Meatpacking plants, nursing homes, schools…here’s how we can get back to work while lowering coronavirus transmission risk.
Dr. Bob Harrison, MD is a clinical professor of medicine at UCSF and an occupational and environmental medicine specialist. He’s a specialist in preventing coronavirus spread in the workplace environment.
In this interview we talk about the tiers of protection that can help prevent workplace COVID exposure, the relevance of face masks, ventilation and testing, the importance of contact tracing, and much more.
See our prior interview with Dr. Harrison on silicosis in countertop fabricators here.
Dr. Z: Guys, this is Dr. Robert Harrison. He is a professor of Environmental and Occupational medicine at UCSF. Is that right?
Dr. Harrison: That’s right Zubin.
Dr. Z: Yeah and you’ve been on the show before. We talked about silicosis in countertop fabricators.
Dr. Harrison: Well, that seems like decades ago. That was before COVID. I don’t know if there was an occupational problem before COVID.
Dr. Z: I don’t think there was compared to COVID right, so tell me so the reason we wanted you back on the show and I think it’s the perfect timing, is that with COVID, you have been on there, on the front lines going, okay, how do we keep workers safe? What’s going on on the front lines? What’s going on in correctional facilities? But you started talking about the opera before we even decided to start the show and I’m gonna fold that in because tell me how in a room, where you’re projecting particles and aerosols you keep people safe.
Dr. Harrison: Well, first of all, Zubin, thanks for having me here.
Dr. Z: My pleasure.
Dr. Harrison: I’ve been helping with a team of my colleagues and other experts from UC San Francisco. We’ve been giving some help and advice to the San Francisco Opera, because after January, certainly in March, when we went into the shutdown, pretty much all arts and live performances had to stop and as a personal devotee of live performance and the arts, I think it’s really at the core of our society. It’s my church. When I go to the opera or the symphony or the ballet, I feel like I’m in church. It just feeds my soul. So getting our arts organizations back running as soon as we can safely, I think is just so important to everybody, including myself and so, when you mentioned how to do that at the San Francisco Opera, first of all, let me just thank all the great artists out there who work for the Opera and other organizations, whether big or small. They’re all shut in trying to provide, the performances to us online, because COVID is transmitted by, as many of the audience probably know, a combination of droplet, surface and aerosol, small particles and we know that people who sing can spread COVID. This was seen in the Spring with the publication out of the “Washington Chorus.”
Dr. Z: Right.
Dr. Harrison: Where there was probably a super spreader, an older woman who was a choral member who came in and sang and dozens of other choral members were infected. In fact, I think a couple unfortunately died in that episode and that was one of our first clues that COVID is airborne. So when we have singers, of course, in an opera, or a symphony, let’s say, if there’s a chorus in one of the symphony performances, there is going to be airborne potential for infection to other performers, symphony members, stage crews and so on.
Dr. Z: So, let me clarify a few things and first of all, just so people know, because we appreciate this and you are a occupational and environmental researcher and doctor because we’re talking in a space, we’ve taken precautions here. We have our masks with us and we wear them until we start the interview. We’re spaced out, we have ventilation going, a fan pulling in air, windows open, doors open. So we do our best to minimize risk but when you say airborne, this is a very charged term right because some people say, well, does that mean aerosolized like measles, or does that mean droplets, like six feet? How do you think about that? How do you talk about that?
Dr. Harrison: Well, the terminology can get really confusing. So when I say airborne, it means that it’s transmissible through the air, through a variety of different particles, particles of different sizes. So some of them are large, they’re emitted, they drop to the ground within a couple of feet rapidly. Others become very small as the water droplets evaporate in the air, they become very small and they can become airborne over a feet or even more, even more than six feet, which is the rule of thumb that we use. So there’s a particle size distribution. So I like to think of the word particle as the best way to describe this. A particle in the air. Droplets generally mean large, aerosol means tiny little particles over some period over some distance.
Dr. Z: And it’s not a black and white thing, there’s a range of particle sizes like you say.
Dr. Harrison: There’s a range of particle sizes and there’s risk through both routes and thank you for mentioning I’m not wearing a mask here today, because we’re at a distance from each other. You’ve assured me that the ventilation in this room is good. I’ll hold you to that, Zubin.
Dr. Z: Did I make you sign a waiver? I don’t know.
Dr. Harrison: Wait, I didn’t see that fine print.
Dr. Z: Oh boy, the COVID waiver right right, and well, so here’s a question. So then you are sort of tasked with this very difficult and also exciting, ’cause this is your kind of life’s work, how do we manage risk and transmission risk in workplace environments? Which are often enclosed spaces right, they’re often indoor spaces.
Dr. Harrison: Often indoor spaces.
Dr. Z: Yeah.
Dr. Harrison: Um it’s what I call layers of protection. So one layer is this face covering. We can talk later about different kinds of face coverings and what we know about these. Face coverings alone are not a Holy Grail. It’s not like what I imagine, Indiana Jones in that movie, you know, he goes into the cave and he finds that goblet.
Dr. Z: Oh yeah.
Dr. Harrison: You know?
Dr. Z: You have chosen.
Dr. Harrison: You have chosen poorly right um, and then the guy disintegrates. That’s one of my favorite scenes, by the way.
Dr. Z: Classic.
Dr. Harrison: Right? So this face covering is not like choosing the goblet of the Holy Grail. It’s not gonna prevent everybody from getting infected. So it has a layer of prevention here. Science shows that it’s probably effective but we still need to socially distance in a workplace and this becomes very challenging. We can talk more about some of these workplaces in which the six feet or more social distancing rule is very challenging, if not impossible for some workplaces.
Dr. Z: Right.
Dr. Harrison: Ventilation is another layer. We talked about ventilation in this room but there are good scientific studies that will show that a certain amount of room air ventilation can reduce the infectious dose of those particles and then the fourth layer is testing and I put testing in three different kinds of baskets and we can talk more about what those baskets are, if you want and then we have all of those in place. We really don’t know if you asked me, Zubin, well, is a face covering more important than ventilation?
Dr. Z: Right.
Dr. Harrison: Is that more important than testing? Is that more important than distancing? We don’t know.
Dr. Z: Yeah.
Dr. Harrison: But we do know that you combine all those together at this point.
