How COVID-19 Actually Spreads (w/Dr. Gloria Hwang)

– Hey Z-Pac it’s Dr. Zubin Damania, ZDoggMD, if you’re nasty. Welcome to the show, “The ZDoggMD Show”, today I’m having a guest that I’ve been wanting to have on ever since I saw her talk on how COVID-19 might be transmitted, particularly in hospital settings and what we can do to keep our own selves from getting sick or becoming vectors of transmission and harming our patients. Dr. Gloria Hwang is a Clinical Associate Professor of Radiology at my favorite place, Stanford. We go way back all the way back to my training days and my wife and her shared a lot of training as well. Dr. Hwang has been tasked at Stanford on the radiology side with quality improvement, in particular around COVID and gave an amazing talk that I was privileged to be able to watch and the minute I saw it, I was like, Z-pack, I got to get her on the show and have her teach us about this because I think it’s gonna be super helpful. Gloria, welcome to the show.

– Thank you.

– Are you in your office there at Stanford?

– I am in my office here at Stanford, I am socially distanced from everyone in this office, I challenge you to find this office.

– You know what that sounds like a radiologist that you guys do social distancing at baseline like this is like natural for you.

– We are the masters of social distancing.

– That’s true, that’s true. So tell me so `cause the talk that you gave was actually interesting because it also really focused on how is it that radiology cannot first of all get themselves all sick, which would be a bummer, or become a vector and transmit to patients? So you went on this mission to review all the available data that you could and presented to your team and kind of what’s your sort of… What did you come up with in the end? Like, what how do you think about this?

– So the reason I went and did this was there was still really a lot of uncertainty about what we were supposed to do. Um, people were still between their taking care of patients, they’d be like standing in the hallways close together, talking to each other. Then they go home and they’d be spaced out It’d be socially distant at home and they come to work and it still felt like being at work and so one thought was like really like, what is the data on this? Are we actually doing everything we can to protect ourselves and our patients? And, and I also was wondering like, why did people come up with ideas like the six foot rule? Like, why are we supposed to space ourselves six foot apart? And so I dug into the literature and I found some pretty amazing and horrifying things I just didn’t realize was true until I went into literature, for example, why do we have to stay six feet apart from each other? People with influenza, they came in through the emergency room or they were inpatients and air samples were taken from around these patients. And what these researchers found was that the air samples up to six feet away from these patients had virus particles in them. And so even patients who are not coughing, who are just passively breathing while putting out these vapor clouds that spread six feet apart And that is how the viruses are transmitted and you might say, well, maybe the viruses are just in those big particles that you spray when you’re coughing or sneezing, but they actually didn’t find that to be the case, at least with the flu. They found that the majority of the flu particles were in those really, really small droplets that traveled the furthest away from you. And at that time, I think people weren’t quite sure whether that translated to Corona virus, which is a pretty similar sized viral particle to the flu but I think lately, as we could see, in the news and literature, people are saying, yeah, that’s probably happening with Corona virus too.

– It’s really interesting because again, influenza the sort of mechanisms that you would use to control Corona virus that they’ve been using in Asia and elsewhere, you would think then, would also control the spread of influenza, but either they’re spread differently or more likely influenza is actually just so prevalent that it’s so out of the bag that even though in those quantities like they’re not seeing decreased rates of influenza which is interesting. So that’s an interesting little twist on that. But yeah, that study in the ER wher they were measuring how what’s this viral cloud around people? This little electron cloud where you, you don’t want to enter and that’s where the six feet came from. But again, we’re extrapolating, right? `Cause we don’t even know, is that six foot radius where they’re detecting virus, is it an infectious dose? That’s actually sufficient to make someone sick? Was there any data on infectious dose? I bet there’s not.

– No, I don’t think we really know what the infectious dose is. There’s still so much we just don’t know about COVID-19. We don’t know what the infectious dose is what we do know is it sticks around for a really really long time once it gets onto a surface. There was that paper in the New England Journal that showed that when it hit plastic or stainless steel, it could stick around for 72 hours, three days on cardboard 24 hours, which was actually worse than the original SARS virus from 2003. That would stick around on cardboard for six hours. This is stuck around for a full day and then people actually went through the Diamond Princess cruise ship and they took samples off of the surfaces of the rooms where people tested, COVID positive, some of those people were symptomatic, some were asymptomatic, and they found virus on the surfaces 17 days later.

