On this episode of Workplace Injury Prevention – A Fit For Work Podcast, WorkSTEPS Chief Medical Officer, Dr. Ben Hoffman, answers many of the questions surrounding COVID-19. Some of the topics discussed include what makes COVID-19 unique from past viruses, traditional pandemic response approaches, vaccine development timelines, newly published studies on COVID-19, solutions for employers, and other health and safety concerns.

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A transcription of the interview is included below.

Workplace Injury Prevention – a Fit For Work Podcast, Special Edition: COVID-19, Solutions for Employers

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Curtis: Welcome, friends, to Workplace Injury Prevention – a Fit For Work podcast where we are bringing the power of prevention to you. I am your host Curtis Kopotic and I am joined by my co-host, Ambjor Brown, and today we are talking with Dr. Ben Hoffman.

Ambjor: Thank you so much for joining us for the special edition with Dr. Hoffman. He is going to give us a little bit more insight on this whole COVID-19 pandemic that we are all experiencing right now so thanks again for joining us and have a listen to our interview.

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Curtis: Thank you for joining us on such short notice Dr. Hoffman, and we have quite a bit of questions to go through and hopefully we can put this into a digestible package for our listeners. So how does the COVID-19 pandemic differ from others that we’ve seen in the past, you know, such as the swine flu or H1N1? How is this unique?

Dr. Hoffman: Well, it has some similarities and it has some differences. The similarities are, number one, it is a novel virus in that it’s one in which we have no human immunity to so that pretty much everybody will become sick, even if they are not feeling the infection, it will infect pretty much everybody that it comes into contact with. One of the other features of this is that it is a very transmittable virus. It’s one in which it’s easy to transmit from one person to the other, and that was true of some of them although there’s a principal in epidemiology – and this is where some of the differences exist – in that the more transmissible a virus is, generally the less virulent it is, virulence meaning how pathogenic or how severe an infection it causes in people. This is a highly transmissible virus. It’s not nearly as virulent as MERS or SARS, the other two more recently circulating coronaviruses.

Curtis: Interesting. So those were also coronaviruses but this is more unique in that it’s easier to catch even though the symptoms aren’t as severe as SARS?

Dr. Hoffman: Well, the death rates are-, were higher with MERS. It approached 50%, SARS is about 25%. The death rate with this virus appears to be somewhere between 0.1% and maybe a high of 3%. The problem is that we really don’t have enough population-based data – that is, how many people have been infected but didn’t really get very sick – so determining actually the actual death rate versus what we call the crude death rate, which is what we are seeing right now, these are unadjusted figures because we don’t really have good population numbers.

Curtis: And is that just because it is so new and we’ve never seen it before, or does location that it- you know, everybody says that it started from China – has that been able to affect the numbers in any way, one way or another?

Dr. Hoffman: Well, it’s a new virus and therefore we only have the data that’s currently available, really since the middle of December, and frankly, because it was difficult early on to attain the data from the Chinese – it’s gotten better in the last couple of weeks as western scientists have gotten into China – to actually determine what the true rate was in the population. The only way that you can really do that is to have widespread testing and we’re still having challenges in this country with the ability to test everyone. We’ve really done a very limited number of tests, and therefore, pretty much the people who have been tested are the ones who are the most sick, but that doesn’t tell you about the overall prevalence in the community or in our population.

Curtis: A common thing that I hear, you know, of being around warehouses and friends is “oh this is such an overreaction, the flu kills more people,” so while the deaths reported from this is much lower, – you know, at the year to date than compared to 12 months of the flu – can you talk about it from your medical perspective? Why is the government response so much more profound than anything we’ve ever seen before? I mean, I’ve never seen this in my lifetime, and I’ve talked to grandparents who have never seen this as well. Do you feel like this is warranted?

