With a panel representing oncology, epidemiology and infectious disease medicine, this presentation sorts out the data to illuminate issues in caring for immunocompromised, COVID-infected and cancer patients. Includes updates on answering common questions, home-monitoring of COVID patients, and optimizing safety in the clinic and hospital; plus, a look at COVID health care disparities.
eso are learning. Objectives are listed here, and we'll go through these quickly but for implementing COVE in 19 best practices, uh, delivering continuing cancer care and identifying high risk populations. And then, of course, we'll talk about epidemiology as well. We have really a fabulous faculty. George Rutherford, who's professor of the CSF Department of epidemiology and biostatistics and director of U. C s F Prevention and Public Health Group, and has been really a huge force here and nationally in with Cove in 19, Bren, Bozell. It has been very involved in our program here in Covina, 19, and, uh, who is an assistant professor and infectious disease division, and then Palin Sinner, whose really led our efforts in the cancer center in terms of our response to Cove In 19, she's a medical director of quality improvement in safety at the UCSF at UCSF's Cancer Center and also a professor, assistant professor in G. I oncology. I'm joined by Laura Criscito and Laura. I'll let you introduce yourself, and since this whole grand ran serious with Laura's idea, perhaps she can introduce a little bit more about that area. Hi, I'm Laura Chris Edo, CMO for cancer services at UCSF. I'm a urologist by training, and this is our first in a series of for CMI events During the course of this year, we're really excited to offer this. The cancer center felt that it was important. Thio, um, to really, uh, spread the information. The good work that we've been doing here at UCSF Thio our affiliates Thio are referring providers and thio our faculty and providers within UCSF. Well, there's been a lot of work specifically on co vid and how to manage our cancer patients. That has happened here. And really, thanks to this excellent faculty, we've come up with Cem, Um, good best practices and a lot of really good information on coming up in the future are several other events which look for the Flyers because they're all going to be on best practices and cancer, and we have excellent faculty lined up for that as well. Now we're really excited, and at the end we have the dates of those next sessions where we're talking about some of the different cancer topics and palliative care and some really exciting areas. I think where we've been doing a lot of work at UCSF. So without further ado, I'll turn over the podium toe. George Rutherford, who will talk to you about a variety of different, very interesting topics here. Yeah, that's a grab bag. Three epidemiologic grab. This is a picture of Wuhan, by the way, in case anybody's, uh, up in there could I have the next one police? So just to set the stage chair SARS. Kobe, too. The novel coronavirus is a r n a large r n a virus from the coronavirus family. All coronaviruses have the spike proteins, the so called S proteins that stick off. So when they're seeing cross sexually or Satch Italy, uh, they will kind of like a crown. Um on the end of that spike protein is a receptor binding domain here conveniently outlined in the right panel as it is in nature in green, just you know, So you know that you see this good the green flash by you know, you're in trouble. And that's the That's the piece that will lock into Ace two receptor and angiotensin converting enzyme two receptor, which exists there. They're fairly ubiquitous through the body, But there especially, uh, prevalent in the upper airways but also in the lower lower airways and Cem Cem glandular cells in the G I tract the next one, please. So, uh, that's spread by three routes. Which your respiratory droplets, uh, aerosols Air airborne spread on dfo monitor surface transmission. Um, the predominant mode of transmission is respiratory, with large droplets that can fall to ground when they're when they're coughed or sneezed out from the upper airway. Andi Uh, eso we say 6 ft, W H o says a meter. The Mexican government says a meter and a half. It's something like that, but it's a you have sort of a blast radius around you if, um, aerosols are, there's This is sort of this artificial distinction between big and little droplets, but air assaults are little droplets. They're so little that they're not heavy enough toe for gravity to pull them to the to the ground. Eso they could remain suspended in on be recirculated through air handling units before everybody flips out. This is I can count the outbreaks that have involved aerosol transmission on the fingers of one hand out of 40 million cases worldwide, so it may get more prevalent as we as we go into the winter months. Uh, it's certainly something to be cognizant of, but it's so far it hasn't been a massive factor. And then finally, foam ITER surface transmission. This was clearly an issue with the original Stars virus in 2002, but really hasn't played out as much of anything here. And it's hard to even find cases that may have been caused by phone my transmission. So drop the transmission is far and away the most, uh, common on the number of droplets that are exhale depends on the force of the X elation. So if you're coughing or sneezing or yelling or chanting or stinging, that really amps up the number of droplets that are that are excreted. We don't have a 90 50 and infectious those 50 for how many droplets or how many viruses or how many viruses or on a droplet, uh, on uh, that's a nice item of intense research. The next one, please. So the natural history of this is is that, um, just to start with s So let's just walk through it. So a day zero, you get infected, somebody coughs or sneezes on you, they talk to you. Whatever you inhale their large respiratory droplets that have virus on them in a sufficiently large inoculation that you become infected, the virus establishes itself in your upper airway. It takes about three days for it to reproduce, to the extent that it could be detected by PCR testing. On Day three, the PCR test turns positive, and by day four people have developed have sufficiently high viral levels. And these are all very general numbers, by the way, sufficiently high viral levels that they become infectious. And they're very infectious on days 456 and maybe seven. Post exposure, um, that symptoms appear if they're going to appear on day 5. 60% of people have developed symptoms. 40% do not. If you do develop symptoms, its's they're relatively non specific fever, cough, fatigue, my Alge A and Oz, me Augusta, maybe diarrhea and their infections in the first few days of that period. But that really Wayne's quickly and by 12 days with the rise of antibody, they're really not infectious, but all anymore, unless they're part of the unhappy, a group of about 15% who go on to more pronounced disease and will actually develop pneumonia, lower tract disease with pneumonia, and a small number will develop. Um, sorry. I'm I'm a pediatrician. I want to say adult respiratory distress syndrome, like acute respiratory distress syndrome. Those people who have lower tract disease especially hurry, innovator and having things done to them, uh, can remain infectious for up to 20 days. And those are the people in the room aerosols air really generated. So when I said I could count the outbreaks on one hand, fingers of one hand, those air community acquired rest aerosol transmission and the ice use. It's a real thing. Yeah, the next one, please. Um I'm sorry. Go back one. I'm sorry. So, just to say, this viral logic phase is where antiviral drugs work and the immune of pathologic is is where you mean blocking blockers like Dex, Dex, and methods own work. So Trump got REM desk severe. He got a bunch of ah, dunk, which God knows what what the hell they were thinking about. But they have got Ramdev severe here in the biologic phase and also got monoclonal antibodies to both the spike and the nuclear capsules proteins of the virus. So these air antiviral treatments. If he had progressed, he would have been in all sorts of other stuff out in here, including. And he did get Dexter methods on, by the way, which really is typically reserved for this period of time. The next one, please. So just to kind of reiterate this point, you become maximally infectious in a relatively narrow period of time. Here se days 4 to 6 or seven. Post infection, maybe a day longer. Maybe, Maybe, maybe. But that's when you have you have sufficiently high levels of virus. Um, to be to be infectious, you can culture it for a while longer, and the P C. R s will stay longer for a very can stay Long can stay positive for a very long period of time, but only at the very highest cycle times. It's really right at the limit of detection. The next one, please. Okay, So in people with severe disease, this is the first thing because you see people in the I. C. U s and stuff. I assume, um, they're people