Aaron Carroll talks with Dr. Jim Wood about his research as a physician scientist at Indiana University School of Medicine and pediatric infectious disease doctor at Riley Hospital for Children. You'll learn more about COVID-19 and some of the immune syndromes we've seen in children who seem to have had COVID-19. We'll also hear about lessons learned so far through the pandemic, as well as what we may be able to expect for the next few weeks, months and even years, as treatments and vaccines for COVID-19 are developed and optimized.
The Healthcare Triage podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care.
IU School of Medicine is leading Indiana University's first grand challenge, the Precision Health Initiative, with bold goals to cure multiple myeloma, triple negative breast cancer and childhood sarcoma and prevent type 2 diabetes and Alzheimer's disease.
Dr. Aaron Carroll: Welcome back to the Healthcare Triage Podcast. Today, we're going to be talking to Dr. Jim Wood from Indiana University School of Medicine. He's a pediatric infectious disease doctor. We're going to be talking about COVID and some of the immune syndromes we've seen in children who seem to have had it. This Healthcare Triage Podcast is sponsored by Indiana University School of Medicine, whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research, and patient care. IU School of Medicine is leading Indiana University's first grand challenge to precision health initiative, with bold goals to cure multiple myeloma, triple-negative breast cancer, and childhood sarcoma, and prevent Type 2 diabetes and Alzheimer's disease. Jim, welcome.
Dr. Jim Wood: Thanks for having me.
Dr. Aaron Carroll: Why don't you start by telling us a little bit about yourself? How did you get to be what you are? What do you do?
Dr. Jim Wood: Yeah, so I got interested in pediatric infectious disease probably when I was a medical student, but never really knew what path I was going to go down. As I went through residency, I found all the cool cases happen to be kids that had infections, at least to me, so I had some mentors in residency and then decided to pursue a fellowship in infectious disease. I went to Vanderbilt University and had a really good experience there with some great mentors and just got really interested in both the clinical aspects of it as well as the research aspects of infectious disease.
Dr. Aaron Carroll: When you talk about the research aspects, what specifically are you interested in?
Dr. Jim Wood: Yeah, so my interest is in kids that have invasive bacterial infections. That's fancy words for kids that come in with bad common infections of their bones and joints, pneumonia, things like that caused by bacteria that often are treated as outpatients in clinics, but sometimes get bad enough where they have to come into the hospital and see us.
Dr. Aaron Carroll: Can you give us a little more information about that? Can you talk about when you talk about research in that area, what specifically do you want to study that others have not before?
Dr. Jim Wood: Yeah, so things that I'm interested in are understanding why certain kids get really severe disease and why other kids have a pretty mild course of disease, and so one of the things that's really interesting to me is figuring out markers and clinical signs of which kids are at risk for really bad disease, and then using those markers and signs as doctors and clinicians to help target therapies and improve the way that kids are treated.
Dr. Aaron Carroll: One of the reasons we wanted to talk to you today was because everyone in the world is focused on the current pandemic and with COVID, and although this doesn't seem to be affecting kids as much, it still is affecting kids. But before we even get into that, let's just start with, in your experience, has this been a disease that seems to be infecting kids? Because you turn on the news and some people are panicked, some people are not. What's really going on?
Dr. Jim Wood: Yeah, I think that you're right, the level of panic and the level of anxiety around this is super high. I think what we're seeing is that, in general, kids from the infection of COVID and coronavirus are really mildly affected, in general. Most kids don't seem to be getting it in big numbers, and if they do, most of them handle it pretty well, either have no symptoms at all, or mild infection. That said, we have seen a handful of kids that have come into the hospital and been pretty sick, and certainly, we've had to take care of those kids as well, but overall, big picture, kids seem to be less affected than adults do.
Dr. Aaron Carroll: When they come in and they seem to be very sick, what are they needing?
Dr. Jim Wood: With COVID, they're needing respiratory support, so they're needing oxygen, they're needing help breathing. The majority of kids are coming in just having a lot of issues with respiratory things, especially chest pain and trouble breathing.
Dr. Aaron Carroll: Are these otherwise healthy kids, or are they kids who seem to have other comorbidities?
