Nirmal Joshi has been the chief medical officer at Mount Nittany Health since November 2017. He has a background in infectious diseases, and has been helping lead Mount Nittany’s efforts to prepare for and respond to the COVID-19 pandemic.
Joshi earned his bachelor of medicine and bachelor of surgery degree and his medical degree in internal medicine and completed his infectious disease fellowship at Penn State Hershey. He served on the faculty at Penn State for eight years. Before joining Mount Nittany, he held positions at Penn State Hershey and Pinnacle Health System.
He served as medical director and chief operating officer, of a for-profit health system in Delhi, India.
WPSU's Anne Danahy spoke with Joshi about what Mount Nittany has been doing to prepare for and respond to the coronavirus.
TRANSCRIPT:
Anne Danahy: Welcome to Take Note on WPSU. I'm Anne Danahy. Dr. Nirmal Joshi has been the chief medical officer at Mount Nittany Health since November, 2017. He has a background in infectious diseases and has been helping lead Mount Nittany's efforts to prepare for and respond to the COVID-19 pandemic. Joshi, earned a bachelor of medicine and bachelor of surgery degree and a medical degree in internal medicine. He completed his infectious disease fellowship at Penn State Hershey and he served on the faculty at Penn State for eight years. Before joining Mount Nittany, he held positions at Penn State Hershey and Pinnacle Health System and he served as medical director and chief operating officer of a for profit health system in Delhi, India. Dr Joshi, thank you for joining us.
Nirmal Joshi: Thank you for having me.
Anne Danahy: First, what's it like for you, the nurses, the doctors, the support staff at Mount Nittany as we start to see the number of COVID-19 cases increase in central Pennsylvania. So we were seeing them already IN some of the larger urban areas in the Northeast and in Philadelphia, but now we're starting to see them tick up here too.
Joshi: Yeah, absolutely. It's, it's, it's been a very interesting time as I'm sure you would. Uh, you would agree. And, uh, while we're certainly grounded in the, in the reality and the really the seriousness of the pandemic, which, um, uh, just can't not be noticed in many ways, but really this is an opportunity to kind of remind ourselves that Mount Nittany is really a special place. Um, the people that work here at are special people and we've always taken pride in providing excellence in care because it's our own family members. As I often walk in the hallways here at the hospital, I'm often reminded of how many of our, uh, of the folks who work here, whether it be nurses, employees, physicians, how many of us have their own loved ones in the community, in the, you know, their family members, their neighbors. And um, when, when you really think about it, those are the people we're taking care off. It really comes from the heart, I think, for many people who are part of Mount Nittany.
Danahy: What are you seeing at Mount Nittany in terms of number of patients, not only those who actually need to be hospitalized but just coming in for treatment?
Joshi: Yeah, so it's, it seems like, you know what, I think most people have noted that if you look at Pennsylvania as a state, that there has been kind of clusters off perhaps higher incidents, uh, in the Eastern part of the state. And maybe to some extent on the Western part of the state. But the center part of the state, that includes us obviously, has been relatively slower in terms of the number of cases and, uh, the volume of cases and perhaps most importantly, um, the mortality, people who are really sick from it, and the few who've passed away. Um, if you look at Centre County itself, um, when I was looking at today's numbers, you know, the total number in Centre County is in the high, and what's perhaps even more important than that has been that, um, that have been no deaths associated with the, with COVID-19 here in our community. I'm knocking on wood and saying "Thank God" and we certainly hope to keep it that way from the standpoint of the care we deliver, people who need the care in the hospital. But in terms of how the epidemic or the pandemic in this case will, um, affect our community, I take every opportunity that I get to emphasize that it's really dependent on us as a community. Meaning how well we practice our social distancing measures, how well we practice other guidance from the CDC, from the governor of the state, from all the things that are coming nationally. The one thing that's common is social distancing works. Please, please, please practice it. And secondly, I keep telling people, going back to the basics. People often ask us what they can do and they come up with all these creative things and we keep telling them, go back to basics. Practice social distancing. Stay at home, wash your hands, sanitize your hands. Those are the highest levels of proof, if you will, of how the pandemic can be stopped. If you go back in time, almost every pandemic or epidemic that is a spread in a similar manner as this... These are the same exact basic principles. So we encourage people to do that. And that is what will determine how our community does in terms of what's coming down the pike for us in two, three, four weeks.