who have who have severe disease will have higher viral loads, and those viral loads remain elevated longer You can see that. Over here, on the panel on the on the right. Okay. The next one, please. Now, So I want to spend a little time in talking about whether cancer or malignancies are a risk factor for progression. Thes. They're kind of the clearly recognized risk factors older age sex, hypertension, diabetes, mellitus, COPD, coronary artery disease and in a great Siris in Wuhan, which is not published very much anymore. Do we don't? People don't pay attention to this. The odds ratio for a history of smoking was 14. You know, for lung cancer, it's 19. So are, you know, for smoking and lung cancer? It's 19. So this is really pushing the upper edge edge of the huge effect size. Andi, get some of these other risk factors in here. The next one, please. So, eso cancer Traditionally considered a risk factor? It's not listed as one. Or if it is, it's listed almost a Zen afterthought. Um, s O but here gives them more data. This is also from from China. This is looking at the incidents of severe events and their two types of severe events. Uh, here, um, with, uh, I see you admission, Ventilation, or I see you. Admission or death plus clinical indications. And you can see that these two definitions people with no cancer or down here people are cancer survivors were in here in the middle, and people with active cancer are up here of the top somewhere between 50 and 80 80% with the of having incidents of severe disease. This is another way to look at it. Over here, on the on the right. Um, this is looking at different types of malignancies. Um, was with remission advanced and not progressing advanced and progressive ing and then for solid tumors and for on for human logic malignancies. And what you could see is thebe proportion who get to the outcome. The outcome here, being severe disease, those so people who have mawr progressive disease, more active disease are more likely to be, uh, to progress. Okay, the next one, please. This is trying to look at therapeutics and how cancer therapeutics might be related to this s o. This is a Kaplan. Meier curves here on the left, is looking at people who have had who had had cancer therapy within the last 14 days versus those who had it more than 14 days and you can see there's a a clear split. So people have had more recent therapy. Our progress more rapidly have a higher probability of severe events, uh, than those who had it more distantly that with hazard ratio of more than four. And then over here in this panel on the right to try and get some of these odds ratios for death based on what people what the effect of anti cancer treatments I have been on on mortality, and you could see none of these is is significant. Okay, um, I also now I wanted to talk a little bit about adaptive immunity, as opposed to innate immunity. For is, um, you know eso the The whole point is here is that we don't know a lot about cellular immunity yet, and we're working on that. But we do know quite a bit about Huma RL immunity, and, uh, and the body doesn't really appear until about day 11 post exposure on its It also coincides with the decline in in PCR positivity. In most people, you get both I, g m and I G, and also I g A. If you look at this at this picture, and there is theoretical and AM nest IQ response that can occur on on re exposure, and we are betting our bottom dollar on that with vaccines that there will be an AM nest IQ response. The problem is that the Alfa Coronaviruses and I didn't go into a lot of philology. Me but Alfa Coronaviruses air like you are I viruses there, four of them. They may cause us much. Just 30% of you, our eyes worldwide. They don't have real lasting immunity associated with them. They'll that it'll last for a season, like for summer or for a while, and then we'll go away. So there's a lot of worry about waning antibodies, but, oh, guess what? That's what antibodies do. Antibodies. Wayne. That's what they're supposed to do. And the question is, are there enough memory B cells left behind? Thio kick off a reaction. Anachronistic reaction if if re exposed and the next one please. So as we look through the different types of antibodies, neutralizing antibodies are what we want and these neutralizing antibodies air directed against the spike protein or specifically against the receptor binding domain. Three green part of it. This is a Siri's. I was gonna say from Vanderbilt both these names, it's not. This is the Shanghai serious. I'm sorry, but you can see that. Um, you know, there's a certain proportion of people who don't develop any neutralizing antibody and a relatively small proportion, like 14% who develop high, tighter neutralizing antibody, say, kind of roughly overall, half the people develop medium to high, tighter neutralizing antibody. But but most people develop some. The next one, please. Now eso As I said, um, there is a literature on how this stuff Wayne's. Okay, so this is this is the one from Vanderbilt. Um, with 18 healthcare workers, they were had high, tighter neutralizing antibody at baseline on. Only 42% had antibody persistent antibody. Two months later, it was more common big numbers here. It was more common in the health care workers who had symptomatic disease than those who had had a symptomatic disease. But that wasn't that wasn't that wasn't significant. Statistically, I think the take home message here is that around roughly 60% of people with high, tighter neutralizing antibody lose them over a couple of months. Okay? Now, whether that means anything in terms of amnesty response or not, who knows? So we all are thumping our chests about neutralizing antibody. And how great is it? The next one, please. So how great is it? So these Air one, These great experiments of nature, This was a big US commercial fishing ship with a crew of 122 people and 122 people. This is from Seattle. So the University of Washington is, you know, on these guys like vampires getting all sorts of samples. Um, and they drew blood before the for the before the vessel departed. It went out for eight days. It had a gigantic outbreak on it with an 86% attack rate. Had to come back toe back to port. They run all the bloods. What was surprise? Surprise The three crew members who had pre existing neutralizing antibody tigers at no disease at all. Okay, nothing. No PCR positive. No nothing. Whereas 103 of 117 that didn't have it had had disease or network became infected. And this this was even though you have to use Fisher's exact test. This was statistically significant. So that's what says So that's That's what I can point to and say, Oh, neutralizing antibodies. Good to have the next one, please. Now, having said all this in, the next question is, can people get reinfected? And the answer is yes, they can get reinfected. How common is it? Who knows right? 40 million cases. I can point to five or six case reports of reinfection, but this is about the time they'd start to show up. The first one was, Ah, a 33 year old man in Hong Kong who had two diagnoses 4.5 months apart, and they had the strange safe so they could compare them right. One was acquired in Hong Kong, and one was acquired on vacation in Spain. Spain was not the place to go for vacation this summer, by the way. Ah, and it's a and they're they're different genetically. There are a couple of additional cases from from Europe and then one from Reno, of all places in late, uh, in late August. Interestingly, this is something we worry about in the world of infectious diseases. um, about antibody dependent enhancement like you get with dengue fever. Uh, one of these guys who got the guy from Reno who got reinfected a second time was more symptomatic the second time. The other is not really eso, you know, who knows what all that means is it's just sort of observational stuff that this point in time But the implication is is that at least in these four patients, these first four patients, that immunity had waned sufficiently in four months that they could become reinfected. Um, the next one, please. So you will have heard, no doubt from the White House task force or certain members of the White House task force about the virtues of herd immunity. Okay, let me put it to you mildly that this is utter and complete nonsense. Unless you're doing achieving herd immunity through vaccination, the the formula for herd immunity is, uh, the effective reproductive number, which is about three plus for SARS coronavirus too minus one, divided by the effective reproductive number. So if the ari is three three minus one divided by three, that's 67% okay. In Sweden, right now it's about 8%. Where they've tried to infect the entire population. Okay, just so you know, however, we do a much better job in California. So here is San Quentin State Prison, and this is per 1000. So they've managed to infect 75% of all the inmates in the population. This is where herd immunity, law eyes and I could point to cruise ships, slums in Mumbai, other prisons. This is where you're talking