Dr. Z: It’s like the Swiss Cheese Model. If all the holes align and you have nothing, you can, you know, virus will slip right through. If you have one thing, well, you’re less likely, but it’s still possible and you can have failure where holes align and you’re just unlucky. You can have all three and still get infected.
Dr. Harrison: Correct, exactly.
Dr. Z: And so it’s important to know that it’s a spectrum of risk. It’s not a black or white, yes or no answer. ‘Cause people will ask me those questions a lot. Like, “Well, okay, Thanksgiving’s coming. My grandfather is at high risk. What should we do? Should we wear face shields? Should we wear.” You know? How when friends and family ask you this stuff, I mean, how do you even begin to address it because you’ve already told us three sort of layers, how do you talk to them about risk?
Dr. Harrison: For Thanksgiving?
Dr. Z: Let’s just say Thanksgiving.
Dr. Harrison: Right, for Thanksgiving specifically, keep those groups really small.
Dr. Z: Yeah, so just lower the probability.
Dr. Harrison: Lower the probability. It’s just a matter of probability. If I have 10 people in a room, I have a higher probability that someone’s gonna be infectious and I don’t know it and if I’m with one other person who I’ve assessed is keeping safe keeping in a relative bubble.
Dr. Z: That makes sense. So here’s a question and let’s go back and let’s dissect each of those three tools that you talked about. So face coverings. Now this has been for some reason, incredibly controversial. You and I were even talking off camera like early on, are cloth masks a useful face covering relative to surgical or N95 and early on, I wasn’t convinced they were. Your colleague, Monica Gandhi, actually has increasingly convinced me that maybe the viral inoculum is lowered by masks and therefore they are useful no matter what kind they are but what’s your thinking? How do you think about face coverings?
Dr. Harrison: Well, I think about face coverings as one effective tool.
Dr. Z: Yeah.
Dr. Harrison: It’s again, I say it’s not some Holy Grail, it’s not some magic answer. It’s a risk reduction tool. You know, in January and February when the pandemic started there was a shortage of face coverings and so what happened is if you remember, everyone was thinking, oh I’m gonna go out and sew my own, I’m gonna get my friend, they’re gonna begin sewing face coverings. Everyone on Etsy.
Dr. Z: I remember this, yeah.
Dr. Harrison: On YouTube and tried to figure out, well, how do I make an effective face covering? And so what I see now is every everything from a buff to a bandana, to a homemade face covering of all different materials,
Dr. Z: Personally, I believe there’s only one face covering worth having.
Dr. Harrison: Zubin I think that’s the face covering. I think you should patent it, I think should put it on Etsy and I think you should sell it.
Dr. Z: I am the most powerful Etsy purveyor in the galaxy.
Dr. Harrison: Well, Zubin can I just ask you.
Dr. Z: Who’s Zubin? I’m Doc Vader.
Dr. Harrison: Sorry, Doc Vader, what would that look like in a meat packing plant?
Dr. Z: Now that’s where it gets real because you know my Padawans, many of whom are in fact meat packers, don’t like it when I come into work like this. So, you know what, I’m gonna get ZDogg so you can talk about that.
Dr. Harrison: You know, ZDogg, I just saw this image. It was like a dream that came to me. There’s this guy in this Darth Vader helmet and he was talking about using that in the meat packing plant.
Dr. Z: It’s a PAPR, honestly it’s a really high quality mask.
Dr. Harrison: I shouldn’t make light because meat packing plant workers have been tremendously impacted.
Dr. Z: And you’ve been dealing with this. So tell me about this, because this, it was fascinating cold environment, what’s going on with meatpacking that makes it so particularly difficult? And let’s relate it to the face covering question as well.
Dr. Harrison: Well sure. So early on in the pandemic, we had a critical shortage of both face coverings and N95s a higher level of PPE, which we so desperately needed for our frontline healthcare workers at the time and so we had all sorts of different face coverings and then a lot of conflicting messages about the adequacy of face coverings and so in meat packing plants and other workplaces where the social distancing was not in effect where, if you’ve been in a meat packing or a poultry plant as I have been at a poultry plant in Southern Missouri about 25 years ago, you’re working a foot away, two feet away max.
Dr. Z: So you’re cramped in
Dr. Harrison: You are cramped in as the, this was a poultry plant. The birds are going by at 150 per minute.
Dr. Z: Wow, it’s like that “I love Lucy” episode where she’s trying to keep up with the chocolates and ends up eating them but if you ate raw chicken, you would die.
Dr. Harrison: Exactly, I show that episode from, “I love Lucy” to my students actually, because I talk about lines speed as a problem in the workplace and so line speed is really the critical factor in a poultry and meat packing plant, because in order to get so much production per minute, you have to have a lot of people in front of that material. It’s just a simple math. So if we slow the line speed down, we can distance workers further apart but what happens when line speed is slowed? There’s less chickens, there’s less profit. There’s less bacon coming out and there’s less profit and such that it’s a very calculated formula between the line speed, the number of workers and the profits being made and so at the beginning of the pandemic, we had dozens of meat packing plant outbreaks around the country related to the closeness of all the workers, the line speed and the variability in the face coverings. So the lack of personal protective equipment and the interestingly, because it’s cold, there’s some thought that the virus may survive for longer at lower temperatures.
Dr. Z: Right, in the air
Dr. Harrison: and in the air.
Dr. Z: And on surfaces.
Dr. Harrison: Exactly and on surfaces so that could be another risk factor in those plants. The ventilation in poultry and meat, packing plants is set up for the chickens and the beef. So it’s actually all designed to keep bugs out of the roofs
Dr. Z: Oh right, ’cause you don’t want the flies laying eggs in the,
Dr. Harrison: Well, you don’t want salmonella contamination. You don’t want the flies. You don’t want the microbial contamination but it’s not designed in the ideal way to prevent airborne transmission.
Dr. Z: Interesting, what’s the difference? What’s the subtlety and the differences?
Dr. Harrison: Well the subtlety is the direction of airflow. If you have a large number in an open space, how do you get enough air changes per hour to turn over in that space?
Dr. Z: So that’s how you think about is how much of the air volume in that area are you turning over per unit time?