Dr. Hoffman: I do, and the reason for that is that I would characterize this as a very very bad seasonal flu, and I don’t think that most people, unless you’re a physician or an epidemiologist or somebody who studies viral diseases, do you realize that seasonal flu has a very high morbidity – that is, sickness rate – and mortality rate. So seasonal flu has a mortality rate of something like around .01%. That doesn’t seem like a lot, so maybe 1 in 1000 people die from it, and it’s one of the reasons that we try to encourage people to get flu shots. Keep in mind that when seasonal flu comes around, it affects a reasonably small percentage of the population, let’s say for argument’s sake, between 5% and 10%, and if you do the numbers of .01% death rate, let’s say 5% of the population, you come up with, globally, about 600,000 deaths. When you have a death rate-, in this case, it looks like it’s higher, my guess is somewhere between .1 and maybe a little bit over 1% – still low in some regards, it’s too many, – but you multiply it out times the population of the world, you come up with a very large number of people. You could do the math yourself, I don’t want to get the numbers wrong, but it’s very large number of people merely because the absolute numbers of people who are going to get sick are so much higher than with an ordinary seasonal flu. I think there’s a certain amount of complacency in our population about how severe an ordinary flu season can be, so when you get this type of situation where we’re trying to warn people that this is, you know, a 10x flu season, people just don’t necessarily appreciate it unless you’re a clinician.

Ambjor: And a lot of the people that we see that are really being affected by this are the elderly or those that have some compromised immune system, so why aren’t we just quarantining those population groups?

Dr. Hoffman: Well, the seasonal flu disproportionately affects people who are elderly, chronically ill, or on immunocompromising drugs, and the number of those immunocompromising drugs in the population have increased particularly due to the [?] that are used use for connective tissue disorders and rhuematologic and all sorts of other disorders. So even in the data that we have from China, the data that we have from Italy, and then we had an unusual though very useful sort of what I would call an experimental situation and with a test tube situation with the Princess Cruise, we’ve seen the same differential in death rates that increase as one becomes older or has these chronic diseases or some immunocompromise. That said, even with seasonal ordinary- ordinary seasonal flu – people who are younger do get sick and die and because again, the fact there’s no immunity in the human population to this, there are going to be younger people, just because of the sheer large percentage of people in the population are young. And the fact is even at the death rate among people, let’s say, in the 20 to 50 age range is .01% that’s still a lot of people. Fortunately there have been either no or very few deaths among children 10 years and younger, and unlike SARS, this influenza bug – the COVID-19 – does not appear to have any greater severity of impact on women who are pregnant.

Now, when you have these types of pandemics or epidemics, you know, the difference between – I think most people know this, but an epidemic is a localized high rate infection; a pandemic means that is geographically widely spread- there are three ways that you manage pandemic or epidemic. Those three ways are, number one, quarantining people who are sick, the second one is what we would call mitigation or suppression, and the third one is treatment. Quarantining is putting somebody who’s sick in a isolated situation so they can’t contact anybody nearby, no ability to transmit illness. That was done pretty effectively in China, it’s not been done all that effectively in Italy, and in western countries it’s not the simplest thing to always quarantine people, but it’s something the public health authorities do and they’ll continue to do once they know somebody is ill with COVID-19. Unfortunately there’s not a lot of testing around so it makes it more difficult to say you have COVID-19 versus some other type of upper respiratory or lower respiratory infection. The second strategy is mitigation or suppression and that’s what most of us are experiencing right now, and that is this social distancing, the cough and sneeze etiquette that is, you know, when you cough covering your mouth with your elbow, if you sneeze make sure that you keep a distance and sneeze into a tissue and throw that tissue out. The suppression is what the mitigation strategies are what are being done now. The third is treatment, so once quarantine and mitigation fails, you want to have adequate treatment and one of the purposes of mitigation in particular is to reduce the number of people who are sick at any one time.

So you’ve heard and seen on the news this concept of “flattening the curve”. If everyone gets sick it once- because people are not in quarantine or people who were not very symptomatic are out in the general population making people sick, you get a surge in people who are ill. That’s what we’re seeing in Italy right now, there’s been this enormous surge, and when there is a surge like that the hospital-, the healthcare system has to be able to respond, and it’s not easy to do that and the key is to reduce the peak of that curve so that you can smooth out or even out the number of cases over a more prolonged period of time so that the healthcare delivery system can provide adequate treatment, because what we know about this virus is that it gets deep into the lungs. It’s a droplet-based transmission, so droplets are larger particles than aerosols. Droplets go a certain distance out – maybe three to maybe six feet – and drop because they are heavy. Aerosols go much further and can even get into HVAC systems. So the key here is to reduce the number of droplets that somebody can get into their face, and if they do get sick and it does get into their respiratory tract, these droplets tend to go low in the lung, and when they go into the lower lung fields they cause a pneumonia, which lower lobe pneumonias tend to be more severe, and people need supplemental oxygen or they need mechanical assisted ventilation in order for the body to develop the antibody response it needs in order to fight the infection. There’s a limited number of ICU beds, a limited number of ventilators, etc. in this country, so that the key is spread out the infections so that the healthcare system can respond appropriately.