– Yeah, and that see and that’s another thing that we should think about and I wanna make sure we clarify terminology here, people are throwing around the term airborne, airborne transmission, but that’s a very specific has a very specific meaning in epidemiology and infectious disease, it means that.

– That’s right.

– These are tiny particles, right? That hang in the air for hours and hours and hours like measles but something can be transmitted by an air route like Corona virus, but it’s in the larger droplets medium or larger droplets that technically might fall off at six feet. So that’s a lot of confusion people like it’s airborne, it’s airborne. Well, yeah, it can be transmitted via air, but it’s not technically airborne in the sense that say measles is. Is that what the research that you saw so far was corroborating?

– It’s, true. And I think what people don’t know is how long it can stick around in the air and again, we don’t know what the infectious dose is for example, if you do an aerosolizing procedure, particles that might not have normally been in the air might stick around a little longer. If there’s air turbulence, there might been the particles could potentially stay around longer. We just don’t know with potential turbulence either because of coughing or, or just the way the air is being moved in a room. Wet weather, the particles may stay airborne longer or not.

– And that’s a very important point because again, and also what is the effect of sneezing and coughing active expelling? Is that a farther distance than six feet? Now you mentioned Diamond Princess, which it feels right, doesn’t it? But if you look at Diamond Princess, like you said, so something like 20% of everybody on that ship ultimately tested positive and of those that tested positive only around 18% remained asymptomatic for the duration.

– Correct

– But that’s still a large component and they were older. Yeah,

– That’s their older, that’s right. That was a large component I mean originally 50% were asymptomatic but then the majority of those people eventually developed symptoms. So that left 18%, who were asymptomatic, but if you look at the population on the cruise ship, they did trend older, and they didn’t just randomly test everyone on the cruise ship. It went sequentially. So they started with people who were symptomatic and only at the tail end, did they test people who are asymptomatic? So you would think you think that in the random population, if you just tested people, randomly, then you’d expect a number higher than 20%. And I think the reason we’re now thinking 25% ish based on other data.

– Asymptomatic, right, and you’d mentioned that and then looping it back to what you said about finding it up to 17 days on surfaces. So I think one of the things that I learned from your talk was that this thing, once it’s expelled, it’s on surfaces and when you’re touching surfaces touching your mucous membranes, that can be a major transmission route and what seemed to some of that data seems to imply especially on the Diamond Princess, not everybody got sick, right? But it seems to cluster in close sustained contact. And they found that in the Singaporean-Korean data as well that you had reviewed. Can you talk a little bit about that?

– There we do know that with close sustained contact, there is more likely to be transmission for example, if you have a close contact with someone who is COVID positive who is a family member 10% likelihood of, of becoming COVID positive versus out in the community, each point of contact is more like .4% likelihood of converting to becoming COVID positive and so that does seem to imply that some of it might be aerosol but there probably has probably has a lot to do with the surfaces that people are contacting. When you’re close to someone, you’re probably touching things that they touch. And what people don’t realize is how often they touch their faces. For example, if someone just happens to be breathing on the table and, and they’re COVID positive and virus is accumulating on table, you might just unthinkingly put your hand on table, it looks like a clean table, and then your hand may go to your face. They did a study on medical students and these medical students who knew about infection control, they got the lecture on infection control, they touch their faces an average of 23 times per hour, and about half of those times were to their mucous membranes, which is probably how we all catch our colds every year.