Dr. Harrison: Exactly, so for instance we’re in this room Zubin, what I’d like is four to six air changes an hour of fresh air,-
Dr. Z: Fresh air, yeah.
Dr. Harrison: Fresh air coming into this room.-
Dr. Z: Not recirculating.-
Dr. Harrison: Not recirculating, ’cause a lot of buildings, because of energy conservation and I’m all for energy conservation, but we have a tension now between healthy buildings, healthy environment and getting enough fresh air changes coming into these buildings to turn over the air.
Dr. Z: Interesting.
Dr. Harrison: Every four to six times an hour.
Dr. Z: So how useful are things like filtration within a recirculated air?
Dr. Harrison: So filtration works, so you have these, what are called MERV, M-E-R-V filters.
Dr. Z: And what’s the minimum MERV say for a household?
Dr. Harrison: Well for a workplace, let me just address the workplace. So you need a MERV 13.
Dr. Z: Oh, that’s pretty high.
Dr. Harrison: It’s high.
Dr. Z: Put stress on the HVAC units.
Dr. Harrison: Exactly, so you have to have an HVAC system that can accommodate it or it can be beefed up.
Dr. Z: Got it.
Dr. Harrison: To run it through a MERV 13 filter.
Dr. Z: Right, but that’s gonna capture viral particle sizes that are in the range of what you’re talking about.
Dr. Harrison: Exactly.
Dr. Z: Fascinating so,
Dr. Harrison: And so if you don’t have a MERV 13, then you need to supplement the air changes in that room. So you can have a MERV 13 with a lower number of fresh air changes but if you don’t have that MERV 13, then you gotta, and you have to build up the air changes in that room. So you gotta get for a lot of buildings and a lot of workplaces, you gotta get an expert certainly.
Dr. Z: Well this has already got me thinking about this space. So I have a MERV 13 filter in our unit here and it’s a newer unit and I put it in after COVID and I run it on fan and that circulates air through the filter and through a vent right there that then goes into probably pulled into the fan out there and so I’m gonna map this out. Is there, how do you, are there sprays or things you can test to see the airflow patterns in a room? Like how do you test that?
Dr. Harrison: Well the only test you could probably do practically yourself is to see if you have an exhaust in this area. If you have a register or a duct that’s pulling air out right ’cause that’s gonna tell you, where you have air in, but then is there gonna be recirculating out of this room? You get a ladder or a step stool, you take a tissue and you hold it against that exhaust register and that’s gonna tell, am I getting exhaust out of here but it’s not gonna tell you how much and what the flow is and then you need to get a tape measure.
Dr. Z: It’s getting complicated.
Dr. Harrison: Yeah it’s getting complicated, isn’t it and you got to measure the volume, the cubic foot of your space and then you’ve got to measure airflow in, airflow out and you got to figure out the air changes per hour in that cubic footage. So Zubin I know you’ve gotten an advanced education, I think you may even have a degree from UCSF I don’t know.
Dr. Z: I’m feeling Pretty dumb Bob. Thank you for that.
Dr. Harrison: So I feel very dumb very quickly around this very issue. So what I recommend to businesses who are thinking about proper ventilation and returning people to work, is getting someone who knows this business to come in and help them.
Dr. Z: So these are HVAC specialists?
Dr. Harrison: These are HVAC specialists.
Dr. Z: Okay.
Dr. Harrison: Exactly.
Dr. Z: So let’s go back to the meat packing plant then. So we talked a little bit about ventilation. They didn’t have the ideal ventilation for that. The distancing was not necessarily there, the face coverings, talk about that again. So what kind of face covering would you like to see to have the best effect in that part of the algorithm?
Dr. Harrison: At least if it’s a cloth, this is not a cloth, this is from my hospital, we get one of these. So either one of these, which is made out of a special kind of material that has a filter built in in the manufacturer of this material.
Dr. Z: Got it.
Dr. Harrison: Right. So and it also has a rigid nose clip here.
Dr. Z: That helps you to mold it and could create a seal.
Dr. Harrison: Exactly, I can get a better seal, out of this, has two straps that’ll fit pretty tightly over my ear,
Dr. Z: And you’re supposed to wear it like this I understand.
Dr. Harrison: Yeah as far below the nose, I’m only kidding yeah. I can’t tell you how many people I see, I would take an informal poll if I had a little clicker and even in my colleagues they’ll be talking to me and it’ll drop.
Dr. Z: It’ll drop.
Dr. Harrison: It’ll drop and you’ll be doing this the whole time and so you got to get that really good seal here. If this is not available, then a cloth is okay but it should be at least three ply.
Dr. Z: Three ply.
Dr. Harrison: Three ply yup and I can share some studies and some websites with you that talk about the filtration that you get from at least a three ply material.
Dr. Z: So you’ll give me those and I’ll put them in the show notes on our website that’s perfect.
Dr. Harrison: Absolutely yeah. I think it’d be very helpful because I get this question often.
Dr. Z: Well it’s an existential question for a lot of people who are like, well if I wear a mask and it’s a garbage mask, like a single ply, polyester thing, is that helping at all?
Dr. Harrison: Yeah, it’s probably not. I mean, it’s helping some,
Dr. Z: Very small amounts.
Dr. Harrison: Right very small amount and there are some also, there’s some recent papers that have compared the effectiveness of different face coverings. So what folks I think need to keep in mind is okay, I put this on right?
Dr. Z: Right.
Dr. Harrison: And first of all, I have a beard.
Dr. Z: Right.
Dr. Harrison: So I’m not getting as good as a seal as you might be getting without the beard. Ideally I should be shaving and especially if I’m going in and I’m seeing a COVID positive patient, my health care frontline, healthcare worker and I’m fit tested or a real respirator an N95, I’m not gonna get a good seal with facial hair. I’m gonna get leakage right around the edges here and that’s why these face coverings, aside from the filter characteristics in the front, why these face coverings are not totally effective ’cause I’m getting particles that are coming out the side.
Dr. Z: That’s right.
Dr. Harrison: And this has been demonstrated time and again, in aerosol physics study.
Dr. Z: Yeah, well what’s interesting though, is even with these surgical masks, the amount of infection and so on and in hospital setting seems to be quite reduced even with just surgical masking, am I understanding that data wrong, even beyond N95.