Dr. Jim Wood: Yeah, we're seeing a little bit of both. For the most part, they're healthy kids. The ones that we've seen, in particular, are pretty healthy teenagers in general. They're anywhere from 10 to 18, 19 years of age, but really, we seen a mixed bag of kids that are pretty healthy, otherwise as well as some that have a little bit more health issues.
Dr. Aaron Carroll: Do you have any sense of whether it's that kids are not being infected as much as adults are, or is it just that most of them don't even notice, or just are handling it well?
Dr. Jim Wood: Yeah, I think that that is a really good question and a bit of a hot topic right now. I think that we don't really know exactly why some kids are getting it severe or not and why kids as opposed to adults. I mean, certainly, when we know what other respiratory infections, young, young kids, and the extremes of ages usually are most affected. That doesn't seem to be the case with this. It seems like, in general, kids don't tend to build quite as much of this big inflammatory response that we're seeing in adults.
Dr. Aaron Carroll: I think that's interesting and I'm not sure, and correct me if I'm wrong, but I'm not sure that everybody understands that it's not just getting the virus that that is dangerous, it's in many ways, the body's response can sometimes be so severe in trying to combat the virus that the immune response can actually become dangerous.
Dr. Jim Wood: Yeah, that's definitely true and that's something not necessarily unique to coronavirus, although we're really seeing it quite a bit in this where the actual infection itself, it can be severe, but more than anything, oftentimes, it's that revved up immune system and that inflammation that the body makes that really affects the rest of the body, and in particular, with this disease, it seems to really affect the lungs in people that are severely affected.
Dr. Aaron Carroll: One of the things that's been going around recently is that people are becoming more and more concerned about an immune response issue that seems be affecting children. We're seeing it in New York. Before we even get into that, people are likening this to a Kawasaki's-like syndrome. Before you do that, can you talk to us a bit about what Kawasaki syndrome is?
Dr. Jim Wood: Yeah, so Kawasaki disease, and I should have probably mentioned this earlier, is another area of interest of mine in terms of treatment of kids with Kawasaki disease. We have studies going on at IU and at Riley looking at which treatments are most effective for these kids, but in general, Kawasaki disease is something that was described first in Japan quite a while ago by Dr. Kawasaki. For lack of a better term, it's a inflammatory disease or syndrome that seems to affect kids, mostly school-age, that's triggered by something. We don't know exactly what triggers this inflammation response. There's been lots of studies and lots of hypotheses about what the actual trigger is, but no one's actually found the one trigger, if there is one. There's likely multiple. But it seems like in kids that are genetically susceptible to this syndrome, there's a trigger in the environment, which sets off a cascade of inflammation in their body.
The way that we see these kids is that they come in with prolonged fever, so a fever for at least five days. They come in with rash. Oftentimes, they have redness in their eyes, conjunctivitis. They'll have hands and feet that are swollen, cracked and swollen lips, and sometimes they'll have big lymph nodes. It's a diagnosis that we have to make just putting all the symptoms and signs together. It's this inflammatory syndrome that kids get and it really seems to affect their blood vessels a good deal. The things that we look most about and worry most about are the blood vessels around the heart, the coronary arteries, as we know that those can be severely affected in Kawasaki disease, so it's this vasculitis and just big inflammatory response that we see in Kawasaki disease.
Dr. Aaron Carroll: What causes it?
Dr. Jim Wood: Nobody knows. There's a lot of work that's been ongoing for a while looking to figure that, but it seems like most likely kids that have a genetic predisposition to this get triggered by something, and whatever that something is, and it's probably multiple somethings, they go down this pathway.
Dr. Aaron Carroll: How do we treat it?
Dr. Jim Wood: It's treated with a couple of different medicines, one called "IVIG," that is a bunch of pooled antibodies, and what that really does is tampen down the immune system. This is a very inflammatory condition. The IVIG, we think, works to decrease that inflammation and it's especially protective for those blood vessels around the heart. We also treat it with aspirin, so we don't generally give kids, especially young kids, aspirin because of risk of Reye's syndrome, but in this disease in particular, we give kids aspirin because it's been shown to help decrease their risk of having a clot in their heart and it also helps in high doses with the inflammation.