Danahy: Right. And you mentioned the East coast and then even parts of Western Pennsylvania are seeing higher numbers. And it does in some ways feel like we're still kind of waiting for it. We have had cases here, 59 as of Thursday in Centre County, 18,228 statewide. But it does, it feels like in some ways in the center and north central part of the state that we're kind of waiting for it. What's that like for the staff at Mount Nittany who are on the front line and have to, in a way, wait and see what happens?
Joshi: Yeah, well it's, it's an opportunity. Every passing day that we are not hit, uh, to the severe extent that some other places have been hit, every passing day allows us the opportunity to plan better, to plan more, to plan for a situation that we hope never happens here in, in Centre County and in this region. But nevertheless, it's critically important to plan. And as a result, we've used this opportunity to be able to put systems in place that can appropriately handle surges that might happen if they were to happen. And I keep telling people there's a big if there, and that largely determines on us... Uh, is determined by us. But that it's offering us the opportunity to prepare. It's also offering us the opportunity to talk people around us. This is a team effort and the key is to be able to stay connected. Our community is so interdependent, if you think about it, on people around us. So whether it be, um, extended care facilities, right? Nursing homes, whether it be, uh, uh, a prison system, you know, close to us or whether it be, um, other people in our community, whether it be the university, whether it be our partners in healthcare, um, uh, Penn State Hershey or a Geisinger or what have you. All of these people come together in this community. And that's the uniqueness of the, of the community. And I believe, uh, and we at Mount Nittany believe that that's both our biggest strength and also at this time of crisis, they're our best supporters where all of us come together and we get a chance to dialogue to say, if X happened, what would we do together?
Danahy: Right. So the reports and the forecast are that this will be peaking in mid April or you mentioned a couple weeks out. So is that when people should be preparing in central and northern Pennsylvania for things to get much worse? I know you said we have a lot of control over that, but in some ways it feels out of our control.
Joshi: You know, different models seem to be, um, uh, talking about slightly different outcomes. And the one common outcome is if you look at any curve anywhere across the country, right? The one thing that predicts, uh, just about anything is, is the kind of measures we talked about. So I don't want to be evasive as far as answering the specific question about exactly when we might see it. The fact is, no one knows, but we do seem to be, at least up until now having an impact that's relatively limited compared to the Eastern part of the state, for example, what we are also seeing is that when we are seeing the disease, at least in the populations that we've seen here, the disease seems to be perhaps not as, um, aggressive, at least with the very limited numbers that we've been able to see. Um, so as far as, you know, the hospitalizations, how sick the people have been and so on and so forth. We still respect the disease a whole lot. We just don't know yet. It's not, uh, it's not fully matured here yet. But we, um, we do know that those are some initial trends. And the longer we can keep that trend in that way, the higher the probability that that peak will be both flattened as well as pushed out in time.
Danahy: I think this question comes up a lot is okay, let's say we get past the peak and we're doing pretty well and then things start to come down again. Does that mean that we can kind of relax our standards or no, we have to continue to socially distance?
Joshi: You know, the, the, there has been, as you probably have heard, um, there are differing points of view on that. Um, and like anything in life we have to, we have to strike the right balance. You can't indefinitely have people be on a near lockdown situation. You just can't. That's not how human beings work. On the other hand, I think the message that you hearing both nationally from the CDC and from other organizations has really been the following. Which is to say if we can kind of, you know, consume this bitter pill of social distancing, if you will in so many ways. If we can aggressively practice it, and they've often said at least for several weeks from now, and that allows us the opportunity to really hunker down and push and be able to have the pandemic under control in most parts of the state and hopefully most parts of the country. Then at that point in time, uh, most epidemics and pandemics eventually do die down primarily because they run out of host targets to be able to go after. And the hope is that at some point in time when one is able to flatten that curve and get down to a number that's tolerable, that one can gently and appropriately begin to relax those guidelines. It is not practical to be, to be in this state forever, obviously. And that's where you see differing points of view. The differing points of view are not so much whether or not. The differing points of view are when. And that's open to question. Most people believe that here in central PA, if we can give a full throttle effort to these efforts, you know, for another, uh, you know, three to four weeks or so, we will have a very good handle on what's going on at that time.
Danahy: We got this question from a listener and they want to know how prepared Mount Nittany is. What's your plan to keep the medical staff safe? And do you have enough personal protective equipment? Obviously there's lots of reports on shortages of PPE.