Dr. Harrison: I think you’re understanding that data correctly, but with one caveat Zubin, in these hospitals studies, like everything else in the world they’re multifactorial. So hospitals that have gone to universal face coverings, like my hospital at UC San Francisco,
Dr. Z: Yep, here at Stanford yeah.
Dr. Harrison: Stanford went to it very early, I think by April, I think we had it required for everybody,
Dr. Z: That’s right.
Dr. Harrison: who came in, but we also put into place very shortly after patient testing everyone who’s admitted, gets a COVID test. We have very strict symptom screening at the door. You can’t get in unless you’ve completed a symptom check, very important we have accessible and free testing. So pretty much I say, if you have a sniffle that you think was more than your allergy that day, a little scratchy throat, call our hotline, you can get a test and get the result back practically the same day.
Dr. Z: So this then gets to that third tier. So we talked about face coverings and so basically let me just summarize quickly for the audience. So for face coverings, ideally, and I’ve been saying, surgical mask is better than a cloth mask. If you use a cloth mask, three ply is better than two or one. An N95 or higher is not necessary probably for most people in public, but definitely for people at high risk and high risk settings like aerosolizing procedures, maybe meat packing.
Dr. Harrison: Or direct care for our COVID patient if you’re a frontline healthcare worker, I would say even without an aerosolized generating procedure.
Dr. Z: Interesting. Important.
Dr. Harrison: Yeah very important. So we now have enough N95s to provide and we should have enough in most facilities now.
Dr. Z: Okay and recently, there was even news out of UCSF that some people tested positive at the facility, was that, do we have any more information on that?
Dr. Harrison: So what happened and this was, I think in the local paper here, we test all patients who come to our facility. You get admitted, you get a COVID test and you’re negative. If you’re positive of course, then you’re put in a COVID room with all the full PPE. All the staff knows and the per person is admitted and is COVID positive but we get people and this was what happened, somebody admitted as negative, but then turns positive because remember COVID testing is not perfect. You can be in this incubation period.
Dr. Z: That’s right and negative doesn’t necessarily mean,
Dr. Harrison: And negative doesn’t mean you might not be positive tomorrow.
Dr. Z: That’s right and so were there staff then that were exposed?
Dr. Harrison: So yes our staff were exposed and did not know, assume that the patient was negative and then the patient, this individual turned positive before discharge.
Dr. Z: Do we know that those staff were wearing even surgical masks?
Dr. Harrison: Oh yeah they were wearing face coverings yeah but the patient was not because she thought.
Dr. Z: Right.
Dr. Harrison: Because I’m negative and I don’t know whether it has some analogies to the so-called Rose Garden Superspreader Event. Nobody knows the details.
Dr. Z: Nobody knows. This is interest because again, it’s that Swiss cheese thing. Okay, well, if patient and doctor are wearing surgical masks that’s better than only one wearing surgical mask. If one’s wearing N95 and one’s wearing nothing that’s a different algorithm but so what’s interesting here is and I remember a reading that says, most of the people who were positive in this case did not have a whole bunch of symptoms or get very sick, am I wrong about that?
Dr. Harrison: No, you’re right.
Dr. Z: So then it gets to again, that inoculum question.
Dr. Harrison: Yeah it gets to the inoculum question and can somebody have a higher inoculum, was this just the individual that had a higher infectious load and then spread it through the air in her room.
Dr. Z: Yeah.
Dr. Harrison: And so, just I think it’s a lesson learned that as much as we think we can cover all the things that we think we’re trying to do right, we have to take heed to this virus that I can be negative today but I can be positive tomorrow.
Dr. Z: Right.
Dr. Harrison: And so I still need to take all those precautions. It’s almost like the universal precautions principle that I remember, drummed into me as a medical student.
Dr. Z: Right, you just assume.
Dr. Harrison: Treat everyone, just assume that everyone has, back in the day it was everyone had hepatitis B. I didn’t wanna get a needle stick. I assumed they were infectious.
Dr. Z: Yes yes yes exactly, universal precautions, which I think are valid and I have a quick question. I don’t know if you know the answer to this, but it’s related to that, have we seen levels of C. diff and other hospital acquired infections dropping since COVID?
Dr. Harrison: That’s a great question. I don’t know.
Dr. Z: This is interesting. I’ve anecdotally, I’ve had nurses tell me that C. diff is not a thing anymore in their facilities. It’s much less of a thing because people are so universally precautious worried about the COVID that they are doing things they should have done anyways. Like hand-washing, general universal precautions, gloving, gowning, all that and this is interesting because it just again shows us how poorly conditioned we are to do the right thing at baseline and so that may be one of the positives out of this from an occupational stand point.
Dr. Harrison: That’s fascinating. I did not think of that as maybe an unintended positive consequence. I get so focused Zubin, on all the negative consequences that occur.
Dr. Z: You and me live in the Bay area. The glass is always half empty here.
Dr. Z: Yeah no no, I hear you. So going back to the meat packing stuff because this was in the news a lot and so you have the face covering inadequacy or inconsistency, you have the pact together people, you have the cold temperature, the poor ventilation. Let’s talk about the testing. So you said testing is one of the principles of this. How does testing help us prevent occupational exposures?
Dr. Harrison: There are three baskets of testing and they all help. The first basket is testing when someone has a symptom. So if in the case of a meat packing plant if a meat packing plant worker comes to work with a symptom, they immediately have to be turned away, not go to work and get a test. If they’re positive, they’re quarantined 14 days. Now it’s 10 if you follow the CDC guidance and so that’s number one. Number two is what I call outbreak or response testing. So if there are a couple of meat packing plant workers on one production line, they don’t share the same household, they didn’t carpool together, they are working within close proximity to each other where it could be spread by contact or through the air, then everyone within their contact circle at work needs to be tested and probably needs to be tested twice. Either within a week or certainly within 14 days because we know the incubation period is that 14 days.
Dr. Z: This is important, needs to be probably tested twice. This just makes sense.
Dr. Harrison: It’s just twice. That’s my recommendation.
Dr. Z: Yeah.
Dr. Harrison: Get ’em twice because if that person is tested twice, you’re gonna cover that time period, end of story. Otherwise now you send that person home if they were close contact but everyone needs to get a test in that contact circle.