about having achieving herd immunity up here, well, north of 60%. Okay. And as I said, Sweden has managed to get to a province of 7.5 to 10%. They're having a big second wave now with everybody else in Europe. So there was no protection from that. And meanwhile, their mortality was five times higher than Mark and 10 times higher than Norway. The next one, please. So cross out herd immunity from your from your from your disease control strategies. The other thing that goes on in a super spreading. Now what's super spreading refers to are people who infect multiple people, right, And it's typically at one time in a in an event, um, and eso the whole the whole idea here is that you got the wrong person at the wrong stage of their infection in a crowd of susceptible people who aren't doing the right thing. You aren't wearing masks who are taking risks. Um, and they're super spreaders have been implicated for clusters as large as 120. Um, it's their typically more like three or four. But it's when it's in this intensely infectious period of between four and seven days post exposure that if you're walk into a you know, walk into a crowded bar like sort of a joke, you walk into a crowded bar, you're gonna affect a lot of people unless people have masks on. Yeah, um, so that's just what this stuff is showing with, you know, calculus. The next one, please. And this is these are actual data from from Hong Kong on disses. Look says that about eso here. The clusters It's cluster is about 55% just by lesson that about 50% of disease occurs in, uh in clusters in about 50% in statin. Sporadic transmission from one person to another, but half goes from one person to multiple people, and there's some people that will say that 80% of transmission is caused by 20% of people. That's some studies to go up to two. That that kind of extreme. Now we now move to our favorite. Next, please. We now move to our favorite super spreader event. Um, where we managed the light up. Ah, half dozen. No, probably a two dozen people in this in this crowd. This probably occurred when everybody went back in for the, uh, for the indoor reception. This is my control group. All these military officers here who have masks very dutifully have on masks. And this is a great case control study, you know, But nobody's gonna let me do that. Um, the next one, please. So I just want to kind of touch on recent epidemiology in the U. S. I redid these slides on Monday morning. Eso their up to date. I think they're up to date as of november 1st. Um, we had more than 100,000 cases reported today in the United States. That's a really you know, that's a riel. Really great landmark. Um, there have been 9.3 million cases totally in the U. S. And now 233,000 deaths were running almost 1000 deaths a day. The case is air elevated across much of the country on a Z can see, They've gone up, you know, more than 100% since the nature here in in in September. So this is first wave second wave, third wave. Okay, Places there especially pronounced her in the upper Midwest. Great Plains, the Rocky Mountains in the mid South. This is the where the largest per capita number of cases in the past seven days have been started. Dakota, South Dakota, Wisconsin. So is really out. There is a real problem. State. Montana, Iowa, Wyoming, Nebraska, Alaska, Utah, in Illinois with the absolutely with the largest numbers of cases in Texas, Illinois, Wisconsin, California, Indiana, Missouri and Minnesota. The next one, please. And this is just a map showing you where the cases were, at least as of as of Sunday. With all this stuff out out here, these the red is bad here, but all through the Dakotas and end of Montana and Idaho in Utah. Um, the next one, please. Now, just so you know, the Super spreader event showed up on The New York Times. Uh, uh. Epi curves if you if you knew where to look for him. So this is the right this consequence of the White House Rose garden ceremony in the next one. Please. Now, why does this happen? It happens because people aren't wearing masks, right? There's enough people who are walking around infectious that you have to protect yourself. And you can see how, uh, variable will be job job we do wearing masks nationwide with the new England and New York and the Mid Atlantic on California and Hawaii. Doing well, um, Southwest doing okay. Ish these guys basket case. Right. And if you take this is a surrogate for how much disease there is knowing somebody is sick. You see how the Dakotas light up here? Yeah, the next one, please. And this just shows that graphically, if you have here proportion of no wearing masks most of all the time in public and the proportion who knows somebody who has, uh it's in either case because I don't remember. I cut off right here. I guess it's case rates. The case rates low high. So the more people that wear masks the lower the case rates. Okay. Pretty compelling stuff. The next one, please. And you heard in the debates These numbers being thrown around, This is kind of the where Well, it was gonna look like in the US in terms of cases, this is his early cases. Um, this is thes air infections middle. And then this is the same way. This is the third projected third wave with peak out here around the around the first of January. And this is if we don't wear masks and act like we live in Florida and everybody could do whatever they want the next one, please. And then this is the mortality curves projected mortality. Uh, and you heard that in the debates? People say, Well, we could prevent 100,000 or 100 and 50,000. That's the difference between these numbers. That's what was being bandied about that I will point out that the U. S. War dead in World War Two combat dead were some 300 something 1000. So here, in nine months, we've we've equaled all the mortality combat mortality from World War Two. The next one, please. Now, I finally wanted to end up with vaccines. Vaccine pictures is better. Um, we I fully expect something to be announced towards the end of the month. Early December. Um, and we think that the trials can end as early as the week of Thanksgiving and with quick analysis and a turnaround in emergency use, authorization turn around that they might be licensed, not licensed. They might be approved for emergency use by the first or second week of December. Um, the ones that are most likely to get approved are the Pfizer and the Moderna. The top two rows Pfizer in the Madonna M. R N A. Vaccine. So what's being injected is a fragment of messenger RNA that's gets in Turk, elated into cells and cranks out baby spike proteins just to spike proteins. Nothing else. And so you have this kind of continuous factory of exposing people to spike proteins, which should create high, tight er's of neutralizing antibody titles, which is what was found in the earlier phase two trials, all good. Two doses. Yeah, and the other complicating things that has to be kept at minus 70 degrees. Right? So because you all I know you all have minus 70 degree freezers in your offices. Um and so this is a hugely complicating factor factor. And the first round of this is likely to be distributed by the military. Andi, it will go. I'll show you in a second. But it's gonna go to healthcare workers and a handful of other people. Thea other one that's kind of fits and starts is the AstraZeneca Oxford, uh, vaccine, which is an adenovirus vector vaccine which uses an adenovirus to introduce the, um, Thio introduce the the the coating for the spike protein. This has had a couple of problems on, has been stopped twice and is now back as now, going back again. I can answer the questions that people are interested. And my final slide, please. Um, this is the C d. C. Uh, surprised everybody in September by sending this out, saying, you know, be prepared for a for two million doses of vaccine to be dumped on you by the end of October, which is probably were probably more like in this range now. But this is the These are the priority groups healthcare professionals, including, including long term care facility, a staff. Okay, essential workers to be to be described to be to be announced. Um, probably police fire. I would imagine national security populations. This is for the federal government taking their cut off the top. The Navy has had tremendous problems with covert on ships, and so you can imagine that and then long term care facility residents. So that's those are the four groups that were supposed to get the first rounds of vaccination. There's not nearly enough for all those groups and will probably, uh, pick and choose among health care workers. So I c u E r um, e m T people are more forward facing are gonna actually be seeing patients acutely will probably get vaccinated. FirstPlus nursing homes. So I'll stop there and happy to come back at the end and answer questions. Thank you. That's great. Thank you so much. That was really an excellent talk. I'm very up to date. I think it gives us a lot of questions and thoughts and what we'll do. I think it's go through our three talks and then do questions at the end. But