Joshi: I think it's a, it's a fair question. Our community needs to know our level of preparation. How are we doing? And uh, we are, we are their hospital. We are a hospital for our community. So that's a very reasonable question. And uh, I think at a very high level it's important for the community to be reminded that we are a 260 bed acute care hospital. Um, so we take care of most common illnesses. And acute care illnesses. And we're certainly very equipped from the, from the complexity standpoint, to be able to manage patients with COVID-19. We have a 24 licensed ICU beds. That's important for the community to know. And it's also important for the community to know that in the situation that we need more, we're able to expand our care services. Uh, you know, if that were to happen, what also able to expand our staffing, uh, if that were to happen. It's also important for the community to know that we have, given the size of our hospital and the size of our community, uh, we certainly have adequate ventilators to be able to care for people if they got in that very difficult situation of needing mechanical ventilation. We have about 41 ventilators on hand and we expect more to arrive soon. Now, just to give you a flavor of, of, um, capacity that'll give you an idea of what that means, is that we currently on, you know, just very roughly speaking, we've had about one to three patients of COVID-19 in the hospital at a given time. Right? So as you might imagine, um, the ability to have 24 licensed ICU beds, that's not to say we can't increase that, um, there are ways to be able to do that, and the opportunity to have 41 ventilators. I think we have a pretty reasonably good capacity. And perhaps even more important, we've been very carefully planning to play out "what if" scenarios. If this happened, what would we do?
Danahy: The Department of Health actually has a new dashboard on the Department of Health website and you can go to different counties and see what type of capabilities and equipment it has. In the last time I looked, it says Centre County has 12 ventilators available. So it sounds like you're saying no, that you've got more than that.
Joshi: Yeah, I don't know what to make of that dashboard. I'll be honest with you, I don't know what kind of data goes into it, and I certainly can't speak for another agency that I, you know, don't have a direct access to how the data is there. So I certainly can't speak for it. I wish we were able to learn a little bit more as to how that dashboard works.
Danahy: Hmm. Yeah, it's brand new. So, uh, maybe more of that will come to light. So there've also been reports of the federal government, Federal Emergency Management Agency, actually seizing supplies from states and hospitals. And now of course, Governor Wolf has said that the state can do that too. Is that a concern, that you're prepared, you're doing all this work, trying to get ready and that that could happen?
Joshi: Well, um, we learned about that just as you did, through media reports, and uh, we're just waiting to learn more. I'll be honest with you. We have, uh, we have just have no more information that then what you might have at this time. So I wish I could answer more.
Danahy: If you're just joining us, this is Take Note on WPSU. I'm Anne Danahy. We're talking with Dr. Nirmal Joshi, chief medical officer at Mount Nittany Health. He's been leading Mount Nittany's efforts to respond to COVID-19. We're being told to wear masks, even just the homemade kind for people who aren't medical health professionals. If I'm going to the grocery store for example, I'm being told now to wear a mask and that's a change from when all of this started. Can you shed light on why that's shifted over time?
Joshi: Uh, you know, I've said this before and I think it's important to note that it's easy to criticize people from back then who said, well, you don't need one and now we're saying you need one. It's really the, the extent of the pandemic and the extent of the seriousness that was then versus what it is now that has, uh, that has caused the change in position. And, and it's important for, for, uh, listeners to know that, uh, what happens is clearly, um, the most effective form of masks when you are in a setting that you are directly potentially exposed to the virus, most often in a healthcare setting, that the most appropriate mask to wear is a surgical or what's called a procedure mask that you're used to seeing in the hospital setting. Correct. That's the one that has been known and sort of proven to prevent the, um, the passage of the virus from the outside to the other side of the mask. And then the further higher level of protection comes from an N95 mask, which most people are now familiar with. And those are specifically recommended by the CDC in very specific procedures that involve aerosolization, meaning a large amounts of virus kind of getting out during a procedure, and so on and so forth. So those two are the forms of masks that are recommended for the health care setting, if you will. Right? Now, the reason the initial reports were not to wear, the mask, because the level of spread was just not to the extent that it is now. And when things got to the extent, I might add very unexpectedly for most parts of the world to begin with, at least, when that began to happen and the virus established itself, um, with a consistent what's called community transmission in the community, then the recommendation became for everyone to be able to put on a homemade mask. And the logic was the homemade mask clearly does not help... Uh, clearly is inferior, I should say, compared to a surgical or a procedure mask. But it is better than nothing. So in situations where you don't have direct control of who might be around you. For example, you're going to the grocery store, you are out there, um, and there might be a possibility of people who can be around you, right? And you can't avoid that. You're going out there for a essential purpose. In that setting where it's not controlled as to who's around you. You are better off wearing something rather than not wearing anything. So it's relative. There is only one study that was done on homemade masks in 2013 that demonstrated that they were clearly inferior to the procedure masks as far as the passage of the virus. Not coronavirus at the time obviously, but related sort of infectious diseases. So they recommended against its use. But knowing that it was better than nothing, they began to recommend it for public use.