– I you know what? It’s hilarious. I’ve never seen a population, a cohort that picks their nose more than medical students like they are just gross. No no, but this is, this is key because you it’s an unconscious thing `cause we’re not mindful of it and its surface to mucous membrane, and that close contact, you said something really remarkable which I remember taking out of your talk, which was .45% of people will get infected from a contact with somebody out in the community that is positive so there’s a contact, but 10% of close family and close contacts get infected. It is, seems uh, again, surfaces and prolonged close contact are key. It’s not like you’re just walking through a vapor cloud and you’re getting infected. That’s very unusual. It seems more that it’s this close contact. And there’s some data from China that when they sent people home initially to quarantine, home quarantine, all they managed to do was infect their families, some of whom got very sick came to the hospitals and infected healthcare professionals `cause they didn’t understand yet the dynamics of the spread. What do you, so one thing that you said also in the talk that relates to Diamond Princess relates to contact in feces. So the median, tell me about how long this thing is shed in the air and then in the poop because this is different.

– Yeah, so that is a thing and you can again be totally asymptomatic from COVID, be COVID positive and not be aware of it and have the virus shedding your feces. This was actually shown in the case report on a child who infected some family members. But what they found in their study was that slightly over 50% of patients who had virus in their airways also had virus in the feces. And the median duration of viral shedding in the feces was 11.2 days longer than the mean duration of viral shedding in areas and so we’re testing people’s airways and we’re giving them a COVID negative diagnosis once they’ve cleared in the airways, but these individuals could in fact, still be transmitting virus in their feces, and there is a concern about fecal-oral or fecal mucous membrane contamination.

– This is and first of all, that’s gross. Second of all, And so Dr. Paul Offit and I talked about this on the show too. He is quite concerned with the fecal-oral, almost rotavirus like spread of this. There’s a respiratory component, but there’s also a fecal-oral component, which means that you have a longer infectivity, but it also requires a lot of close contact and a lack of hand hygiene. What, you revealed some amazing studies. Tell me about this study where they took bacteriophage tracers, a bacteriophage is a type of virus and just tell me about the study because it’s crazy. It’s about workplace and how we spread things in the workplace and why hand hygiene is so crucial.

– That’s right there. So there was a study about workplace spread of virus and so people have done like benign tracer studies, but to really study a virus you want to use another virus because that’s where two things like hand hygiene that work on viruses but might not remove a particle from your hand really matter. So this group did a study in which they cut a viral tracer on one individuals hands they had for control so no one knew if they were that person who actually had virus on their hand, and also on the entry door knob to an office, and this was just in the morning, and then they kind of let people come in and do their thing, and what they found, and then they tested 68 surfaces in office, and they found that by 2:30pm, all 68 surfaces were contaminated with virus, Every single one of them was contaminated.

– That so gross,

– Which is terrible.

– I am never going to work again, never.

– What they did find was that when the high touch surfaces were disinfected once between when they painted the hands and when they tested the surfaces. I think all the surfaces were contaminated but the amount of contamination was decreased by maybe about half and when they provided a hand hygiene pack to the office workers and said hey, use this they did they weren’t dogmatic about it. They just provided this and say this is available to you. They found that the contamination levels had gone down by 85% which just goes to show that hand hygiene really, I mean, people are gonna touch things but with hand hygiene, you can at least decrease the load of virus in the environment.

– That is really quite remarkable. So it’s the cleaning of the surfaces they just clean once a day, right?

– Just once.

– Once and then told people hey, here’s some gel or whatever, or ability to wash hands, whatever it is, and dramatic reduction. So these things are doable man, like this is just a simple matter of changing our habit patterns and behavior and habit energy. And yet, but instead, we’d rather spend $2.2 trillion rescuing the economy from our failure to manage our habits, like stop touching your face, wash your hands, don’t poop and wipe it with your hand. I mean, maybe people don’t do that. Maybe I’m the only one but I’m just saying, right? So this relates, I think a little bit to what you saw in the Korean experience. Was at the Korean or the Singaporean experience where they looked at health care professionals and what they were doing. It was Atul Gawande’s review in The New Yorker.

– That’s right.

– Yeah. Can you speak to that a bit? Because I’ve been talking about it a bit. Yeah.