Dr. Aaron Carroll: I mean, it sounds serious. Is it?
Dr. Jim Wood: It can be serious, especially untreated. We recognized early the risk of complications, especially with heart complications is pretty low, like less than 2% when it's treated early. If it goes undiagnosed and not treated, the risk of coronary artery inflammation goes way up, and so it can be very serious, especially if not caught, but if treated, in general, it's a very treatable disease.
Dr. Aaron Carroll: What is some of the research that you're doing in Kawasaki disease, then?
Dr. Jim Wood: Yeah, so it's pretty well-established, as I mentioned, that the treatment for Kawasaki is IVIG and aspirin, and that's pretty much what every kid across the US gets when they have the diagnosis of Kawasaki disease. We know a subset of these kids, probably about 15, 20% or so, end up having symptoms after that first initial treatment. IVIG is, as it sounds like, an IV treatment that we give over about 12 hours. In about 20% of kids, they have fever that pops up after the giving the IVIG. We watch them for about two days after giving them the treatment to make sure that their inflammation is down and make sure they don't have fever. In the kids that have fever again, there's really not a good or established treatment regimen for those kids, and so what we're looking at as part of a big group of centers across the country is what is the best treatment for kids that have what we call "refractory Kawasaki," or fever after that initial treatment. We're comparing two different treatments, one, a second dose of IVIG versus a medicine called "infliximab," both of which are pretty potent at decreasing that inflammation.
Dr. Aaron Carroll: Talk to me a bit, then, about this immune syndrome we're seeing with kids with respect to COVID and why it should or should not be compared to Kawasaki disease.
Dr. Jim Wood: Yeah, so reasons that it even has come up in terms of the discussion of Kawasaki disease is just because of the remarkable overlap of symptoms in a lot of kids. What we found is that in places where Kawasaki disease, we have an idea of the level or the number of kids that get admitted to children's hospitals with Kawasaki disease. What we started to see is these big numbers and clusters of kids that were coming in with a lot of the symptoms that looked like Kawasaki disease, so high fever, rash, conjunctivitis, cracked lips, swelling of the hands and feet, all those things, and people started saying, "Wow, we're seeing these big clusters of kids with Kawasaki disease." But what the link was was that all these kids seemed to be, or most of them, anyway, had some association with COVID-19, so they either had disease or when tested for antibodies for it, looked like they had past disease for it, and so that then people started to think, "Okay, is this an inflammation syndrome that's associated with COVID?"
That's where we're at right now is seeing kids that have had this either exposure to, or passing, or in the minority of kids present infection with COVID-19, they're having this big inflammatory that has a lot of the same features as Kawasaki. There are differences. It's not exactly the same. We're seeing kids that are a bit older and the average age is somewhere between eight to 10, wherein Kawasaki, it's a lot younger. Usually, it's less than five in most of the kids. The inflammation markers we're seeing are a little bit different as well in this COVID-related inflammatory center.
Dr. Aaron Carroll: Are all the kids who've had this syndrome, they've all had COVID?
Dr. Jim Wood: Most of the ones that are tested. I think some of them, as you probably know and as a lot of folks know, the testing isn't the best.
Dr. Aaron Carroll: Right.
Dr. Jim Wood: And so, in the kids that are negative, we're still pursuing that workup and looking to see if we can retest them and see, but by and large, the vast majority are associated.
Dr. Aaron Carroll: How common is this?
Dr. Jim Wood: It's rare. It makes the news because it's a disease that's affecting kids and it's COVID-19, but in general, this is a rare condition. This is something that a lot of states are seeing, but if we think about how many kids are likely have been infected over the course of the whole population, this is a pretty rare entity.
Dr. Aaron Carroll: Why do you think, then, that it's making so much news?
Dr. Jim Wood: Well, there's probably a few different reasons, but any time we see a disease that pops up in kids, it gets everybody scared, and rightfully so. From the get-go, with COVID, we've said kids are not generally severely affected. We've said that, luckily, we're not seeing big numbers of kids admitted to the hospital, and then boom, we start seeing these kids being admitted with this syndrome, and so even though numbers are low, anytime you have a serious infection requiring kids to be in the hospital, especially in the ICU of the hospital, it's a big deal and it makes headlines...
