing phased rules, this is the single easiest thing that I can dio like. I unfortunately, there has been such a failure of sending a clear message on that front. The distancing and if you can't distance putting a mosque on blocks, respiratory viruses, it's really that simple. And, you know, we got through a whole lot of sort of issues about personal freedom, and we talk about issues about sort of reluctance toe, you know, to sort of Thio go along with this trend. Um, but at the end of the day that the virus doesn't care. This is a very fundamental thing that this fire spreads through people who approximate to each other and it spreads through the air. And if that's the case and mosque fundamentally helps and and you know there's there's just no way around the fact that this this this is a business continuity tool like that's the frustrating part to me that has happened in the last sort of six months is that we've somehow seen this as becoming something that will prevent us from, you know, having an economy that continues to get through this. This is the way to keep the economy going on some sort of level by squashing out this virus. And so for people to think otherwise that it's just it's just inaccurate. I had to say, I am hit the nail exactly on the head when we were forced to move, to lock down, to save thousands upon thousands of lives in the spring and and endure the economic hardship that resulted from it there was so much we didn't know about what to do to prevent spread. Now we know we know that a mask makes a difference. And taking those kinds of simple steps Azaz, Cam and David have touched upon um, and doing that universally. We'll keep us, I think, in a much better position than we're seeing other parts of the country who are already progressing now back to lock down. Yeah, I agree. Just a It's hard to add anything to that. But I just think folks who are open minded and and really thinking hard about this we know why there is aversion to mask. It's. It's part of a political narrative that the administration really didn't want to acknowledge at some point that there was a crisis going on. Um, and as part of that, if everyone is wearing a mask, it would have been, um um acknowledging something that was trying to be suppressed. And so I think it has its origins in a narrative that's no longer operative. We should move past that. We all realized now that there is a pandemic, numbers are going up. A quarter of a million people have died. Many people still have lingering symptoms, and we have to move on from that and just use some practical sense. But the mask is the last line of defense, but it's an important line of defense is Camp said. Distancing is really important. Some of the measures that Chris was talking about, just how we can reduce the density of people. Your last line of defense is your mask, and I think it just is a sign of strength that we're taking action. But this is a tool we can use. It's a weapon if you want. And for those of us who really care about our fellow human beings, it's a courtesy to help prevent them from getting infected. In case we're shedding the virus, we are wanting a go ahead. Go ahead, Dr Ben, No matter your political background. And at this point, CDC has said it doesn't just protect other people that protects you. Yeah, we are one week away from Thanksgiving. I know people in this country are dealing with pandemic fatigue. They're sick and tired of it. Um, and they wanna have some normalcy in their lives. And Thanksgiving is that time when we all come together and break bread and enjoy fellowship of family. What would you tell people who want to go once I have a traditional Thanksgiving get together with family and friends, eh? So I will say when? When I was growing up, our traditional family, Thanksgivings involved 30 or 40 people in very small places, with family members ranging in age from baby to 80 plus. And I don't think there's a way to do that safely right now. Eso when we're thinking as a family about how we celebrate things giving, we're mindful of the things that we know prevent spread of co vid and keeping gatherings small and within close knit family members staying kind of away from others as much as possible in the last week and the week leading up to Thanksgiving. I'm, ah, strong proponent of the kinds of pre testing policies that are out there. Recognizing tests aren't perfect. It's something that we can do. I want to celebrate the holidays as much as as everyone who's watching today. We need that kind of restoration in our souls right now, but we have to find a way to do it safely. Otherwise, the winter is going to be very, very dark. Mhm. Any any advice for people you touched on? Some of it there, Dr D'Arienzo. But people who are going into the holidays and want Thio get together with family and friends. What? What advice would you have for them? Because there's a lot of people wondering what to do to stay safe. Dr. Wall, would you like Thio? Yeah. I, um I think there's gonna have to be sacrifice. I'm sorry. This is a really terrible