Danahy: Here's another question we got. Is it safe to have food delivered or to get takeout food? Could the container carry the virus. And I think you could kind of have the same question when you go to the grocery store and you come back like, Oh, do I have to wipe everything off?
Joshi: Yeah, I often tell people something that's an interesting concept. Which is that, yes, it is absolutely okay to have food ordered for takeout or delivery. The key thing is two or three things. One is you've, you've seen this data that's been out there and consumers sort of latch onto that data, which is to say the can stay on X surface for this length of time. It can stay on cardboard for this length of time. It can stay on steel for this length of time and so on. And all that's good to know so that you can have reasonable hygiene practices of disinfecting surfaces at home and so on and so forth. That being said, what people don't realize is that ultimately the way the disease is transmitted from these surfaces is that you've touched these surfaces and you potentially can then touch your nose, right, where the virus enters from. So what I tell often tell people is basic common sense precautions make sense. So I'll give you an example. If you had a takeout pizza box, and obviously pizza inside the box, the box itself can be rapidly discarded in the trash in the garage fairly quickly. You would get the pizza in, place it on whatever plate that you have indoors. And then the key step is to be able to wash your hands and disinfect the surface that you are, um, you know, serving that on. Those are the two things that are ultimately the final common path in which the virus can actually stay there and then eventually infect you through your nose. So if you think about it, it's back to basics. Washing your hands and disinfecting surfaces. The box is now long gone. It's in your garage in the trashcan.
Danahy: Right. Okay. So I guess we got a question too about dropping off groceries for a sick neighbor. So it'd be the same type of thing. You can drop them off and then when they bring them in, they just have to follow those old fashioned precautions.
Joshi: Absolutely. That's the key. If you follow those precautions, it's absolutely okay to do.
Danahy: We got this question, too, who can get tested? There's lots of information about that floating around, not just in Centre County, in Pennsylvania, but nationally. Do you have to have a certain type of cough or fever? Do doctors have discretion now about who can get tested?
Joshi: Yeah, absolutely. Doctors have discretion and actually have always had discretion. The problem has been, it's not the exact definition of who ought to be tested. The reason those definitions came into being, um, was that there was a real shortage of tests. So when you have limited numbers of tests and if you were to theoretically overwhelmed them with asymptomatic people who didn't have symptoms, you would not have any tests for people who had real symptoms. So that was the sense people were getting early on in the epidemic. And even now, that somehow there is a little bit of a hesitation to order the test unless you had symptoms. To some extent that's still in place, mostly because the tests are a study done by a limited number of um, uh, of commercial labs. And uh, and if we were to overwhelm those labs, then the test results take increasingly longer, uh, to come back. But to your question, um, doctors certainly have discretion as to who to order. We're getting more and more humbled by the kind of symptoms the virus is causing. So what doctors are learning is that even for relatively atypical symptoms, physicians are going ahead and ordering the test. And so I would strongly urge folks to ask their physician and you will find an increasing willingness to get tested with what I would call atypical symptoms. This is also a good opportunity to remind people that the typical symptoms are cough, fever, shortness of breath, and a strong addition to those three has been the unique symptom of lack of taste and lack of smell. Which is a unique and a distinctive symptom in the absence of sinus disease and allergy and that kind of thing. But those are the four big ones. Some people have only presented with abdominal pain. And then beyond that, there have been an assortment of symptoms, but somewhat unusual without these primary symptoms, if you will.
Danahy: Sure. But you're right, that's the question that's been coming up. Well, I have some of the symptoms, but I don't necessarily meet all of the criteria. So now it sounds like there's more openness to testing. Is it useful to get people tested because then you do start to get a better handle on how much of a problem it is in different areas. It's generally considered a good idea to be tested. Um, uh, because to your point it gives you a flavor of how much is out there. Uh, what some people have said though is that uh, once the infection has a strong hold in the community, in any community, uh, at that point in time, uh, it's called, uh, what I'm sure you've heard Tony Fauci and national experts say. At that point in time it's essentially what are called mitigation efforts. You're trying to contain the pandemic. And what works for that at that point in time, testing or no testing, is social distancing, regardless. And the logic is, let's say I get tested and I'm positive, yes of course I know that I can spread the disease and therefore I will take whatever precautions I can and others will too. On the other hand, I can be asymptomatic. And up to two days before I get symptoms, I can still be transmitting the virus without any testing at that point, right. So it's best practice to social distance regardless of knowledge who is positive and who is not positive.