remember, for the audience who's on the Q and A button, feel free to put on any Q and A. You want there's no identification of who you are or what you know. So anything that pops into your mind, we'd be more than happy to discuss this. We go through and I've been making a little list of some of my questions as we go along, too. So now it's a great pleasure. Have been, boss. Let introduce you before whose had such a big role in our management of Kevin 19 overall in the ambulatory setting. Talk to us a little bit more. Thanks so much hope and thanks Toa Everybody who's joining the call today and thanks to George for that really interesting talk. I feel a little bit sheepish following George, but I will do my my best. So my rule that UCSF, since Kobe 19 began is really, um, as the medical director of the ambulatory Kobe 19 response Eso Most of my work has been really focused on the outpatient setting. I do spend some time in the inpatient setting, So if people have some questions about inpatient management, I can't promise anything, But I will hopefully be able. Thio Thio. Answer them a t end eso next line. I have no disclosures. So I think we all know at this point that there's a really wide range wide spectrum of illness severity for covert 19 ranging everywhere from patients who are totally asymptomatic or just really mildly symptomatic, and maybe dismissed some of their symptoms to allergies or something like that all the way to really critically ill patients. But for the ambulatory setting, um, if you could just click next, I'm just gonna focus on these top three categories. So patients who are asymptomatic or minimally symptomatic patients who have mild illness and patients who have moderate illness. And there's a lot of words on this slide. But what? What I'll say is that the main difference between the top categories in the bottom two is the need for oxygen. So if you're a patient who is who is needing supplemental oxygen, then we really want you to be in the hospital setting where you can take advantage off some of the medications that have known efficacy in in Covina 19. But for other patients who are at their oxygen requirement baseline most of the time, they can stay in the ambulatory setting, and that's what we'll be focusing on today. Next line. So I thought I would just start with a case. So let's say you're managing a 68 year old man. He has a history of well controlled HIV, hypertension and obesity. And he is complaining of a fever, cough and Malays. His attempt of 39 Celsius heart rates a little elevated, but his oxygen saturation is 97% on room air, which is normal. His blood pressure is okay, his lung stung clear and his chest X ray is normal as well. Next slide. So what do you think is the strongest risk factor for this patient developing severe cova disease? Is it his age, which is 68 HIV hypertension? The fact that he's a man or obesity just going to give people a few seconds to think about it, cause I don't have any clickers or anything like that. Um, so hope you wanna click next. Okay. Thank you. So it's actually his age next slide. So we know that advancing age is one of the strongest risk factors for a severe disease course in a severe outcome in Cove in 19. So if you're a patient who's under the age of 50 out of 1000 patients who have Cove in 19, almost nobody in that category is going toe to die. Um, when you get to patients who are in their fifties and you look at 1000 patients, five or 10 of them will succumb to Kobe 19. But once you get up into patients who are in their high sixties seventies eighties, you start to see that out of 1000 patients over 100 are going to succumb to Kobe. 19 eso. As people get older, they accumulate risk next line. And we also know that as people get older, they oftentimes accumulate other conditions that are coexisting and very common and problematic in terms of risk factors for Cove in 19 severity. And I think George really reviewed a couple of points on this, Um, could you click one over Hope So age is right there at the top, and the Stacy actually also lists active cancer at this point as being a risk factor. So I'm certainly patients with the history of cancer might not count in this category, but somebody who has really active cancer being actively managed with chemotherapy would be considered to be at a higher risk than other other patients. And if you look right down this list of risk factors, you can see things that many many Americans have in their health history, like C K D. Cardiac disease, diabetes, obesity, smoking. All of these things are common, especially as we age and many patients have, if not one, then multiple of these conditions. Um, just, I think, this past week the CDC moved pregnancy also into a stronger predictor prediction category for severe disease. The patient and my example had HIV, and I picked that because I'm an HIV specialist in my pre covert life. But actually, HIV doesn't seem to be a very strong predictor for a severe disease course. So that was really good news for for me in my patient population. Um, next line. So George reviewed this already so I won't go through too much of it. Um, but whenever we have a patient with Cove in 19, what we see is that the average incubation period is about five days from the time of patient contracts the illness to a time when symptoms start. However, unfortunately, there can be a bit of a wide range anywhere from two days, perhaps with someone who got a, you know, a really big inoculate. Um, or, you know, maybe they're just a sicker person all the way to two weeks in some cases, which really helps us to inform our quarantine recommendations. After that point, about half of patients developed symptoms, and of those patients who developed symptoms, about 20% will go on to develop more severe disease. And that tends to happen about 7 to 10 days into their disease course. And that's why I think, um, to go back to President Trump whenever you know, he was kind of going around in the car outside the White House and are outside the hospital and then speaking at the White House, and it had only been three or four days into the illness. I think a lot of infectious disease experts and other ex reports were really concerned because it seemed a little bit too soon to declare victory. Um, and then ultimately, of patients who are sick enough to be admitted to the hospital, 15% will unfortunately require critical care level support. Next slide, please. So how can we tell if this patient, in my example, is going to end up in that group that ultimately gets admitted to the hospital. S o. There is this phenomenon that I've I've heard on the news described, um, as happy hypoxia or silent hypoxia of Covad 19. And there's a lot of theories about why this exists. One theory being that it's really are carrot bearer receptors that are the are the recipients of information in our bodies about oxygenation levels, and there are aced two receptors present there as well. Maybe you know something about Kobe 19 binding to those ace two receptors. Somehow effects are carried a bear receptors. There are other theories as well. But one thing that we know is that sometimes patients can actually be hypoxic and not look completely ill or short of breath, or even feel that ill. And I had this happen to one of my own patients who who called me and said, I'm 87% on my pulse ox, but I don't feel that bad. Which should I dio. He ultimately got admitted to the hospital and was there for about five days, so I was very glad that he had a home pulse oximeter, and this is something I really recommend to patients. There's a wide range of different brands, some that you can get for pretty cheap. Um, they do have this ability to detect something called an absorbency ratio. I don't know too much about that. Please don't ask me, and they use an internal algorithm to make an estimate of what your your oxygen saturation is. You do need to have Paul settle arterial flow, so patients who have significant peripheral vascular disease might have an issue with thes thes Paul socks emitters. Additionally, they are considerably less accurate, the more hypoxic you get A Z. You can imagine whenever the manufacturers of these devices were sort of of testing them on healthy adults and maybe Children. You probably couldn't get those volunteers very hypoxic. Thio calibrate the machines down to those low levels. Eso they do lack some lax and sensitivity. The worse off you get and then finally are are darker skin. Patients might have less accurate results, unfortunately, and nail polish will also interfere with detection. Next slide, please. Despite these problems, I still advise patients to pick up a pulse oximeter and at UCSF we. Actually, we obtained some, um, supply and were able to give it toe. Some of the patients earlier on FDA approved models are better if you could get them. I discourage patients from using smartphone APS. They are out there, and they're not, um, super reliable. It's nice if you could get a device that gives you info on signal strength. Some of them do, um, encourage patients