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Ambjor: Just a little break from the interview today- I’m wondering, are you a healthcare provider looking to get out of the reactive setting and into more of the preventative setting? Take a look at our website www.wellworkforce.com. We have positions open all over the United States and maybe one is near you. Take a look and join our team in preventing injuries before they even start.

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Ambjor: Along with that spreading out and kind of distancing everybody, a lot of organizations as we’ve seen- supporting organizations, various companies- are shutting down for a period of time right now. It’s kind of a twofold question here: What can employers do to help protect their employees while they remain open, and then the second part would be, you know, if a company or organization has shut down what precautions can they take when they’re considering re-opening?

Dr. Hoffman: In terms of the mitigation and suppression, what happened-, society can do a number of things to reduce the chances that people will get sick from one another and it’s all part of the social distancing. So schools shut down, other public places, restaurants, etc. Employers can shut down or if they don’t shut down to provide adequate social distancing, another mitigation strategy, like I mentioned before, is to encourage people to have sneeze and cough etiquette and fight this infection. Employers right now are really struggling with how to keep their operations going. It’s a lot easier if you are a company that people can telecommute. It’s much more difficult if you’re in manufacturing or the types of work activities that require people to be present some place in order to do their work. Those companies are doing everything they can. I have a fair number of customers globally who are in this situation and what they’re doing is they are identifying and first encouraging people that have symptoms not to be at work. The second thing they’re doing is once people come to the facility is having them answer a series of questions confirming that they haven’t been exposed to somebody that is likely to or is known to have COVID-19, that they haven’t traveled anywhere that’s high risk, and that they don’t have any symptoms consistent with the flu, with COVID flu, and in addition many employers are beginning to institute temperature screening, because the one thing we know is that temperature is the one common denominator across 90% of people roughly that get sick with this. And although most people sort of know they’re not-, when their temperature isn’t right, some people don’t. Some people have other reasons they want to be at work, because they think a replacement or other reason, so the key is to try to develop an effective way to screen people before they enter a facility. Then once they do enter the facility and they don’t answer in a way that the questions are being asked or they don’t have an elevated temperature, if they can determine that, or the individual could self-attest because they checked their temperature at home, is in the workplace to create social distancing. It’s not always so easy if you’re in a manufacturing company or you’re in certain types of operations where the distance is sometimes preset- let’s take an assembly line- but there are ways to do that. I have a one very large manufacturing employer that’s working on what are call “tack times,” which is the amount of time it takes for something to come off the line, so it’s how much-, how quickly things move through the line, and the quicker something moves through an assembly line, usually the closer people are on the assembly line or there are more people are trying to reduce the tack times a bit so they could maintain no less than three and ideally six feet from one another on the assembly lines. Regardless, another typical strategy is to shut down cafeterias and to provide other forms of, you know, other ways to obtain a meal whether it’s bagged lunch or dinner or, you know, a lot of these companies work multiple 24/7 shifts, providing disinfection through hand sanitizer and frequent hand-washing. One of the other things is really turning off the traditional water fountains in which people put their mouths down next to. There are some newer types of water fountains these days, you know, that are used to fill water bottles that seem to be fine. Hand dryers are also potentially a source of taking a droplet and aerosolizing it, so turning off hand dryers, and there are other techniques like that are being done to reduce the risk that infection can spread in the workplace.

Curtis: Those are some great tips. I mean it’s just very practical and easy and I know one of the facilities that-, a grocery store distribution center that I cover, they’re still operating and trying to get people food as quick as possible, so I’ve seen definitely some of those implemented. Thank you for those tips. Now, a question I’ve heard people ask too is about vaccines and, you know, is this something that can be created in six months or a year, like what’s kind of a realistic expectation for a vaccine for this?