Dr. Aaron Carroll: Are there kids in Indiana who've had this?
Dr. Jim Wood: We have seen kids across the state of Indiana that have this. Here at Riley, we see a lot of them. We were actually just talking today amongst our group about discussing with all the other hospitals across the state to get a good idea of the numbers of cases. The state department of health is collecting that data, but certainly, getting more information for all of us is also helpful.
Dr. Aaron Carroll: What's been going on in New York? It sounds like it's been much worse.
Dr. Jim Wood: Yeah, so New York just, most likely because of how severe COVID-19 was there, more kids were exposed, and so therefore, more kids have this link of having disease, and what we're seeing is, on average, it's seemingly around four weeks or so after they were initially exposed where they're getting this inflammatory syndrome, so yeah, numbers in New York are a lot higher than anywhere else in our country and that's likely because of that exposure.
Dr. Aaron Carroll: Do we have to do anything different for them or is it just wait and see?
Dr. Jim Wood: There's been a lot of talk about that, too, and we're almost on daily calls with our critical care folks, with our rheumatology folks, with lots of people that treat kids with a lot of inflammation, and we're establishing guidelines locally as well as nationally how to treat these kids. For the vast majority of these kids, we are treating them very similar to Kawasaki disease, so almost all the kids in our hospital and a lot of the hospitals across the country are getting that same IVIG medicine, a majority of them are also getting aspirin, and then depending on the situation, some of them are getting other anti-inflammation medicine, so steroids and other kinds of potent inflammatory medicines to help tampen down that response.
Dr. Aaron Carroll: Is there anything people can do to look for this or prevent it?
Dr. Jim Wood: There's nothing that we know of that can prevent it, other than obviously trying to limit exposure to COVID-19, so keeping with that social distancing, listening to all the health experts in the area about ways to prevent getting COVID-19, but in general, there's not really a good preventative way to deal with it. I think that the big thing is, for families and parents to look out for, is that anytime their child has a prolonged fever, and that's a tough thing, I realize, because a lot of things can cause you to have fever for a while, but this is a fever that's unrelenting for three, four, five, six days. That alone should make you start to want to call your doctor and at least be in communication.
But if you start pairing that with things like rash, things like redness of the eyes, one of the big things we're seeing, too, is abdominal pain, so real severe abdominal pain in kids along with these symptoms, those are some of the distinguishing features. One of those on the surface may or may not be the syndrome. When you put all those together, it's certainly something to talk to the doctor about.
Dr. Aaron Carroll: Does any of this change your thoughts about how we move forward?
Dr. Jim Wood: Yeah, that's a good question. I would say that it doesn't really change the thoughts about how we should move forward to me. Any policies that were put in place should be protecting kids, anyway, right, and so despite kids not having severe infection in general with COVID-19, we never wanted kids to get exposed because of that risk of we don't know who's going to have bad disease, so to me, this is just another piece of the puzzle to say, "Okay, something to look out for," but I don't really think that this changes how we move forward.
Dr. Aaron Carroll: Are there nationwide networks set up to watch for this? Is there any organization for that?
Dr. Jim Wood: There are multiple different study groups and organizations that are looking into this. We, again, as part of this network of centers that is looking at and studying Kawasaki disease, we just recently got information that we'll be doing a study tracking this, and so we'll be looking at the number of kids that come into each center with this syndrome, what their clinical features are, so what their symptoms are, as well as their labs, as well as we'll be looking at some of their blood work to look, to see what some of the features of this syndrome.
Dr. Aaron Carroll: How is testing going for COVID, in general, do you think?
Dr. Jim Wood: Obviously, it varies quite a bit, depending on where you are. I would say, in general, we are getting better. It is certainly not great and it's not where it probably needs to be. In terms of antibody testing as well as that nasal swab testing, things are getting better and I think that our capacity to do these better and we're figuring out which tests are good and bad or better or worse, all of that is getting better, but we're not where we need to be.
Dr. Aaron Carroll: I know you're actually conducting a study right now looking into how prevalent this is. Could you talk to us a bit about that?