to take the readings at rest, using their index finger and middle finger. Make sure they don't have nail polish room up their hands if their hands are cold, and then step quietly for about a minute and figure out what's the most common value that you're seeing and do that a few times a day. If patients start to see values below 95% or if there are patient who's kind of chronically hypoxic, maybe they have some C O. P D. They see it go 3% of their usual baseline. Then they need to go to the emergency department and not mess around because these are the patients that could end up with more severe severe outcomes. Next slide, please. So how do we treat patients who are ambulatory with Cove in 19. Unfortunately, right now, the answer is we don't It's supportive care. Um, there are no FDA approved therapies for for outpatients. However, there are a large number of clinical trials in progress for both in patients and out patients. And so, um, whenever I have a patient who is newly diagnosed and they're, you know, they're asking about therapy or else what can I do? You know, Should I donate plasma, etcetera? I point them to these websites. Um, you'll see, there's a UCSF website, um here and these air try websites that have trials that are actively enrolling for patients who are interested and and willing to get involved. So I encourage patients to take a look at these A tease sites next line. So patients, they're also gonna ask about what things they can do to both prevent cove it as well as Treat Cove in 19 that aren't FDA approved therapies. And there is a lot of buzz out there about, you know, certain vitamins or over the counter medications. And so I thought I would just try to address some of those eso vitamin D. We know it can have an immuno modulator. Ori effect on Do we have seen some observational data that patients with Cove in 19 are more likely to have vitamin D deficiency? And so this has lead people toe feel that taking vitamin D might treat cove it or at least ward off co vid. Um, there's no clear data of that yet. Um, and in studies that don't involve patients with over 19 but that do involve critically ill patients, Um, providing them with vitamin D has not ultimately helped outcomes in those critically ill patients. And so, um, there's really no strong recommendations about vitamin D right now. Vitamin C, similar story. We know it has antioxidant properties. Maybe it's, um, anti inflammatory, and people are looking at it to see if if there is a role. I think I saw a trialing earlier today about ivy vitamin C, but so far there hasn't been any signal. Um, that vitamin C is effective. Zinc similar story, um, some theoretical benefit about decreasing viral replication, but no strong data to support its use. Um, for Modine similar some evidence that maybe patients who are taking from OTA Dean had improved survival. Um, but data is is sort of murky at best. And then finally, I got a lot of questions from patients who are already taking medications that are prescribed medications like ACE inhibitors. Statins. Um, some people are taking insides for various reasons, and they're wondering, Should I stop this therapy? Could it increase my chance of getting Kobe 19? Or they say, I've read that these therapies can help me prevent Kovar 19. Should we should we increase my dose? Should my wife start taking this, too? And right now, there's insufficient evidence to recommend either starting or stopping these medications for the prevention or treatment of covert 19. Same thing for aspirin. We we think that patients with Cove in 19 might have an increased risk of thrombin and Bolic events. The dad has kind of been, um, up and down in that realm, but there's no recommendation to start people, particularly outpatients, on any kind of, um, anti coagulation therapy for in patients. We do start people on DVT prophylaxis, but that's just, you know, sort of the standard of care for your impatient and not really related Thio the Cove in 19 diagnosis. It is an area of active research, so there might be a different answer in the future. But for right now, um, no strong recommendations in those categories. Next line. So, in summary, older men are probably the highest risk population for severe cova disease. Active malignancy can be a predictor for severe diseases. Well, but unfortunately, conditions that are very common in the older American population will compound and further increase the risk of severe a severe course. People tend to get worse about 7 to 10 days into their into their illness. And so that's the timeline in which you really need to be watching them. Silent hypoxia is something that is seen in Kobe 19. So we encourage patients to have a pulse oximeter at home if they can. Andan. Fortunately, there's no approved therapies for out patients, but patients conjoined studies. And although these adjunctive therapies aren't recommended, they're probably not going to cause harm so long as your patient isn't trying to take ah, 100,000 units of vitamin D a day and 20,000 mg of vitamin D. I think it's okay and, you know, maybe even good to encourage Well, vitamin D supplementation next slide, please. Okay, so what is my patient considered to be recovered from covert 19. So let's say you're seeing a 25 year old woman. She has a history of Hodgkin lymphoma. She's on chemo therapy, and she was found to be covert positive after attending her sister's wedding. Shouldn't have done that. Her cova 19 diagnosis was made 10 days ago because she was having an asymptomatic pre procedure test. And luckily for her, she has remained symptom free, and she wants to know when she can come out of isolation. My, my my husband, who is an oncologist, pointed out that this patient would not have hair at this point. But I'm just gonna pretend that this is a very nice, um, wig next slide. So when can this patient come out of isolation from covert 19? Is it 10 days from diagnosis? 20 days, 10 days Plus, in the negative PCR 10 days plus two negative P C. R s or 20 days plus two negative p. C. R. S going to give people a minute to think about it. Okay, hope you can click. Okay, so the answer in this case is 20 days from diagnosis, and I'm just gonna go through some really quick data for you on this next line. Okay, so the CDC made these updated recommendations several weeks ago. UCSF, which had, you know, actually currently has a 30 day hold on patients from coming back into the health care setting is going to be adopting these recommendations very shortly. And what the recommendations are is that for the vast majority of patients who are not severely immuno compromised and did not have a severe or critical illness, they can come back into care after 10 days. So long is there a fee brow and their symptoms are improved. However, if you were critically ill or you do have, um, you know, compromised then you should wait 20 days and, you know, also be a febrile and symptoms improved. Uh, I'll give you some data on on Why that is next line. Okay. So, first, though, what is defined as what? What is severe? Immuno compromised. How do you define that? And it's actually it could be quite a few people. Eso anybody who's receiving chemotherapy for malignancy or or any treatment for human Hologic malignancy. Patients with advanced untreated HIV infection, primary immune deficiencies, patients taking medications that suppress their immune systems, such as high doses, um, for a prolonged time of steroids or certain biologic agents, as well as patients who are solid organ or stem cell transplant recipients. Um, how do you define severe or critical disease? I think we did that on an earlier slide. But, um, there's lots of details here that I think, you know, probably you don't need to memorize. Can you click next Hope? So what I would say is, if you're hospitalized for Kovar 19, then you meet the requirements for severe or critical disease. There gonna be some people that are hospitalized just because they're at risk and they actually don't meet these criteria And they're probably gonna be people sitting at home with mild hypoxia who we never find out actually have severe illness. But the vast majority of patients were going to capture. If we just say, if you were hospitalized for cova 19, you fall into this this category next slide. So why did we pick or why did the CDC pick, um, 10 and 20 days And why did they move away from the former criteria which included, um, test based discontinuation of isolation there a couple of reasons. Eso for one, patients could be persistently PCR positive for a long time, and they can totally recover clinically but still have intermittently positive PCR s and the way that we look at a PCR and and, you know, hopefully trying to decide if the positive result is significant or not is really looking at the cycle threshold. And that's just the number of PCR cycles that needs to happen In order for the PCR to turn. Let's let's say we call it positive eso. Obviously, if you have lots of nucleic acid and a sample, you don't need very many PCR cycles for that that test to term positive. But