situation. It's a terrible situation that we were put into because of a lack of earlier response and even didn't catch up the way we're clearly not going the right way. And like I said, e think Chris Point is a good one. Regardless of your political affiliation, I wouldn't care of. It's a red president or Blue president or a blue administration. My criticism would be leveled the same way. We're not in the right place right now, so we're putting this very difficult situation and making these tough decisions. Personally, I am not going to have any family member come over who is not in our bubble of my wife and my two kids. If my mom, who doesn't live with us, comes over. She would have to be outside and at a distance. We would not do it indoors, and I think she wouldn't want it any other way. That's a smart way to do it. That's a zero risk approach, and I think people should be looking at that. We know there's going to be some transmissions during Thanksgiving because of gatherings. We know some people will die because of the gatherings that occurred during Thanksgiving. Let's try to keep that number as small as possible. We really need to do so in doing that means taking precautions. We want there to be future Thanksgivings. So sacrifice this one if you need to. So we could have future Thanksgiving's Dr Wolf. What are you most concerned about? Is we had in the Thanksgiving? Yeah. I mean, my two colleagues here have summed it up beautifully. I'm the guy with the accident from a place that never had Thanksgiving. So heaven forbid for me to tell people want to do this this holiday. But, you know, I would go back. Thio. Well, I reiterate what they had said. Like my family made a choice not truck. My my animals are in their seventies and eighties and nineties. Um, and I am not in North Carolina. And we made an active decision to say that our transmission rates here and in other states are high enough that I don't want to put my at risk in laws under any threatened that that's number one. Number two, I think if you if you want to go back to what we've learned over the last six months about how this transmits, I think there's a few key points. Number one people in their teens, twenties and thirties, often have no symptoms. We've learned that out the hard way on a Duke experience here, and we tested, tested our students very liberally and found almost 50% of young adults unaware of that kid that they carry and transmit coat. So when I then think about what's happened, what happens typically on a Thanksgiving tradition, just like Chris mentioned, you have all age brackets getting together, many of whom are in their teens twenties and thirties. We have college kids coming back from college, and there is a high likelihood, I think, almost an inevitability that people will mix who are 20 and 30 unaware that their minimal symptoms or their lack of symptoms still allow them to transmit Cogan to their 70 89 year old in laws. We think about what we know about indoor transmission being higher than outdoor transmission. This is occurring in late November, and everything is getting called. People will be indoors. You think about the typical things that occur. We all travel. An airport is nothing else, if not designed as a a za people blending facility. I mean, that is You talk about blending your bubbles. An airport does that in spades designed. We sit around the dinner table community. We share food, sit around the couch, much football or whatever people want to dio. They are wonderful ways of transmitting this virus, and we now know that clearly. So I I hate to be sort of nihilistic, but I'm with David and that I that I have to concede there will be There will be mortality that comes from Thanksgiving, and that is that's horrific to think about. But, boy, if we've put in so much effort in the last 6 to 9 months to try and get through this that I would really implore people just to consider. This is the one Thanksgiving that has to look different in order for next year's to get back to something akin to what we're usually familiar with as we end this call because we've got a couple minutes left any any encouraging words is there? Um, clearly, there's some vaccines and development that look extremely promising, but any positive note that you wanna leave people with So I think the vaccines, the vaccines work phenomenally effective. Like I cannot underestimate how impressed I was to get more than 95 90 to 95% efficacy. That is a that is a profound impact on DSO that gives us a horizon of only knowing we have to do this for another couple of you know, a good few months here will absolutely help us. Mhm Dr Wall. You feel pretty good about the development of the vaccines as well, E dio. I feel very good about it. I think we are going to get a little bit more data really soon. I think a couple more months we'll have even better safety data that will reassure a lot of folks and then, as can mentioned, probably June July, there will be a kind of distribution that I think will get us to that level of immunity that will help