Dr. Z: How important is the over dispersed nature of this? In other words, the superspreader favored kind of dynamics of this disease that there’s a hyper emitter, a clustering phenomenon that seems quite prevalent here. How do you think about that in terms of something like a meat packing plant? Would you do reverse contact tracing, like going back and figuring out who the prime spreader was, how do you think about that?
Dr. Harrison: Well, I recommend going back to days now that’s interesting ’cause it’s where the 48 hours comes from. The incubation period of this is two to 14 days. So if I have a positive worker or let’s say a meatpacking worker, I contact trace back 48 hours. That’s really just set as a kind of a pragmatic rule of thumb.
Dr. Z: It’s semi arbitrary, mostly pragmatic.
Dr. Harrison: Mostly a pragmatic rule of thumb but let’s say we go back 48 hours and we contact trace everyone in the workplace and at home, get everybody quarantined and tested a couple of times and if need be, and this is what has happened in several meat packing plants around the country, shutting down that line so that you can reset that workplace. I kind of like think of it as wiping out the hard drive.
Dr. Z: So you know it’s clean.
Dr. Harrison: You know it’s clean. You then are starting from a clean slate. If that line is shut down and no one’s working with the possibility of transmitting to each other.
Dr. Z: Right so you could do a hard drive reboot there. Interesting and so we talked about symptomatic testing?
Dr. Harrison: Outbreak testing. Okay and the third is what I call monitoring testing or surveillance test.
Dr. Z: Surveillance.
Dr. Harrison: I don’t like to use the word surveillance.
Dr. Z: Right because it has a connotation in the USA that will already people don’t like being told what to do. Now you’re gonna say you’re under surveillance.
Dr. Harrison: Under surveillance yeah. So I like to call it sort of testing for prevention or monitoring testing and that’s what we’re doing in nursing homes or long-term care facilities.
Dr. Z: Correct. Such high risk. You survey them every so often.
Dr. Harrison: We’re doing it I think at least once a week.
Dr. Z: Got it.
Dr. Harrison: In many nursing homes around the country.
Dr. Z: Got it.
Dr. Harrison: We’re doing that in the California prison system, testing custody staff and healthcare worker staff in the prisons in many facilities once a week and that’s gonna pick up the positives that are asymptomatic that they’re not gonna get picked up by symptoms as they come in the door but we’re gonna pick up all of those who don’t have symptoms, who could be walking in and being a superspreader, don’t know it and here you have 2,000 inmates.
Dr. Z: And let’s remember, that’s why this is so difficult. It’s not like SARS one where you were symptomatic when you were contagious. This is 60% to 80% of people can be asymptomatic in which case you don’t know. So this kind of intermittent testing of high risk facilities like correctional facilities, nursing homes, is a crucial part of the strategy then because otherwise people will slip through, like you said, you don’t know they’re a super emitter and suddenly there’s a huge cluster of infection in an enclosed area.
Dr. Harrison: Exactly, I think that that third piece, all of these by the way are not only my recommendations, they’re CDC, public health agency recommendations also. The third piece, which is this monitoring testing has been from the point of view of the overall public health organization and COVID control the most challenging by far. We’ve been limited for several months by a testing shortage. Now we have what I call testing maldistribution. I think of it sort of like the maldistribution of physicians in the United States.
Dr. Z: Tell me about this.
Dr. Harrison: So we may have enough doctors in total but we have them in the wrong places.
Dr. Z: Right.
Dr. Harrison: So we have testing labs that say, “Oh, we have plenty of tests that we can run” and then we have employers or worker groups that are saying “I don’t know where to get a test Dr. Harrison. Where do I go? How do I get one?”
Dr. Z: Common problem, huge problem.
Dr. Harrison: So I don’t call it maybe when we say we have plenty of tests. It’s a, where are they?
Dr. Z: Where are they?
Dr. Harrison: Where are they? And what system do we have to distribute them in a way so that if I’m a warehouse, a meat packing plant, a nursing home, a school district, I know how to set up a testing program. We still haven’t solved that challenge.
Dr. Z: What are their resources? What resources do businesses have? Do they contact folks like you? Or are there other consultants that can help with that?
Dr. Harrison: Well, there are websites that list testing companies and testing locations and that’s as I say, that’s just a place to start but then what we have, unfortunately, from my perspective of helping people stay safe at work, um a wild West, we have a free marketplace of testing vendors and testing companies in this country. So we have never had a testing strategy that’s been coordinated from the federal to the state, to the local level. We have a lot of folks working on that in that direction but the reality is because we have over 300 emergency use authorizations now by the FDA, so a panoply of testing companies and laboratories.
Dr. Z: So you have to hope first of all, for accuracy, availability, turnaround time, turnaround time has been abysmal in some places. I had a friend who got tested. It took 10 days for the result to come back. So that’s a useless test in many ways.
Dr. Z: Yeah I could have taken that a hundred bucks that your friend might’ve paid. Give it to me. Send it to my offshore account Zubin or as I say when I go to Las Vegas and I play the slot machines, I could have just taken my 10 bucks and gone to the bathroom and flushed it down the toilet, my odds of winning on that slot machine.
Dr. Z: Bingo.
Dr. Harrison: So 10 days is useless,
Dr. Z: Useless.
Dr. Harrison: I think maximum of 48 hours.
Dr. Z: Yeah I agree. What do you think about Michael Mina from Harvard? His idea of a rapid home-based, and this is difficult from an FDA standpoint, a salivary antigen test that isn’t very sensitive but it’s repeated every day, costs about a dollar a test and it can be self administered and it’s most likely to be positive when you’re most likely to be at a high viral load and infectious. Have you thought about this kind of testing at all?
Dr. Harrison: I have.
Dr. Z: Yeah.
Dr. Harrison: And I like it. I am a fan of that concept. I don’t know about the specifics of the antigen test and the FDA approval and the test characteristics but from a conceptual point of view.
Dr. Z: Beautiful right?
Dr. Harrison: It makes total sense to me that what we need to know is who’s infectious to isolate even if we’re wrong,-
Dr. Z: Right.
Dr. Harrison: Right, so I think I would rather be wrong with the false positive.
Dr. Z: Yeah exactly.
Dr. Harrison: Right? Okay all right.
Dr. Z: So I get to stay home for a few days.