Dr. Hoffman: Most experts are saying that it’s going to be on the order of 18 months. It might be able to get sped up to between 12 and 16 months but there is a normal, ordinary process that has to be gone through in order to establish that the vaccine works and that it doesn’t have any untoward side effects. So, there are multiple companies right now ramping up vaccine development, they’ve already entered early phase 1 trials, which are animal type trials, to see whether or not these vaccines are safe. There’s been a lot of effort in recent years to come up with different ways to develop vaccines other than the traditional methods that have been used over the past century and I think that there’s a lot of bright people in this world that are giving this a lot of thought and there’s a great effort, tremendous effort, to try to figure out some other ways to develop immunity through novel sources of vaccination. I’ve read a little bit about them; I don’t frankly understand all the details around them but I do know that there’s an enormous effort going on to try to speed it up. The vaccine here is absolutely essential because what the infectious disease epidemiologists are saying, and there’s a paper that came out of the Imperial College in London in the last two days – Imperial college is a very fine medical and other university types, you know, general science university, in London, sort of one of our best Ivy League schools – and they had started studying this about a month ago. They were modeling the length of this pandemic and it was used to have the UK develop all the policies that they have for the national health service and other sorts of reasons, and what they have said is that mitigation strategies, that is, the social distancing-, well, quarantining to begin with, but then also the mitigation strategies of social distancing and the sneeze-cough etiquette and disinfection; those three things are suppression mitigation activities that do dramatically lower the curve, you know, it spreads out the number of people who get infected. However, their opinion was that this is going to go on, for all intents and purposes, until the vaccine comes on to the marketplace. Although, there may be some windows of opportunity for society to catch its breath and be able to have some more open society with less social distancing when community rates of infection are low, but in order to really tackle this it’s going to require a vaccine if the current progression of the disease continues.

Now, there have been some contrarian or alternative views to that and there was one that I read today which was really interesting from some very capable people who looked at the range of long-term impacts, you know, basically how long is this thing going to last and how bad is it going to be, and they gave the range, but one end of the range, the what I called the “best-case scenario” is that it is possible that this virus will mutate, not to be worse, but mutate to be better. So as you begin to develop widespread immunity in the community because, you know, 80-90% of people aren’t getting sick, the virus really has no place to go to, and it continues to mutate looking for ways to spread itself because, keep in mind, it can’t live outside of a human organism at the moment, and it could very well mutate itself to the point of burning itself out. That’s what, for all intents and purposes, what happened with SARS, and that possibility exists. What the chances are, they didn’t say. The other end of the spectrum is this thing does mutate to something worse and, you know, even though the projection of the 18 months is what it is, maybe warm temperature and humidity on the Southern-, the warmer months for the northern climates may mitigate it some more. It could come back in the Fall in the northern climates and come back with a vengeance. Right now, it hasn’t been terribly bad in the southern hemisphere; it’s been a much lower rate of community transmission probably because the virus doesn’t like warm humid environments with lots of UV. It does survive but it doesn’t, you know, people are outside, it’s hotter, these things just- these organisms- don’t particularly find that environment hospitable. But it will turn cooler in the southern hemisphere as the north warms up and it could easily find a reservoir of people down there to have its toll, so the need for a vaccine is paramount here and hopefully something will happen sooner than later.

Ambjor: That was great information regarding that vaccine and you actually answered the one question that had come up as far as, gosh, is there going to be a vaccine before it burns out? So thank you for that mutation information as well. Kind of turning our focus a little bit to some of our clients, both WorkSTEPS and Fit For Work clients: what are some benefits they have of having an on-site medical partner such as athletic trainers, physical therapists, doctors, such as yourself, or nurses around during a crisis like this?

Dr. Hoffman: Well, that’s an interesting question I’ve been struggling with now for the last few weeks. You know, most of the clinics exist inside of employer environments are not traditionally focused towards the management- which includes triage and other sorts of things- of pandemics. You know, they’re meant really for working on injuries and returning to work and medical surveillance, so what we’re doing here is we are in the effort of trying, or we’re trying to make the effort of trying to re-purpose these clinics and it’s challenging because the training of the people-, they have other day-to-day responsibilities that have to be done. It’s a major pivot here to do that, and it’s happening. It’s happening slowly. It’s really wonderful to be able to have on-site health staff to assist in this. Employers- this is important- employers are looking to other methods to evaluate and triage employees and also their family members, dependents, and using telehealth. Most larger companies, you know, even at the middle employer size- which middle and larger employers predominate in the Fit For Work and WorkSTEPS book of business- they typically have telehealth providers. Actually, the rates of using telehealth are fairly low in the benefit structure, you know it runs 5% of the population in a given year. It has had a slow uptick among people. I don’t know if you yourselves have used it, it’s a very useful benefit.