– Sure this is I think Singapore and Hong Kong and what they were fortunate or unfortunate to have an earlier go at this was SARS. And what they said was that during the SARS epidemic, they saw some devastating things. They saw a lot of their colleagues get sick, they saw that they were actually the vectors of transmission to otherwise healthy outpatients, and back then they said, never again, we’re not gonna do that. And so they made, they had some great ideas on how to prevent transmission and overlaid on all this was excellent hand hygiene, following hygiene protocols. So between every patient regardless of whether that patient carried diagnosis, they were just really careful about cleaning all of their equipment `cause they understood that there could be asymptomatic transmission. They made sure that all health care professionals exercised good hand hygiene, the cohorted patients and providers so providers formed teams So that if someone got sick, he didn’t take down the entire division and they cohorted the patients to reduce the likelihood that a healthy cohort would get infected by an unhealthy cohort by interleaving those patients on any equipment. They also, they point and I actually directly communicated with one of the physicians in Singapore, they also made a point of everyone wearing masks and masks protect you, but almost more importantly, mask protect other people from you if you happen to be one of those asymptomatic transmitters. And so it was just quite normal for everyone to wear a mask and at the time that article came out, unfortunately, we were and we’re still in a situation where that’s hard for us to follow because of the number of masks available in the United States. But even with the fact that they formed a very incredible national stockpile of masks prior to COVID-19 because they knew that they were gonna need it someday. Even in Singapore, they said “yeah, like we don’t just use and abuse our masks, “we reuse the masks very carefully.” And the way that you do that carefully is you gel before you touch the mask, you gel before you put it on, you gel before you take it off, you take it off in a way that you don’t contaminate the inside of it, so that you can use it again, and they were even had a quota of how many masks per day an individual could get. And they were told, “hey, you get two masks one before your lunch break “one after your lunch break. “If you have to use the bathroom, “use it during your lunch break.” And that’s how they were able to give everyone a mask and preserve their mask count.

– Wow. So it feels vaguely draconian, but it’s really not. It’s actually given what we’re having to go through now. You know.,

– True.

– It’s like, in fact masks, the whole masking thing has become such a source of contention, controversy, fear, anger, all of this stuff but let’s talk, let’s back up and let’s use some reason and science on this. So you actually looked at a study comparing n95 to surgical masks for influenza. And it was a pretty decent randomized control trial, what did you learn from that? Tell me about that.

– Yeah, this was a study in JAMA from 2019 and then it covered five years of data. They did a pragmatic cohort-based randomized control trial where they had clinics, over several sites. They had certain clinics that would wear n95s when patient facing and other clinics would wear surgical masks when patient facing and then their endpoint was to see, was there any difference in influenza transmission or influenza symptoms and influenza positivity in the healthcare providers who wore surgical masks versus n95s. And the answer was, no, there actually was no difference, even though they saw the same percentage of patients who turned out to be flu positive. Even though at home, the same percentage of family members turned out to be flu positive. There was no difference whether they’re facing these patients in the clinic setting wearing surgical masks versus n95s, because of the way that influenza, it’s very again, very similar to Corona viruses, you would think that the n95 might be more protective but that suggests that, that alone doesn’t protect you because some of these folks still got the flu but they seem to be as good in that setting. And that was a large trial. There was also one study from Singapore, in which inadvertently 85% of the providers of a patient who had aerosolization of COVID wore surgical masks, whereas only 15% wore n95s. None of those providers developed COVID.

– And that was 41 caregivers in that room, though, got three exposed.

– That’s right.

– And not a single one and all of them wearing masks but most of them were wearing the surgical mask.

– Exactly.

– This to me is really interesting because it says it implies right we can’t really look at causation here. We were just saying it might be that the surgical mask is protective enough if you do some other things like wash your hands `cause notice both those other guys got got flu in both groups and you wonder how much of that.

– Exactly.

– Was touching stuff on the thing and then touching eyes and that kind of thing or other exposure outside of the clinical environment.

– It’s true.

– So this then really reframes like oh okay, the n95s are specifically very short supply, all masks are in short supply but should

– Yes.

– We be focusing on surgical mask amazing hand hygiene, and what about housekeeping and environmental services? How does that play a role into this?