Dr. Harrison: Now that can be a problem for folks who can’t afford to stay home.
Dr. Z: Essential workers don’t minimize it.
Dr. Harrison: I don’t wanna minimize it it’s certainly an issue. It’s actually a critical issue in getting people to participate in testing?
Dr. Z: That’s true because they’re worried if they’re positive.
Dr. Harrison: Oh my goodness.
Dr. Z: Their livelihood.
Dr. Harrison: Big issue.
Dr. Z: What I hate is when people blame people for that kind of behavior, you’re like, no, this is their life, this is their livelihood. They’re gonna do what they can to protect it. They’re behaving in their own rational self-interest in their mind. So that fear is real for people.
Dr. Harrison: Yeah I remember a year ago we had talked about medical testing for silica dust and how hard it would be to get someone to go for a chest x-ray to say that they had early silicosis because then they couldn’t keep their job in that stone fabrication plant. Well, I see the same challenge now. Okay, I’m gonna go get a COVID test. You’re telling me I’m positive, I feel fine. I have to stay home for a couple of weeks.
Dr. Z: Yeah.
Dr. Harrison: I wanna be sure that I have salary, that I’m compensated. At UCSF we have had a very generous leave plan if somebody tests positive but there’s a wide variation of those policies across the country. We need to have that in place for everybody. I mean, I think the meat packing plant workers should have the same benefits that we have at UC San Francisco.
Dr. Z: Yeah I feel we’ve really squandered resources on things that haven’t helped and haven’t really focused. We ought to learn from this for whatever the next pandemic is and for this moving forward now this is our chance to do this correctly. Really support the people that then at the highest risk and the vulnerable essential workers and which again gets to the question of like, do you think that healthcare, frontline healthcare workers are more out of the woods than they were in the beginning? Or do you think now with new surges around the country this is becoming a big problem in healthcare facilities again and particularly with traveling nurses who are at risk and so on?
Dr. Harrison: Well, I think that I’m seeing very positive signs or I’m hearing that about the adequacy of PPE. I think we’ve slowly begun to realize that this virus can be transmitted through the air. Not only through the larger droplets that I mentioned, but through the finer particles and that we need the highest level of PPE that we can have available, which is at least the N95 and so I think with the provision of N95s, with really good symptom screening, really good testing for healthcare workers, universal testing of inpatients, I think the good news is that we can drive down the risk to frontline healthcare workers and I think that hopefully is better in this surge 2.5 or surge 3 than it was with surge 1 and that’s what I’m hearing from my colleagues that we’re in a better place now for frontline healthcare workers than we were back in March in terms of those worker protections and those programs that we have in place. Now, I think we’re still seeing a huge amount of stress and strain on resources and I certainly think emotionally we’re all in a much different place than we were back in March.
Dr. Z: Yeah yeah and there’s a staffing strain, so they just can’t staff these places and travelers are burning out and that’s a very expensive strategy to bring in nurses and then the nurses are there was a “Kaiser Health News” piece about how they feel abandoned by their agencies. That some facilities are less good with PPE, less good with testing and things like that and so it’s variable around the country. I think you and I are in one of the bastions that seems to have done it mostly correctly which is a blessing and there are other places that have done that too but then there are some places where it just really has been difficult.
Dr. Harrison: I don’t wanna forget Zubin though, the nursing home.
Dr. Z: Yeah tell me about that.
Dr. Harrison: Workers because I think what I was describing maybe is the A+ the Cadillac model that maybe the major medical center is in the UCSF and the Stanfords of the world and the,
Dr. Harrison: Exactly but we’re still seeing outbreaks in nursing homes in spite of the testing, we are still seeing continued problems in long-term care nursing home caregivers, working multiple jobs, those employers, those facilities don’t have the worker protection resources and knowledge in infection control that I have and my Stanford colleagues have.
Dr. Z: Right, and it’s a problem because that’s our most vulnerable population. Those are the ones who are more likely to die. 45% of the mortality seems to be in that age group and nursing homes have taken a big hit and that population has been a big hit and at the same time, we’re isolating them keeping them lonely, so they’re dying alone and some are dying of the diseases of despair of loneliness and isolation as well and so it’s been really tough year, man, like, yeah.
Dr. Harrison: A really hard, I mean the isolation and the loneliness of our relatives in those nursing homes, just is achingly sad. I think that we know how to get ourselves out of that however. You see I think that it’s terrible, but there is a solution and that is testing that’s widely available, frequent rapid testing, COVID gets into nursing homes from staff. It’s not getting in from visitors, from family because nursing homes are not allowing them. So it’s still from staff that are coming in that are positive. So widespread, accessible, rapid universal testing, combined with the resources to do good, PPE and infection control in those facilities, providing the funding.-
Dr. Z: That’s the trick.-
Dr. Harrison: To those homes, facilities, I mean, 40% of all COVID deaths are in our relatives in nursing homes.
Dr. Z: Yeah, so 200,000, about 100,000 odd, it’s really something that if we’re talking about targeted groups and protecting them well, then we better try to do that. I mean, we can talk about it, but the practicalities are tough without throwing resources and organized leadership at it and so on and we haven’t really done that and I hope we learn from this because this is not the first, this is not gonna be the last pandemic.
Dr. Harrison: It’s not the first rodeo, this is not the first or last virus that we’re gonna see.
Dr. Z: Not at all. Now relating to that and I think this is a question on many people’s minds and I’ve spoken about this a bit, but it’s tough. This one really conflicts me a little bit and that is schools and how do, we have an aging public school infrastructure, now there’s a disparity, and I’ve talked about this on the show before, between more affluent people can send their kids to private schools with distancing and smaller class sizes and lots of testing and so on and then you have the public schools in particular in San Francisco that remain closed. How do we think about keeping our teachers and students and their parents safe in an occupational setting in school?
Dr. Harrison: Well, first of all, I come at this from the perspective, as I do to all work places, that we should offer the same level of protection for the under-resourced school district, the under-resourced workplace, the worker who come from a multi-generational family household with high rates of COVID transmission in the community who is working in a meat packing plant, we should keep the meat packing plant worker as safe as the worker in a tech company who can work remotely.
Dr. Z: Now that’s what are called communism.
Dr. Harrison: Thank you, Dr. Fauci.