Ambjor: I actually have just a few weeks ago, definitely had a phone conference with the physician.

Dr. Hoffman: Good, good. And so leveraging their capability and using them to triage cases is something that is being done now and most companies are leveraging that relationship to get employees the help that they need, but the on-site health centers have a role and repurposing them does not occur overnight, and they need to be trained and be provided proper personal protective equipment.

Ambjor: So, Ben, to wrap up our conversation here: what are some things that we all can do to help us all get over this virus and the spread of this virus? And I know that we’ve talked about some already here during the recording, but just had a quick summary on what you think are the most important takeaways for our listeners today.

Dr. Hoffman: Okay, I think that this is affecting all of us, and also me personally with family members and everything else, but the reality is that we really need to focus on the social distancing piece. We need to limit our interaction with people that could potentially he be sick and to do what is being requested of, you know, keeping a certain distance from people, doing the disinfection related activities, using cough and sneeze etiquette, trying to not go into larger public settings. You know, do what the government is saying that needs to be done right now. All those things are really really important. The one thing that I am struggling with myself is how to process the mental health impacts of all this, and I think this is going to leave scars on all of us for a long time to come. And it’s what can you do to help yourself get over this now, you know, and manage the emotional and social impacts on this is really the biggest challenge. It does create loneliness and people are social beings. You don’t realize how social you are until you can’t go out, and I think that using social media and all sorts of types of connections that you can use that are not the face-to-face connections are what people need to focus on for the moment. And I think that a lot of companies will hopefully be offering some sort of mental health support to people as they go forward, you know, some telephonic support, but leverage whatever you have, utilize whatever you have to try to get through the day, and to provide what you can do to try to reduce the fact that-, reduce the potential that if you are sick you’re going to transmit to others. One of the hardest things here is that what appears to be the case-, what does appear to be the case, is that younger people don’t get sick nearly as much, but they easily could be infected and transmit it to people who are at risk, and maintaining that distance -particularly with people who are older or people who you know are not well- is very important.

Curtis: I think those are great parting words, and just reminding us -thank you for bringing up the mental health aspect- that this is a very unique time for everyone.

Ambjor: Definitely.

Curtis: If we have a little more realistic expectation and appreciation for it, I think that will help a lot because mental health takes a toll. All the unknown is the hardest battle to win, so I think that’s a great point there. So, thank you so much for taking your time, I know it’s been busy for you, and having your expertise on this has been very eye-opening for me. So, thank you so much for your time.

Dr. Hoffman: You’re welcome, and it’s very good to speak to you.

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Ambjor: Once again we are really thankful to Dr. Ben Hoffman for taking time out of what I am sure has been a crazy last few days as the chief medical officer of WorkSTEPS. I am also really appreciative that at the end there he brought it all around to us focusing on our mental health and what all of this social distancing and isolation is doing to all of us, and I know, myself, have arranged a virtual happy hour with some friends tonight, so I’m looking forward to hanging out since it’s online with those I haven’t been able to see over the last few days. I know FaceTime-ing my niece and nephew this week just to see everybody has been an uplifting thing for myself.

Curtis: I love the simple ideas, turning off water fountains, closing break rooms, turn off hand dryers, so that there’s a lot of things people can do in the workforce because there’s certain things that need to happen. There’s a lot of comfort in me knowing that, hey, the food supply chain is working, that if we prepare ourselves for a longer duration and have that mindset of not looking at “okay, I just got to get through this two weeks and it’s all gonna be over,” but having a greater appreciation. Just want to thank you for listening to this special episode of Workplace Injury Prevention – a Fit For Work podcast, where we are bringing the power of prevention to you. Please like and subscribe on Apple podcasts or wherever you listen. To get started preventing injuries please visit our website at wellworkforce.com or email us at podcast@wellworkforce.com with any questions or comments, and remember: prevention improves lives.

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