if there's hard landing nucleic acid in there, you're gonna have a lot of cycles that are required for that test to turn positive. And most manufacturers say that their their cut off for cycle threshold is less than 40 for positivity. But we do see a lot of patients who have these sort of lingering positive PCR s have cycle thresholds that are, you know, in the 35 to 40 range people who are earlier in their infection, who are more likely to be contagious. Have much lower C T values in the 20 to 30 or even lower range. And then that tends to go up as the viral load goes down over time. And these PCR zehr really detecting sub genomic RNA and not necessarily infectious or replicating virus. But they do freak people out when they're positive. Um, next slide, please. So there's been a lot of studies trying to figure out, at which point we can say Okay, this patient has a positive PCR, but they're no longer really contagious or a threat to other patients. Eso There have been a number of studies in patients with mild to moderate illness like Onley included. A few on here which show us that persistently positive PCR s are usually due to viral debris and not actually live infectious virus eso. In the studies that I included here, we looked at a number of patients who had, you know, persistently positive PCR s. But in all of these cases, there was no cultural live virus after day eight or nine, and there's been a lot of other studies that I didn't include here that have found similar numbers next line for more severely ill patients, however, and patients who are more immuno compromised. That is not always the case. Eso There've been a number of studies, but I'm just including one of the larger ones out of the Netherlands, where they looked at about 130 patients with more severe illness. Most of the patients were in the I. C U about a quarter where, um, you know, compromise some severely. So and they took about 700 samples in total from all of these patients. And just like other studies that I showed you, the median culture positivity was about eight days on. The probability of detecting viable virus was less than 5% after about two weeks, however, there waas some signal and there's like this dot right right here the 20 day mark. If you look a little black dot um, where there was a culture positive at 20 days after the onset of symptoms, Um, it wasn't a lot of patients, but we did. We did see that on DSO. This is where we kind of come up with this. This realm of most patients 10 days, some patients 20 days next slide, please. What other data do we have about whether or not these patients are infectious? Eso I really liked this study out of the Korean C. D. C. Where they reported on close to 300 patients who had recovered from Covert 19 tested negative but then unfortunately tested positive again median 45 days later, after their initial illness. And of those patients, about a third of them were able to get viral cultures and they were all negative and also Encouragingly, none of the approximately 800 contacts of these patients were found to be positive, including family members and other very close context. So I think that gives us just some additional reassuring data next line. Okay, so in summary, we know that patients are really most infectious immediately before, as well as the day or two after the onset of symptoms. And then they're viral load tends to rapidly decrease in about 10 days for most patients and a little bit longer for patients who are critically ill and therefore persistently positive. PCR s are common but not likely associated with contagiousness eso. Most patients can come out of isolation at 10 days, but the immuno compromised patient like in our example, or patients who are hospitalized should delay until 20 days from onset of symptoms or positive test next line. Okay, last case and I try to make this fast. Eso This is another situation that we get into a lot, unfortunately. So we have a 57 year old male clinician, and he gets that dreaded call. He looks unhappy from his hospitals Infection control office, telling him that he's been in recent contact with the covert positive patient. He explains to them that he was wearing appropriate PPE e, including a surgical mask, and I shield. During the approximately 30 minute visit, the patient also stayed masked and the clinician stayed at appropriate distance. However, he did examine the patient for about five minutes and very briefly took off the patient's mask to have a quick look in their mouth. Um, next line. Okay, So when can this health care worker return toe work? Is it after a screening, PCR is performed a negative after 14 days of quarantine, even if a baseline PCR is negative after 15 days in a covert test is not needed or immediately as this. This was no high risk exposure what people think about it. Okay, Click. So this patient actually does not count as having a higher risk exposure next slide. So how do we define exposure to covert 19? So it's really defined as prolonged close contact, which is within 6 ft for 15 minutes or longer over the course of 24 hours, which was just added in the past two weeks. Um, so that means that if the same clinician examined a patient, you know that same patient three times over the course of the day for five minutes each time, then he would have met the definition. We tend to contact trace for two days, starting to prior starting prior to symptom onset or positive test for asymptomatic people. And while exposed persons are are frequently and I think should be offered testing for contact tracing purposes, even if those those tests are negative, they still need to be monitored for symptoms for 14 days and stay on quarantine, no matter the results of that initial PCR tests. And I have some details below just about slightly different scenarios between community health care worker and returning travelers. But I'll just leave those there and won't go through them right now. Next line. Finally, I get asked a lot about acceptable assays for Kovar 19 testing. We sometimes have patients transferred into our hospital who have gotten a test elsewhere, or we have patients who are planning to come to our hospital, and they want to know if they could get a test closer to home. And so then we get the results of this test, and then nobody knows whether it is a quote unquote good test. Eso We recently made this table for our staff to help. Better understand whether a test was high quality and for our symptomatic patients or patients who are going to be going undergoing high risk aerosol generating procedures. We really want the best of the best test, so we ask that patients get PCR tests for these scenarios. Um, similar acceptable tests are nucleic acid amplification tests, transcription mediated amplification or loop media. The amplification called lamp tests. These are all acceptable tests have a high degree of sensitivity for covert 19, we get asked a lot about antigen tests, including or not including, but also rapid tests such as the I D. Now or other point of care tests. Ah, lot of places around the city, like dignity, health, are offering these tests that, you know, you get the result in 10 to 15 minutes. Um, I think that those test could be acceptable in certain scenarios. Like I have some patients that every time they want to go out and have fun on the weekend, they go get a test before and they go get a test after, Um, you know, we haven't UCSF some large scale screening of our of our asymptomatic health care workers eso for those purposes, I think that these tests are probably fine, but I would not use them for a murder for contact tracing or for symptomatic patients. And then finally, while serology and antibody tests can be, um, interesting and provide useful information, they're not useful for ruling out, uh, Cove in 19 next slide. Okay, so in summary, Kovar 19 is defined by prolonged close contact. Most interactions that you're gonna have, like sharing an elevator checking out at Safeway, are generally low risk because of the prolonged incubation period of covert 19 and exposed person might actually need to remain isolated for longer than a patient with known, um positive Kovar 19, which often surprises people. And then finally, for contact tracing purposes or symptomatic patients, please use a top performing s A like a PCR and not a point of care or, ah, rapid test next line. That's it for me. Thank you so much. This is my email address. If anybody has questions, they want to send me afterward. Thank you. Thank you so much. That was just fabulous. And I learned a lot, too. I think these questions are ones that come up all the time in our clinical practices and with our patients. And also I think it's something that we can. If we're more informed, we can inform our community so much better and really spread appropriate information around, since we at the moment aren't learning it on the news. Although I have found Twitter is a good source, eso now we're going to go on and have our own Palin sin are not that everybody isn't our own, but Palin is within our