Dr. Z: Fauci, he’s the little devil on my shoulder that makes me say things that pop into my head. No you’re absolutely right.
Dr. Harrison: First of all, I come from it from that frame and so that’s full disclosure.
Dr. Z: That’s a good frame to come from.
Dr. Harrison: While we have very well-resourced public schools or private schools that can put everything in place and our kids can return to those schools with relatively high reassurance. We have many schools that don’t have those resources and so I come at it from, well, we have to give those schools what we can give the really well-resourced schools and so that is the same layers of prevention that I mentioned. A school is a workplace for teachers but it’s also a unique workplace because we have children in this workplace.-
Dr. Z: Fomites, vectors.-
Dr. Harrison: Fomites and as we all know, they are filled with germs when they come in of all sorts and we knew that before, COVID, they’re all gonna have sniffles galore.
Dr. Z: They eat their boogers Bob.
Dr. Harrison: Exactly.
Dr. Z: I’m concerned some of them eat other kids’ boogers.
Dr. Harrison: Exactly, right and then we have this other unique aspect, not only as a workplace with children, but those children go back, and so they’re there for what? Six or seven hours a day and then they go back and they pass those germs back to their family members.
Dr. Z: Right.
Dr. Harrison: In a big time way. It’s not like we’re gonna tell a eight year old, “Well, just go home and quarantine. You might be positive. We suspect you had an exposure, just go home and quarantine.” When was the last time you tried to quarantine from an eight year old.
Dr. Z: Good luck with that. Mom, I thought you were in quarantine. Someone needs to wipe my butt.
Dr. Harrison: Right and exactly. So that’s for anyone with kids and I’ve had kids, I know that that’s impossible. So we have this unique trifecta in schools that makes all of those layers even more complicated but possible.
Dr. Z: Doable.
Dr. Harrison: Doable. and so it obviously starts with the commitment, a frame that we’re gonna do this and then it has to follow with resources, a plan, getting somebody responsible.
Dr. Z: I’m starting to get chest pain ’cause these are our public schools we’re talking about. Those board meetings last eight hours and then the last hour they start talking about COVID.
Dr. Harrison: Yeah and these are folks who started out pre-pandemic rightly concerned about education. The last thing anybody in a school district knew about before January of 2020 was something like COVID. The preparedness planning for something like COVID, a sneaky infectious disease that transmits when kids don’t have symptoms, goodness, that’s really challenging for schools.
Dr. Z: Now it’s reassuring that the children themselves don’t seem to get terribly ill relative to adults it doesn’t mean they don’t get sick, it doesn’t mean they can’t die or have long-term consequences but that’s one reassuring thing and there are things stacked in schools favors. Do you think there’s data showing that schools have been really pivotal in spreading this or the opposite?
Dr. Harrison: There is data that suggests that younger kids become infected less frequently and spread it less than older kids.
Dr. Z: That’s right.
Dr. Harrison: So there’s a continuity from, but that doesn’t mean it’s zero,-
Dr. Harrison: Right, it’s a spectrum.
Dr. Harrison: It’s a spectrum from little to big.
Dr. Z: Yes.
Dr. Harrison: So I think high school students are more like college students,-
Dr. Z: Yeah that’s right.
Dr. Harrison: Than they are like elementary school students.
Dr. Z: I agree yeah, 16 and above yeah.
Dr. Harrison: Or even 12, 13 and above in terms of their behavior. You could watch them in school as soon as they leave the school, they’re hanging out on the street corner with 10 other kids.
Dr. Z: Smoking cigarettes, which by the way are very effective face covering Bob. I mean that filter, I mean, that’s how many layers polyester or whatever.
Dr. Harrison: I hadn’t thought of that as a public health strategy.
Dr. Z: Okay guys, let me just tell the people. As a doctor I advocate Marlboro Reds they’re highly, Yeah.
Dr. Harrison: Yeah so I, you know, and we’ve seen tens of thousands of college kids become infected. We know that because many colleges and universities have put in very intensive testing programs. You have to spit in a cup at least once a week at a lot of colleges and universities and if you’re positive, you go into the quarantine dorm.
Dr. Z: Got it.
Dr. Harrison: And we don’t have that widespread data in high schools because well, for one thing high schools have largely not been opened yet and where they are open, we don’t have that intense monitoring in high schools but I suspect given the behavior of high school, kids are closer to college and then down into the continuum in the lower grades, clearly there’s a finite risk of infection, it’s not zero and there have been outbreaks in schools around the globe when they’ve reopened it’s certainly in part driven by community risk and that’s the way we set it up in California. If you’re in a yellow County, you’re low risk, you have a more clear-cut pathway to reopening.
Dr. Z: That’s right yeah and I think that makes sense. I think we have to weigh the downside of keeping school close which I think is tremendous on children and families especially essential workers and so on and it’s been very complicated math on that, mental math, emotional math too because, I think half the, I had this wonderful interview with the Indiana school board official on NPR and he basically said no matter, what it used to be when we’d make a decision, 40% of the parents would not like it, 40% would really like it and there was another like 20% in the middle that were on the fence. Now it’s like any decision they make about COVID half the parents are really angry and half are really happy and it’s just how divided we are in general about thinking about this pandemic and they asked him well, what do you think is based the basis of that division? And he goes, “Well, there’s the one half that is really catastrophizing and is terrified of this disease and there’s the other half that’s really minimizing and is blowing it off as a flu” and I thought that was pretty indicative of what’s going on in general.
Dr. Harrison: I think what we have to get across here is that there’s a connection between community risk and reopening schools.
Dr. Z: So explain.
Dr. Harrison: So I think the last figure I saw was more than half or more of the counties in the United States are in the red zone. Surging,
Dr. Z: Surging.
Dr. Harrison: Surge 3, COVID across the country, largely West and Midwestern States.
Dr. Z: Yeah.
Dr. Harrison: And so if we urge to reopen schools and to figure out a plan to do that kind of phase reopening of schools, which I agree with, we have to look at that map and we have to make the connection between being able to reopen our schools and getting that map from red to yellow.
Dr. Z: Right right right, they’re all intertwined.
Dr. Harrison: They’re completely intertwined but you know, unlike, well, we might be able to segregate a warehouse or a meat packing plant or even a nursing home which I think is even tough to do because those nursing home workers are living in that same community.