– So is important to clean, cleaning is very important but what we do know is you can’t just rely on standard housekeeping protocols to keep you healthy. So there was a study on housekeeping where this group took the housekeepers that they thought were really good. They thought these are exemplars and they just were curious. Hey, if we go into these patient rooms after these housekeepers, cleaned and that their standard protocol, how contaminated were the surfaces? And there was amazing variability for the different surfaces for the same housekeeper and also between the housekeepers as to how clean these surfaces were. And, and these housekeepers actually knew that they were participating in the study. So they knew that their work was going to be tested after they were done. And so that seems to show that even in the best of hands, it may not be enough and so it’s really important particularly in these times when you have such a highly transmissible virus to develop cleaning protocols that are above and beyond normal and one thing that our department is doing and hopefully everyone is doing is taking personal responsibility for their space. For example, radiologists sit in front of a computer, so we’re being told, as much as everything is being cleaned it is your responsibility before you even touch that keyboard to disinfect it, the mouse, the microphone, the monitor edge. If you had something that you might be grabbing at the tabletop, anything that you might be touching, you disinfect it when you come, you disinfect it when you go,

– That’s awesome and my wife, being one of your colleagues, is fastidious like that. So she’ll come home and I’ll be like, did you disinfect every single thing? She’s like, dude, you know me, like, I’m so OCD. You think I’m not gonna get every single square centimeter of that, of that surface? So, you know, relating to that, so, radiology in general now, so we’re talking about making sure to be responsible for your own space, hand hygiene, these kind of things. What is your take on the radiologist sort of role in this in terms of mobile scanning devices, portables, going through the halls, what are the vectors that you guys could be part of the problem if not addressed?

– So, the most I know that throughout our hospital and that sounds like from every hospital we’ve communicated with, people are really trying to minimize bringing portable equipment in and out of rooms of patients with COVID, they just know that those are potential vectors of transmission. It won’t be never but really there, everyone is doing their part to minimize that. The most high risk device I think for us, there are two, one is the X-ray machine, the portable X-ray machine and the other is the CT scanner. And so I believe University of Washington may have started this, but several institutions have now developed protocols and Stanford is going to be kicking it’s all protocol off either today or very soon to take radiographs through glass so that the machine does not have to go in and share air with the with the COVID positive patient. There still will have to be a plate that’s placed behind the patient, ideally covered in plastic to again, minimize chance of getting contaminated. But there, but people are looking at creative ways to minimize these like rough edge machines having to go in and get contaminated, `cause it’s really, really hard to clean every nook and cranny of a machine. And also with the CT scanner, really developing cleaning protocols above and beyond the normal even for asymptomatic patients to make sure that every scanner, every surface that might be touched or breathed on is cleaned.

– And absolutely, and one thing that you mentioned you touched on earlier is, hey, let’s actually let’s make sure we don’t do inappropriate stuff. So I’m seeing this revolution in care. We’re doing a lot less than we ask for, as a quality person you know, a lot of what we do is just pure harm. By the way I failed to mention to the to the tribe here. Gloria is an interventional radiologist. So she’s actually doing procedures on patients, right. She’s not just sitting behind the thing and so you understand that things we do have consequences. So if we’re scanning unnecessarily. So it turns out we’re not scanning a lot unnecessarily, particularly at Stanford, we’re doing it judiciously because we have to clean in between and be cognizant of that. We’re not doing so many labs and draws and things like that, that we would normally do just mindlessly to have the data or cover our butts and it turns out, it’s probably a better practice, COVID may have a silver lining and how we do things. So that’s super helpful. But in your interventional practice, I imagine your cases have dropped because elective procedures are canceled and are you keeping yourself safe with n95 and those procedures?