us a lot. Even when we have a vaccine, we know that still people get infected. Even in the the Modern and Pfizer vaccines, people who got the vaccine, some of them a small number. But some of them did get ill. Maybe not a severely, hopefully, fingers crossed, so we still need treatments. I think that's going to be very important as we talked about. We don't have treatments for people fall through the net that research has to keep going, so we're not completely out of the woods. But boy, it's more than a glimmer of hope. Monday was one of the happiest days I've had and most hopeful, days I've had in eight months, to be honest with you when we saw another study find these kind of results. So I am very encouraged on. I think there will be a light at the end of the tunnel, but in the meantime, people will die. And I think what all three of us are saying is, let's keep that number. Lo. We have tools, masks, distancing, policy, messaging these air very, very potent instruments for getting people to do what we need to do. And I'm very hopeful that we can start doing that in the beginning of next year so that people really do not put their head in the sand and not suffer, You know, horrific Lee, because of the way that they were message the way that they were lead or because of ignorance, wilful or not, so we have the tools in our hand. We can make a big difference right this moment with what we have even before a vaccine is which, and with the therapeutics. Your mission, in the meantime, is to secure more of the randy, severe and hydrochloric when these other, well, Hijazi cleric one. Let's just be clear. It's a good example. Just doesn't work on DWI. Got a system in place where we've had therapies that are not only unproven but turned out to be maybe harmful, approved for granted authorization for emergency use. We have to be very careful. I'm hoping we can emerge this next year from the politicalization of Kobe 19 and just go back to science as it is, we need good outpatient therapies. We need something that not just given to people in the hospital, but people that are at risk for getting hospitalized. Um, you know, all of us are working on outpatient therapeutics, Duke, and you and see for sure part of this active to rise above Kobe dot organ initiative, where we're really looking at finding something like you could take, like, right now for flu. If you get the flu, we all go to the pharmacy and get a flu medicine that helps fight the virus. Um, Tamiflu, things like that. We don't have anything like that for this. And I think that's something we need on that will help augment whatever we do with the vaccine. So people still need to be there for clinical trials. For us to understand. Maybe we need a better vaccine. Maybe some could only be given in one shot. Maybe some that doesn't need to be in a freezer. Uh, we need good treatments. So there's lots of opportunities for this to get even better. We're not gonna get out of this just because we have vaccine made by Pfizer. Madonna, We need more than that. Mhm. And just to be clear, Several months ago, Hydrochloric one was This was seen as possibly this magic bullet, but you're making it abundantly clear. That's not It is. It is not. Not really quickly. It does not fundamentally part of a narrative that it was trying, Thio indicate, I think we could all just be transparent, that things air not so bad. Hope is around the corner. Here's a magic medicine followed by convalescent plasma, which was quote unquote liquid gold. It's not liquid gold. We don't even know it works. And now it's very hard to study because of the perception that it's liquid gold. 80,000 people have received it. We should just be careful. Maybe it does. Maybe it works great. We just haven't been able to study because of the politicalization of these therapies. That's really hurt us, and it slowed things down. And I think we have to move forward in a very, very deliberate way based upon the science based upon the way you do this kind of work on. All of us I know are dedicated to that, and this is what's great about working in North Carolina. We just have so many partners, networks that are trying to get us to the where we need to be, but doing it rigorously and safely and based in evidence not based in rhetoric. Brian, you asked. You asked what gives us hope? Andi, I wanna build on on that. Being in North Carolina this past weekend, I was out food shopping and I got a haircut, two things that we now know how to do safely. And while I was out with in Wake County, uh, with family members wearing our masks, I would say 95% of people were doing the things that we know we need to be doing, and I wish that was 100%. I absolutely do. But we're so much farther than we were in March and April, both in knowing what we need to do and in general acceptance of North Carolinians in doing the things that we need to do. It's just this much farther that we have to go. It's just this much doctors. Thank you. Thank you very much for your time. On your expertise, your insight. This was extremely valuable