Danahy: Do we know yet if we can expect the coronavirus to die off in the warmer months?
Joshi: The only evidence, uh... First of all, we don't know. The only evidence we have is that, um, in lab conditions, and there was a recent paper published in the Lancet, uh, literally about three or four or five days ago. Uh, there is a paper that talks about the virus becoming, uh, in the lab now please keep that in mind, that's the big caveat. In the lab becoming inactivated at higher temperatures and higher humidity. Uh, but we have no idea if that laboratory, uh, observation can be extrapolated to real life conditions. So we just don't know at this point whether that would be the case or not.
Danahy: So we got one other question from a listener and they want to know if Mount Nittany Health will serve everyone regardless of health insurance coverage. How does that work?
Joshi: As a community based health system, um, we take care of people who need help. That's our mission. Uh, and that's how we, uh, that's how we function. So, you know, within reason and particularly in situations where, where you need acute help, you know, we will serve anyone who needs help in our community.
Danahy: And one last question. There've been some pretty grim forecasts about how many people will die across the country from this, but recently there have been some more positive reports that social distancing might actually be working, that we might be seeing that curve go down. What's your take on this? Are you hopeful?
Joshi: Yeah, I think it's very real. And I think it's... What the data is showing us, and I'm sure you've looked at the same data as I have, which is that from the national stage, what we were hearing was that even in the best case scenario, we might end up losing 100,000 lives. More recent data within a week of those statements has been that the current predictions are that that number might be down to about 60,000. Now you can argue whether one is right, another is right, or maybe that is a yet another number that may be right. Those numbers are still quite scary. But what it is telling us is that one thing is consistent through all that data is that with the passage of time and more and more people social distancing, that that in and of itself goes into the modeling. And that then demonstrates that we are able to have a lower mortality and less number of people affected. So once again, giving even more proof to the fact that yes, that is, if there is such a thing in this, you know, within this very, very large black cloud, if there is a silver lining, it's that. That, you know, we've got to just hunker down and do this and then odds are very high, if we do it consistently, odds are very high. Um, and I think it'd be important for, uh, uh, for listeners to know that there is a concept of what's called R naught, which is R0, which is how many people, a certain virus is uh, if a certain infected individual, uh, can, can actually infect how many other people. So in highly infectious diseases such as measles, the R0 for measles, for example, is about 12 to 14. Indicating that a single case of measles can affect, those people who are susceptible, about 12 to 14 of them. You know, the common flu, you know, can affect about 1.2 or whatever, something of that nature. And then those infectious diseases such as this, such as, uh, the novel coronavirus, can infect two to three people with one infected person. Making it highly, highly infectious. What has been said is that if you practice social distancing or if more and more people became immune over time, right, the virus does not have as many people to infect. And therefore the R0 value goes down and epidemics begin to generally begin to get contained at that point. So the moral of the story is really is that if you keep those basic things going, odds are very high that that R0 will keep coming down and eventually the virus has no where to go because essentially it's dying out at that point.
Danahy: Follow up to that. Are there concerns, is it realistic that if it comes down and in the summer, but then it would come back up again in a wave in the fall. That not everybody has developed that immunity and we don't, we don't have a vaccine by then.
Joshi: Yeah. And that's the part that's been, uh, very, very intensely studied being studied right now, looking at antibody responses to the virus and how those antibody responses do. Unfortunately, only time will be able to tell that. Right now there is just not enough information. And which is why the, uh, the hope is that if we are able to generate a vaccine by that point, uh, and by then if social distancing has become sort of broadly incorporated into our culture in some way, not that the same severity as now, but if it had become ingrained in our culture to practice, uh, safe hygiene measures like we've talked about that the hope is that even if it were to come back, its impact would be substantially less than what the impact has been. Because we were sort of caught, caught off guard in so many ways across the world.
Danahy: Definitely. Well, Dr. Nirmal Joshi, thank you so much for talking with us.
Joshi: Thank you. Thanks for having me.
Danahy: We've been talking with Nirmal Joshi, chief medical officer at Mount Nittany Health. To hear this and other episodes of Take Note, go to wpsu.org/take note. I'm Anne Danahy, WPSU.