cancer center. And during the cove it, um, the peak of when we were dealing initially with Cove it Palin was having a morning session every week to talk about how we were managing the pandemic, and this was incredibly helpful. And one of the silver linings of the pandemic, I think from my point of view, has been greater interactions with people who we just didn't interact with otherwise, both at work and outside of work on this was one of them. I mean, we really became a community through all of these, uh, discussions. And so I'm excited to hear from Palin now. Thank you. Hope I'll run through these slides quite rapidly, just in the interest of time to allow everyone to ask questions. So if we could go to the next slide, maybe we can. There we go. You. So I thought that I would start with our journey and how we started everything back in February as a health care system. Uh, in February was the two patients we received as a transfer who had confirmed cove in 19 and shortly thereafter. A few weeks later, Maryland and Breed declared state emergency on March 2nd was when the search planning started at U. C S F. When the screening guidelines were implemented on on March 6th, non essential visitor restrictions for in patients were placed. March 8 marked the accelerated care unit opening outside of the ER to allow for a dedicated area for patients to be evaluated, perhaps treated, who had concerning symptoms for co vid for the cancer center. Our journey really started on March 9th. I would say that's when we actually got together and formed a cove in 19 task force. During that time period, the respiratory screening clinic was opening up at Per Nass's um, and restrictions on large gatherings were coming together. And as a cancer center, we started discussing how we would convert in clinic visits to video visits during that time period. The following day, we asked each department and discipline to really identify physician champions to form the physician. Champion Cove in 19 Task Force on the Cove in 19 Inpatient unit opened up at per NASA's on that day. The RSC planning started on March 11th for us at the Mission Bay campus, and we really wanted a dedicated unit where we could evaluate our patients with cancer by our own eso. It was really touching, actually, to have all of our faculty members from different disciplines. Some surgeons mostly human. Tell him it'll Odjick, an oncologist and a PPS and RM Mazar ends, all of whom volunteered their time to be able to staff the RSC at Mission Bay on that ultimately opened up on March 20th. We can go to the next slide early on. As hope mentioned, communication and transparency seemed like the really key thing for us to focus on. There was so much uncertainty that resulted in high levels of anxiety not only in our patients but also in our colleagues and our team members. So as we formed the Cancer Center Cove in 19 Task Force, we had daily meetings. This was mostly cancer center leadership and key stakeholders from each of the different areas, whether it's ambulatory infusion center. We also had daily huddles with cancer center physicians. And as hope mentioned, we have never really had a venue where we got together and spoke to our surgery colleagues and radiation oncology colleagues, supportive care services, um, and and really discussed guidelines and work flows in a way that has never been done before. And of course, you see yourself. Health had a command center, and in alignment with that, we were able Thio. Uh, we lost the slides. Um, but in an effort we were able thio really discuss what the guidelines and work flows were, Um I lost the slides, but I can pull up my slides, if you would like hope. I think he got disconnected. I think she got disconnected. Here we go. Can you guys see my slides? Yes. All right, I apologize. I'm gonna go to my own slides really quickly. Thankfully, I had it open on its good. Here we go. So I wanted to really quickly mentioned all of our colleagues who were not only part of the Cova task force and some of whom are actually missing from these pictures just because I couldn't find their pictures. But all of these, um, colleagues have now become a part of our now every two weeks meetings. And it has moved on from a Covad 19 discussion to cancer center operations guidelines, new policies and workflow. So it's really been ah, wonderful way to develop that community now. Our prevention and mitigation strategies. I think you're all familiar with it. If you've been at UCSF, we ultimately started out with universal masking and more recently, with the CDC. Guideline changes I protection has also become a part of our PP and and and to reduce exposure risk. Um, the visitor policies have ranged from limited to no visitor policy. We continue to encourage no visitor policy in the ambulatory setting on bond. There are some exceptions, as you all know, for end of life on DFO, or important discussions for patients. A swell as those patients who have dementia, delirium, etcetera. But in the in patient world, we are allowing one visitor per patient per day. The RSC, as we discussed, have been a really dedicated unit. Not only did we evaluate and test patients here at the RSC, but we actually develop work flows to people to continue providing care and systemic therapy for some of our patients who had Covic but needed to continue their treatment because of their cancer. We developed guidelines and algorithms in collaboration with Dr Boss lit really to triage patients thio er, RSC, or whether they could stay at home. There was a covert positive patient management team that was essentially taking care of all covert positive patients and escalating their care if they were symptomatic and as We like taking ownership of our own patients. We worked really closely with them to see how we could help out with that, and we wanted to continue to provide high quality care. Our patients have cancer, and we wanted to continue to be there for them. We didn't want to affect their outcomes. And early on we asked the multidisciplinary teams to get together, whether during their tumor boards or site committee meetings, to develop guidelines, especially, and limited surgeries and procedures that didn't allow perhaps an upfront surgery that would have been otherwise. The case and so coming up with treatment guidelines that were evidence space was quite important for us. We considered alternative dozing schedule for our patients to allow for fewer in clinic visits or in in person visits. I should say on Dorrell on politics were considered if it was equal int or if it was appropriate. And of course we all know that the to reduce the exposure risk the interval between scans were extended on some cases if appropriate, and the use of biochemical markers in lieu of scans to evaluate for treatment responsible is also recommended. We developed protocols to be able to do some of the care we provide in the outpatient setting to be done at home. Of course, this does not include any infusion, all chemotherapy, as that would just not be safe. But pump this connection administration of growth factors hormone therapy where some of the examples of therapies that were done at home and we all knew that focusing on wellness was going to be an important aspect of continuing to care for our patients with cancer. They were already distressed about their diagnosis, their prognosis. And now they have to worry about Cove in 19 and the risk that that carried so providing resource is for oneness and stress. Stress management for our patients was very important. We developed a frequently asked questionnaire that was available on our website once again to reduce anxiety because there was so much uncertainty. Supportive care Psycho oncology are oncology. Social worker colleagues continue to provide supportive care to all of our patients and art for recovery. Continue to use social media to be able to offer opportunities for our patients. And of course, we also have to think about our team. Members are colleagues to continue to provide a safe environment. Andi, as you all recall appropriate and adequate personal protective equipment. What uncertainty in the beginning. But ultimately we were very fortunate that we were able to continue to provide a safe environment for everyone. Patients continue to be tested prior to surgeries admissions prior to any transplant Carty therapy or aerosol generating procedures. Ah, pilot study under the direction of occupational health has been started on random on site employees testing via self administer nasal swabs. Ondas Doctor Boss Lit mentioned there may be an extension off the asymptomatic patient testing for extended treatment and radiation oncology patients in the near future Centralized resource and website To be able to communicate these ever changing guidelines and work flows was also an important part, and we were very fortunate to have U. C s F health leading that effort. Daily screening was started during the pandemic and continues to be an integral part of us coming back toe work to be able to set clear guidelines