– So we’re following our hospital guidelines for the procedures. First of all, like in order for a patient who is COVID positive, to undergo any procedure requires actually going fairly high up the hospital hierarchy there is people we really are looking to make sure those procedures are absolutely necessary and that would be true for an interventional radiology procedure, a surgical procedure, anything. But even in the asymptomatic patients. We because of the, because PPE is in such short supply, we are being very careful, at least in the short-term to only do those procedures that absolutely have to be done in the short-term. If something can be postponed until our until things have stabilized, then we’re doing our best to really postpone those procedures. And so patients who still need to get done, of course emergencies, bleeding, sepsis, and cancer patients who have rapidly growing tumors who need to be treated,

– Hmm it makes sense. You have to triage in that, in that in that way. And then I’ve heard from ICU people that keeping people from coming into the room during codes just not burning through your PPE, even if you’re just using two masks a day or one mask a day and you’re protecting it with a cloth cover and all of that. And one thing so if I can summarize some of this and you can fill me in on anything else you would, is there anything we missed that you wanted to talk about, specifically?

– I don’t think so.

– Yeah, I think we kind of did a tour de force here. So let me see if I summarize it and you correct me where I’m wrong. So basically this thing is spread somewhat through droplets, somewhat through surfaces and fecal oral and touching eyes and mucous membranes. So hand hygiene, washing hands, cleaning surfaces and it seems like a surgical mask if we had the resources to give it to everybody that might be nice because you protect people from people who are infected more than even protecting yourself. In hospitals,

– True.

– Do you think we should be advocating every hospital has its own policy? And we’re gonna talk about the shortage of PPE in a second, but assuming we have the resources, should every clinician in a hospital be wearing a surgical mask whenever they’re facing patients and even when they’re not? What are your thoughts?

– I think that if the hospital has the resources, yes, and I think the way hospitals have done it is that if a clinician is facing a patient who is asymptomatic, so lower likelihood of being COVID positive, then the clinician can actually wear that same mask to see multiple patients. Once that mask gets contaminated in any way, then unfortunately it has to go and a new mask needs to put on, when that physician is in a situation where the mask is obviously going to be contaminated such as a COVID positive patient, or in a room with an aerosolizing procedure where the mask is at risk, then that mask will have to be exchanged. And and I know face shields are also in short supply, but those have been considered as a potential barrier of protection for the masks.

– Right, right. It makes sense and so I’ve been talking since I did a rant the other day about how our leadership has not really provided us enough PPE and are silencing doctors. I’m not saying our leadership at Stanford or anywhere here I’m saying it’s happening, I hear the stories around the country and physicians feel very disempowered. They’re risking their lives. Everyone on the frontline is risking their lives. and since then, I’ve had a few conversations with leaders of large, large, large health systems and what they tell me is truly it’s a mixture of extremely difficult to hear, sad, and you actually feel for how hard the struggle is, which is there just isn’t the PPE available. They are dealing with middlemen in China who are jacking up the prices and they still can’t get the PPE. And this was a failure of planning from back in the day like we’re not even even acutely, you just can’t get it. It’s not. They’re trying to throw money at it and they can’t. They’re struggling to keep the lights on because their elective procedures have bottomed out. They’re struggling to pay staff without furloughing them so they’ll have them ready when the surge hits. And for one of the few times in my life, I had the deepest actually empathy for our colleagues who tried to run this thing. As much as I rant and rave about them, this is a real struggle. So I think it’s important for us like you and I Gloria and other clinicians to say okay, let’s look at the science. Here’s the bare minimum that we need. Let’s work with our leaders to try to get it and then we’ll figure out who to hang after this thing’s over. But right now we need to we need to get on and what do you think?

– I totally agree. I mean, until our institution came up with these our new PPE guidelines, I was feeling a lot of moral distress, having read the literature on on what, on how COVID could be transmitted, kept transmitted, and actually seeing what we were being told was okay, and not okay, based on national guidelines that were continuing to change. I was just very concerned. And so it sounds, it seems like nationally, we’re all moving to a more coherent understanding, but that doesn’t get rid of the fact that we’re all still struggling to have enough PPE to feel secure, especially as many of us are still looking at the upswing and we haven’t gotten into the surge yet.

– Yeah.

– And so I think we all really just need to do our part to, to make sure we still have, that we’re protecting ourselves that we make sure we have the resources in a few weeks when we continue to need them more.