Dr. Jim Wood: We were super interested as pediatricians and pediatric infectious disease physicians to figure out within our community and thinking of extrapolating this to the bigger community how many kids and families are affected by COVID-19 that have no symptoms at all, so we were able to partner with the All IN for Health network, which is a research network within Indiana and within the IU School of Medicine to recruit families in the community. What we were able to do is bring testing kits to these families so they didn't have to go to a testing center, and so throughout our area around Indianapolis, we brought testing kits, we were able to do nasal swabs on families especially focusing on kids to figure out how many kids were actually carrying COVID-19 without any symptoms.
Dr. Aaron Carroll: What are the results going to be out for that?
Dr. Jim Wood: We've wrapped up this study. We're hopeful to get the results in the next couple of weeks.
Dr. Aaron Carroll: Do you think people will be surprised that it's more common or less common than they think?
Dr. Jim Wood: I think people will likely be surprised that it's less common than they think. I think as we hear more and more, again, we hear lots and lots about it, the expectation is that most of the population has already been exposed to this and we're covered and we're good and we should just get back on with our lives, but I think that that's really unlikely to be the case. Certainly, there is a number of people that had asymptomatic infection, or had COVID-19 without ever knowing it, but I think the numbers are likely going to be a lot lower than we think they are.
Dr. Aaron Carroll: What do we do about schools in the fall? How are we going to reopen school and have it be safe?
Dr. Jim Wood: Yeah. That, again, is the million-dollar question that we all wish to know, and there's not one right way, I don't think. I mean, it's really going to be dependent on what the local prevalence is, and so partnering with the local health departments and understanding where we're at in terms of this disease in the community is going to be super essential to knowing when it's safe to go back to school, when we need to pull back a little bit. I mean, completely understand and recognize that getting kids back to school, getting them back into the routine is really important. We just need to be very careful about how we do that. I think that what that's going to mean is going back to school at times in person, if we start to see a big spike in the community, pulling back a little bit, and potentially going back to e-learning or decreasing the amount of students, and each school system is going to have to be real thoughtful how they do that, and also making sure, I think, that each school has the resources they need to be able to do that is super important.
Dr. Aaron Carroll: Do you think that's going to happen? I mean, it's funny because I totally agree. I think there's so many things we say we need to do, but I can't even imagine how schools would make some of the changes we've already just told restaurants and businesses they need to do, like have your capacity. We can't just do that in a school, or space kids out every six feet. How do you do that in a ...? Are they just going to not, or do you think that they're really going to have to make a swing at this at every single level?
Dr. Jim Wood: I think being a parent of a four and six-year-old, the idea of keeping them separated and/or masked throughout a school day is completely unrealistic. I just don't think that's going to happen. It's great on paper and a lot of things are great on paper, but practically, what are we going to do? I think that potentially in older kids in high school, maybe, but again, they're have this feeling of invincibility, so they're probably not going to listen, too, so I think it's really just going to be having to pay attention to what is going on within the community. I don't know that going half the students coming in is a realistic way to get around this. That's a really hard logistical thing to do.
Dr. Aaron Carroll: See, this is where it's like I'm fascinated because I feel like this is a solvable problem, like with enough time, money and effort, we could do this. We could send some kids in the morning, some kids in the afternoon, we could send some kids Monday, Wednesday, Friday, some kids Tuesday, Thursday. We could figure out ways to have every kid eat at their desk. The food will be made in the lunchroom, but brought to them. We could figure out ways to stagger bus systems. We could do it. It would require money, don't get me wrong, but we could, but it would require massive amounts of planning and thought, and I'm seeing no one do that yet. Do you think that's going to happen, or are we going to bury our heads in the sand, and then freak out in August, and then just throw the doors open?
Dr. Jim Wood: Exactly what you said, is a realistic thing, but that whole money issue and that whole, how much time that will take. If this was something they could do in a year from now, heck yeah, I think it could be done, but just with schools in some places supposed to restart up in a couple months, it's going to be a tough sell, I think.
Dr. Aaron Carroll: Do you think that there's going to be long-term changes to the ways we all behave because of all of this, or do you think we'll retrench, we'll someday figure this out, and we'll go back to normal?