to follow regard regarding return toe work guidelines and we continue thio, encourage telecommuting whenever it's possible and appropriate for our patients. Video visits were an integral part of the care that we provided Onda. We'll discuss that briefly as well. Similar to our patients. The level of burnout, the concern for wellness and stress management was also important, and UCSF Health developed the co program. To be able to provide resource is for our colleagues and for people like myself who have little Children at home. Child care resource is were very important for us to be able to continue to do our work, but also make sure that we're able to provide for our families. This still continues to be a problem for most of our colleagues whose Children are still doing remote learning from home. Um, this is just a summary of some of the interventions that I mentioned, but I wanted to bring your attention to clinical trials. A zoo. You recall we had quite a bit of a decrease cruel to our clinical trials early on, just because of the uncertainties are not being able to do biopsies for studies, collect specimens, not being able to see patients in clinic Um, and not knowing when all of that would start. We also wanted to make sure that we provide a safe environment for our clinical research coordinators who most of the time actually started doing work remotely. This opened up a really large opportunity for us that we probably would not have ever explored Elektronik Documentation Elektronik and Remote Consenting to be able to mail medication, study medications to patients at home. Being able to remotely document and monitor patients, side effects, symptoms and adverse events was really an integral part of the pandemic, and I think that it will be hopefully a part of our practice going forward. Um, Dr Rutherford has already mentioned that there is some data coming out that suggest higher incidence and patients with cancer. And I wanted to briefly mention some of the experiences in other countries in China compared to incidents in the community patients. Um, sorry. This these air actually flipped. I apologize. Patients with cancer actually have a higher incidence than they do in the community. Um, in Italy, 8% of the patients admitted to the I. C. U had Cove in 19. And in New York, 6% of hospitalized patients with Cove in 19 had cancer. Um, and as Dr Boss Lit mentioned patients who are older with medical co morbidity ease happened to have an increased risk. And those patients specifically with the meta logic, malignancy, lung cancer and metastatic disease also appeared to be at higher risk. I also wanted to mention health care disparities and inequities. We knew prior to the pandemic that there is a gap in the care that is being provided in oncology, and we believe that this care this gap has actually widened during the pandemic. We know that marginalized or minority groups are at increased risk for covert 19 simply because of increased risk of exposure, increased susceptibility and decreased access to care. There are more likely to hold essential jobs that don't allow for flexibility of working from home. They're more likely to work lower income jobs that don't provide health insurance or are minimal coverage. When they looked in the rates in 2018, 11% of blacks and 18% of Latin X population on Lee had health insurance, and we know that structural barriers and getting tested was visible in the early days of the pandemic. When we look at the general patient population, while blacks comprise 13% of the US population, they actually made up 16% of the cove in 19 cases and 20% of the deaths related to Cove in 19 and the Latin X population, who account for 17% of the population. Um saw a 27% of the cove in 19 infections, and close to 16% of that's related to Cove in 19. Now, when we look at those patients with cancer, um, looking at the ASCO cancer linked data that was recently presented at the ASCO Quality Care Symposium, we saw that there were 965 patients with cancer who had Cove in 19 but black and Latin X Patients with cancer had a higher risk of developing Cove in 19. You can see here that the Hispanics had a relative risk of 5.25 and black population had 1.69 Reassuringly, the all cause mortality wasn't elevated in this in these patients. But of course, there's more studies to be done in this. Similarly, when we look at E. D visits or hospitalizations for patients with cancer who have covert 19, we see that 14% of patients who were cove in 19 these are specifically for cancer patients, um, were black, but When we look at the distribution for hospitalization and E d visits, we can see that 18 or 19% of those patients are hospitalized and 27% of hospitalized patients. Um sorry, Edie Visits were also by a black patients, and when a multi variant, largest logistic regression was run, the odds were 2.19 for black versus white population. So clearly there is, uh, there. There is some disparity when we think about telehealth, we always think about all the positives that are with it and that it's going to be an integral part of the care that we continue to provide. But I think we also have to recognize that there are barriers to using telehealth. There are some patients who are unable to access or navigate technology who don't have phones. Computers who don't have WiFi, um, or they have inadequate Internet connection to be able to allow for appropriate communication and or lower healthcare literacy that once again may not allow them to be able to communicate with their providers over a video or telephone. Minorities and studies have shown this or individuals with less education those in lower SCS or social economic status are less likely to engage in telemedicine activities. And this is a study that was recently again presented at the ASCO Quality Care Symposium that essentially showed that 19% of of the black population contributed to telehealth, compared to 23% of the patients actually being seen. This was at Mount Sinai and the Hispanic population was 6%. The big question, I think, for all of the providers, is well, what happens once the coronavirus preparedness response supplemental act is eyes lifted. But we know that in a way, in California were protected because California law that was passed in 2011 shows that reimbursement needs to be made on the same basis to the same extent at the same rate as the same service provided in person a lot of sames in that sentence, S o. We think that telemedicine will continue to be a part of it, and for CMS, there's actually talks and very strong prediction that it will continue to be more expanded than prior to the pandemic when Onley patients in rural communities would be able to contribute to telehealth. I also wanted to quickly mention Cove in 19 registries. There's multiple. There are multiple registries that are collecting data on our cancer patients and and essentially all of these patients and their outcomes as it relates to Koven, 19, will be a really value to all of us and just plug into the U. C s F on and you see, I should say, you see cancer centers. Covert Outcomes Project, led by Erik Small here among with a group of us is definitely a big effort on. We're very excited about the opportunity to collaborate with other UCS. So can we identify opportunities to redesign and not just recover back to where we were before? Can we learn something from the pandemic? Andi. I think that there were a lot of lessons learned. We talked about telemedicine already. I think that the possibility of multidisciplinary clinics via telemedicine onda potential of increasing access to some of our patients not only a standard of care but in the clinical trial setting, um is an important aspect of it. We have to continue to focus on healthcare equity. I think that's that's one other area that has become a big focus for our cancer center and digital tools that were implemented so rapidly more more faster than it ever could have been before the pandemic. We hope to continue to use them as patient reported outcomes tools. Um, sorry that I ran so quickly through that, but I think we're pretty much at time. I thank you for your attention. Thank you, Palin. That was really nice. Can you go to the next slide? Because you have the slides. You have them up there, you might be able to just a last slide. Eso Yeah, I apologize. That will break. But our Internet here at the cancer center dropped for some reason so but were back in action. So we have, uh, two minutes. So we'll we'll ask some questions. But I'll just point out our next webinars which we'll talk about different cancer topics. We'll advertise them way in advance on duh. These are available to attend for both CMI and non CMI. And then you all got the flyer from Kirsten del Rosario. Andi. She is the had the overall, um, manager, I guess of the this particular program. And if you have questions, uh, that you weren't able to ask today things that have come out please email Kirsten dot to del rosario, UCSF dot e d u and she'll triage the questions out to the Panelists, so that will work out well.