– Yeah, I’m with you 100%. And we have to at this point, kind of really rally, circle the wagons, all hands on deck and trying to everybody do their part to make this happen. And I know it’s frustrating on the frontline when people realize, okay, there’s different, there’s different CDC saying one thing WHO say they’re changing it. Some of this is based on the reality of resources and people are risking themselves, right not having the resources. That’s why I think it’s so important that we say you know what, if you can use a surgical mask, use a surgical mask, the n95 reserve it for people that are having aerosolizing procedures, etc. And there may be new guidance for public mask wearing which is interesting that has been intimated today. So there’s a lot of stuff going on. One thing, one story I want to tap so just so you guys can tell Gloria does her research knows her stuff. There’s reasons that I trust her on this stuff. The main reason I trust her on this stuff is when I was a resident, or yeah, I was a resident in the Stanford ICU. Gloria was a medical student on service, I think either on ICU or on a consulting team. And she consulted I don’t think you even remember the story, Gloria. So I’m telling this for the first time in years. She consulted on one of my patients and I don’t know if it was as ID or what roles the consultant was. The note that went in the chart as a fourth year medical student, which by the way, has no business even writing notes `cause you’ve already matched and it doesn’t matter. She already got her radiology in it. It was the most epic note I’ve ever, it brought tears to my eyes as an internist who loves that. I was like this note. This person’s life story is here. All the data it was cited with like bibliography. I was like, this is the gold standard of all notes and, and ever since then, I’ve been like, anything Gloria says I believe it. Cause I know she’s diligent and prepares. So Dude, I really I’m so stoked. You could take time out of your day to teach the Z-pack about what you’ve learned. It’s so, so helpful. And I hope you’re staying safe. So when you come home, how do you debride yourself before you, hang out with the kids and your husband.

– So you know what? I don’t believe in getting naked in my driveway but I do, I do like —

– That’s makes one of us. That’s makes one of us.

– So I do pre-debride myself in the hospital, I will make sure that that I changed right before so if I’ve traveled around the hospital, I will change right before I leave the hospital into something fresh and then once I walk in the door, I will then change again. What I wear.

– That makes sense.

– I think some people hop in the shower immediately when they get home. You know, I get hungry. And I kinda have to have dinner before I do that.

– I hear you, though you know what, actually I’ll bring that back to one other point that you found in your data search, which was when they looked in China at negative pressure rooms where COVID patients were being housed and they checked all the surfaces I think you’d mentioned you finding this stuff on different surfaces in the room all around including the air vents which may imply they is been sucked right. But when they tested the PPE on the caregivers that were going in and out of the rooms they did not find virus except for on one shoe front. So.

– Exactly.

– That’s encouraging at least in a negative pressure room.

– Yeah.

– yeah.

– Which hopefully not most of the patients will be in that situation but you’re right the PPE all tested negative, one shoe front but they even swap the entryway so you figure if the shoe front was contaminating the entryway, that would have been positive entry was also negative for virus.

– And the last thing I would point I wanted to make about this is again, we just don’t know what the infectious doses so it could be that you detect viral viral RNA, but it’s infectivity isn’t known so there’s still a lot.

– Exactly.

– We can learn. Yeah. Gloria Hwang what a pleasure. This was a tour de force. I enjoyed it a lot. Will you come back if you learn more, will you teach us?

– Absolutely.

– That’s awesome. I am gonna blow up your DMS by not giving out your DMS.

– Thank you.

– But, guys, Z-pack please do me a favor, share the show, leave a comment, tell us what your institutions doing. And we’ll do more stuff like this with your support, thank you to our supporter tribe who subscribes for 4.99 a month on Facebook or any amount on YouTube, we really, really appreciate it. It keeps the show going, especially in a time when everybody’s struggling financially. We really, really appreciate it. Hearts and thoughts go out to all the frontline staff out there that are working through this that are heroically working through this. And I’m gonna give a shout out to our good leadership that is working around the clock to try to support the clinicians on the frontline and to our quality improvement people that are trying to learn as much as we can so we never make these mistakes again, Gloria thank you girl.

– Thank you.

– And we out peace.