Dr. Z: That’s right.
Dr. Harrison: But you know, okay, maybe we can somehow parse those workplaces off but we can’t do it for schools, because of this triangle because we have the community, we have the kids, we have the teachers and they’re all living In the same place.
Dr. Z: In the community. They are the community, that is their community.
Dr. Harrison: That is the community. So we have to think of that frame as the school as the community and the community as a school. So if we’re gonna be successful in reopening schools, it has to start with that public responsibility and that public, you know, taking care of each other and messaging.
Dr. Z: That’s a powerful message actually. I think that’s a message people need to hear because if we’re in this together, which we are, and, you know, look you can have differing opinions on how much of a threat to your community this thing is in terms of like, Oh, there’s elderly people and this and that, but the truth is you’re not gonna get back to a reasonable frame of life until these red areas turn yellow or green and that requires us doing the simple things that are actually in the beginning of the talk right. Face covering, ventilation in places and businesses, some distancing, testing, that’s it , it’s not.-
Dr. Harrison: Yeah, now we didn’t talk about contact tracing, now that is an important, I talked about that outbreak, testing and contact tracing I would probably add there too.
Dr. Z: I kind of fold them together but you’re right absolutely.
Dr. Harrison: We just need to do that and we need to be willing together to be contact traced.
Dr. Z: Right.
Dr. Harrison: We need to be open.
Dr. Z: This is tough.
Dr. Harrison: We need to be open to answering that phone, admitting who we’ve been in touch with. I just read some interesting data on how many people don’t really wanna fess up.
Dr. Z: Right, oh it’s a huge.
Dr. Harrison: It’s quite interesting.
Dr. Z: Well I’ll say this Bob and this is because my audience is so diverse and around all around the country, you and I live in a little bit of a urban bubble where we’re willing to sacrifice some autonomy in favor of community. There are lots of parts of the country where people choose almost to live in those parts of the country so that they can have more autonomy and less community and I think they’d be more resistant. So in a way, all healthcare is local, all politics is local. That’s hampered our ability to have a national policy around this, as opposed to say South Korea where they’re like, okay, we have a plan, we’re all gonna do this, we’re gonna give up some autonomy, they’re gonna contact, trace our phones, we’re gonna use this and they’re willing to do that. I think in the US it’s a tough sell, it’s a tough sell.
Dr. Harrison: Yeah Zubin, a couple of weeks ago, a midsize Chinese city, small 10 million,-
Dr. Z: Yeah, a little midsize size,-
Dr. Harrison: A midsize city of 10 million in China, they had 13 coronavirus cases.
Dr. Z: My gosh
Dr. Harrison: 13.
Dr. Harrison: Yeah.
Dr. Z: It’s a rounding error on one like street over here.
Dr. Harrison: And do you know that they tested the entire city?
Dr. Z: Oh my gosh, the whole city-
Dr. Harrison: The whole city now they did it in five days. Hard to know whether the data, how accurate the numbers really were but even if they tested a million, even if there was an order of magnitude over exaggeration, let’s say they tested a million people, they did it in five days. They had 4,000 testing sites. Now I don’t think we’ll ever do that in the United States because you mentioned the different cultures, the culture, I don’t know how to put this. It’s a different place.
Dr. Z: I’ve said it before, it’s our strength and our weakness. It is, it depends like in a pandemic, it’s a weakness. Many times it is a strength. It’s the reason people come here. They want that degree of autonomy and freedom and it’s a cultural thing and I’ve talked to so many people about this and they really have painted this picture for me, that that’s what America is about and it’s been a difficult ride for a pandemic, for that reason. The Chinese, they can do that, Koreans can do that, New Zealanders can do it.
Dr. Harrison: Right, New Zealanders can do it. British Colombians can do it. They’re in a different place than we are. So I think that we just have to recognize the differences among us and those different attitudes and different places, the Bay Area is not a Montana. My daughter lives in Montana and so I go to visit her I realized, it just needs different metrics and different attitudes.
Dr. Z: Yeah and in a way, I think environment shapes, I’ve said this before, environment shapes that adapt cultural adaptation and you know Montana is this big sky country and the Bay Area is beautiful it’s a dense, urban diversity that in order to function we need to have some social lubrication and a little bit of the liberal value there, Montana you may not need that. In fact, it’s adaptive to be more autonomous, but man we’ve come up on an hour. Every time I talk to you, I learn like I’m back in medical school, man. It’s humbling and beautiful and thank you.
Dr. Harrison: And thank you for the opportunity to meet Doc Vader. I’ve been seeing him for the last couple of years, but I’ve never met him in person. I feel honored, thank you.
Dr. Z: Doc Vader has many issues. He’s got several board complaints against him, so he’s struggling now. So it was really a joy to see him come out of his shell.
Dr. Harrison: But I just wanna say that Doc Vader, if you had COVID you just think of all those viral particles that were concentrating inside that mask and then you release the mask you get this huge bolus.
Dr. Z: Vader doesn’t care about other people. He’s like, he’s getting filtration but when he exhales,
Dr. Harrison: Maybe that’s the HVAC system I hear, that breathing.
Dr. Z: Could be, he’s got his own HVAC, how many air exchanges per volume times?
Dr. Harrison: That’s our next talk.
Dr. Z: You know what, speaking of our next talk I can’t wait to have you back and fill us in on any more of this stuff. Dr. Harrison, Bob, it’s such a joy man and to have an expert like you right here in my neck of the woods just fills me with happiness and being able to share your wisdom with the crowd. So guys do me a favor. If you like this kind of stuff, just share the video. Like it, leave a comment. If you’re on YouTube, subscribe and click the little bell. If you’re on Facebook, hit like. If you wanna support the show, become a supporter, it’s like five bucks a month and we go deeper in these conversations that get really real and super authentic and it keeps us free of all this commercial jazz and gosh, I love you guys, Bob thanks again man.
Dr. Harrison: Thanks for having me here.
Dr. Z: Yeah let’s put these on ’cause we’re gonna go now and we are out peace. You think that was dope, Hey, become a subscriber. Click the subscribe button then right to the right of this little bell. Hit that bell, boo ya! You get notifications, never miss any of our stuff. I love you guys, we out.
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