Dr. Jim Wood: I think there will be a new normal for quite a long time. How long, who knows? I mean, this is not the first pandemic the world or our country has seen, right, and we've all forgotten, not that most of us were alive back then in those other things, but a lot of the lessons learned and a lot of the things that were done had faded away. Now, how long that took, hard to say, but for a long time, we're going to be doing things differently. We're going to be thinking about where we go, how many people are around, but there will be a sense of getting back to normal at some point. It's just that, how long? Man, I don't know.
Dr. Aaron Carroll: Where do you stand on vaccine? Optimistic or pessimistic?
Dr. Jim Wood: I am optimistic that a vaccine will be produced and available. I am not optimistic that it is going to be a cure-all for everybody, but even decreasing some of that numbers, being able to provide protection for those that are most at risk, I think, is super important, and I am optimistic that that's realistic. Now, the timeframe that's been laid out for that, probably unlikely. I mean, the quickest vaccines that were ever made, you're talking about years, not months, and so it's pretty unlikely to me that we're going to be seeing a vaccine in 2020. Now, they are going through trials and they are accelerating fast, and so that's great. But to me, the safety of these vaccines and the improving the efficacy is really super important, and I want to make sure those things are safe, and I am a very pro-vaccine person.
Dr. Aaron Carroll: Oh, yeah, of course.
Dr. Jim Wood: But making sure they're effective, and more than anything, making sure they're safe is going to be important before we roll them out.
Dr. Aaron Carroll: First of all, I agree with you. I think there's very little chance to see one in 2020, but what I think a lot of people don't grasp is there's a difference between the day that the vaccine is approved and when everyone's going to get one. I mean, realistically, how quickly can we make billions of doses of vaccines and then get them out to people?
Dr. Jim Wood: Yeah, and a lot of that will have to do with what vaccine actually makes it to market, right? There are some vaccines that are able to be ramped up pretty quickly, and again, not days, but pretty quick. There are other vaccines that take a heck of a lot longer to make and that just depends on the technology that's needed to make these vaccines, and so I think it's possible that these things can be ramped up, again, on the order of months, weeks and months, not days, but a lot of it will depend on which vaccine actually makes it the market and which technology that we're using.
Dr. Aaron Carroll: How would you prioritize who gets the vaccine first?
Dr. Jim Wood: Yeah, that's another great million-dollar question. I think we look at the people that are most severely affected with the disease, and that's unfortunately not a necessarily fair way to do things, but unfortunately, in a lot of things in medicine, when we are pressed with making tough decisions and tough choices, I think one of the important things is making sure that we are protecting the people most vulnerable, and so high-risk populations and especially those folks that are on the front lines as well as folks that are at high risk for getting severe disease probably should get the vaccine first.
Dr. Aaron Carroll: What lessons have you learned from this syndrome?
Dr. Jim Wood: Yeah, so there's been a few lessons that I've learned and I think the whole medical community has learned. One, it's that when a new disease comes out, even when we think we have a handle on what's going on, we always need to be on the lookout and looking for new things associated with it. In general, the medical community has done an impressive job of coming together to send out that signal and alert of, "Hey, we're seeing something funny here and we want everybody to know about it." Some of the folks in England were the first to report this and it started popping up in the US and everybody came together. Like I said, we've been on conference calls with folks across the country, the CDC and everything, to really delve into what's going on. That's been an amazing thing, just this open line of communication and breaking down some of these silos that traditionally the medical community has had have been really impressive.
The other thing is that, and probably most important, is that although it's a new syndrome, our doctors, and especially our ICU folks and critical care folks, they're really good at taking care of sick kids, so they know how to take care of kids with complications around their heart or with their lungs, and so I think that it's reassuring to me that although this is a new syndrome, the symptoms and signs are very familiar to folks and they know how to treat it and we know how to handle it, and so it's been a really interesting thing to see unfold as we've taken care of these kids as how we're all collaborating together and working together to share information and really treat these kids well.
Dr. Aaron Carroll: It's important work. Jim, thanks so much for joining us.
Dr. Jim Wood: Thanks for having me.
Dr. Aaron Carroll: Again, this Healthcare Triage Podcast is sponsored by Indiana University School of Medicine, whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research, and patient care.