Today I have a special episode with Lawrence Mayer MD, MS, PhD. Dr. Mayer is an epidemiologist who is devoting night and day with his team to pour over the data surrounding COVID-19.

Today’s Guest

Lawrence Mayer MD, MS, PhD

Dr. Mayer is an independent consultant and scholar that holds the position of Visiting Fellow, Program in Integrative Knowledge and Human Flourishing, Harvard University.

He has been a full-time tenured professor with recent appointments in statistics, biostatistics, epidemiology, biomedical informatics, public health and medicine (psychiatry). He held various titles including Professor at Arizona State University, (Part-time) Professor, Bloomberg School of Public Health and School of Medicine, Johns Hopkins University, and Affiliated Professor of a Mayo Clinic/ASU joint program in Biomedical Informatics, and a member of the Research Staff at Mayo Clinic.

He continues to do research and mentor young physicians and medical students while doing a limited amount of consulting in epidemiology, biostatistics, statistics, epidemiology and clinical trials. His consulting projects often focus on model development, execution and inferences. He is one of the few MD/PhD biostatistician-epidemiologists. He now resides in Dana Point, California.

Dr. Mayer is an expert on the epidemiology of the Coronaviruses including Covid 19. He is leading a group of over 1000 epidemiologists that tracks and reports on the Pandemic. He also actively supports several physician groups, including a group of 1500 Critical Care physicians, with interpreting the rapidly emerging epidemiological literature on the current pandemic.

 

Email: [email protected]
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COVID-19 Epidemiology Group

 

Key Takeaways

  • Dr. Mayer is concerned that clinicians are determining treatment based on what they hear on the media over true science.
  • Lawrence and his team have reviewed all available data on hydroxychloroquine (Plaquenil) usage in COVID-19 patients and have found no compelling evidence that it is effective. He also warns that there are indeed serious side effects of the medication.
  • Additionally, he is worried about the decreasing availability of the drug to patients with lupus and rheumatoid arthritis who need it.
  • Dr. Mayer stressed “physical isolation” to contain the virus.
  • He is concerned about the lack of leadership from the CDC.
  • Lawrence hopes this pandemic will fundamentally change healthcare in this country for the best.
  • There is no data to suggest whether or not pets can transmit the virus.
  • Preliminary data suggest no vertical transmission from mom to baby.
  • Lawrence states for those COVID positive mothers having c-sections, the infant and the mother should be separated instantly.
  • Dr Mayer feels is will be quite some time until it is safe for elderly people to go about their normal lives.

“Our biggest failure is that we didn’t do early testing. We don’t know even the simple sensitivity and specificity of the test we’re using because we aren’t testing enough people.”

 

 

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Disclaimer

All opinions expressed by the guest in this episode are solely the guest’s opinions and do not reflect the opinions of Andrew Tisser DO, Talk2MeDoc LLC, or any affiliates thereof. The guest’s opinions are based upon information he considers reliable, but Andrew Tisser DO, Talk2MeDoc LLC, nor any affiliates thereof warrant its completeness or accuracy. The guest, Andrew Tisser DO, Talk2MeDoc LLC, or any affiliates thereof are not under any obligation to update or correct any information provided in this episode. The guest’s statements and opinions are subject to change without notice.

Transcript

Andrew Tisser 2:47
Dr. Lawrence Mayer Welcome to Talk2MeDoc podcast. Thank you. So I already recorded a little bit about you for the listeners, but it just if you could give a brief bio of who you are, what you do and what you’re working on right now.

Lawrence Mayer 3:14
I’m an epidemiologist, an MD, PhD, originally trained in psychiatry, and actually trained in epidemiology as a psychiatrist back in 1970, and then went on and got a PhD in mathematics and statistics. I never formally practice my life has been devoted to epidemiological research. In particular, I’m interested in the transference of models from one science to another. So for example, I’d be interested in taking economic models and applying it to public health or medical issues.

I have had various appointments of various universities until Two years ago, when at the time I retired from Johns Hopkins and appointment at Mayo Clinic at Arizona State University, all being a professor of medicine, public health, psychiatry, Bioinformatics, statistics, biostatistics, and related related subjects. Since then, I’ve taken a fellowship at Harvard.

It’s a fellowship in arts and sciences. I’m very proud of that not in the medical school, but it’s a fellowship on human flourishing, which I study the impact of models and analysis on studies of human flourishing and obviously the COVID 19 is an issue of human flourishing at the most basic at the basic level. I moved from Annapolis, Maryland and Scottsdale, Arizona to Laguna Beach, or have a home above the ocean and spend my time watching whales and doing research now run a group, the COVID 19, clinical epidemiology discussion group, which are about 1200, epidemiologists and friends where we try to critically appraise the literature coming out to separate what is known from what is not known from a scientific perspective.

Andrew Tisser 5:30
Great. Yeah, I’d like to be watching whales right now. That sounds pretty nice. So, what I know there’s been a lot, you know, a lot in the media right now. And it’s really hard to determine what’s real and what’s false. And I know that following some of your work on the groups has been really helpful and just looking I mean, we’re all scientists at the basis right. So not not kind of honing into our media craze right now. But do you feel that the media is is Miss portraying some of what’s going on or just kind of change or changing the truth? Or what do you feel about that?

Lawrence Mayer 6:09
I think the media does as good a job as it can. We’re in a polarized environment. So some of the media is overly polarized. We need to come together at a time of urgency. But I think the media follows stories where they have to, I have no criticism of the media. I am critical of physicians, particularly frontline physicians and other health care workers, nurses, nurse practitioners, pa is who looked at the media and decide on treatment based on what they read in the media. I think that’s very dangerous.

They need to go back to original sources or come to our website to determine what is shown and what is not shown. I’m sympathetic to the fact that in this kind of situation, they shouldn’t clinicians are grabbing for anything that even my Work that can also be very dangerous principle. They forget that, above all, we should do no harm.

Andrew Tisser 7:07
Yeah, agreed. Well, my particular issue my wife’s clinical rheumatologist, and she’s very concerned about the hydroxychloroquine use and her patients not being able to get it. Have you delved into some of the papers in regards to hydroxychloroquine and COVID-19

Lawrence Mayer 7:25
Yes, we reviewed everything that we can get our hands on, on this issue, and we are concerned that people are using it, claiming it has no adverse events, which is not true. And there is no proven efficacy, which is true.

Andrew Tisser 7:45
Fair enough. And is that literature coming out of China? Or is that our own studies? Where’s that coming from?

Lawrence Mayer 7:51
Well, there are really four sources of literature one, there’s an open label study from France by one professor who was picked up By the health minister, the professor has been a supporter of HCQ for a long time. And you have to kind of discount what he says there second articles coming out of reading England in Great Britain, which provide no data whatsoever. And then there’s a claim by the Chinese that they have 20 complete clinical trials which prove that HCQ is effective against COVID-19.

But they neither released any data, nor have they given access to the data. In my world of epidemiology a clinical trial isn’t a clinical trial until somebody gives me access to the data early shows me very specific statistics on the data. So as of now, I should say there’s one more there is a paper Published in Chinese, which we had a Chinese medical student read, which does say that they have, he has tested in the small clinical trial about 35 patients HCQ and found no efficacy whatsoever.

Also in the popular means becoming a safe drug and has side effects, including a psychiatry, depression, psychosis are also other. There’s kidney failure, cardiac failure, prolonged QT interval. The side effects are rare, but they do occur. And now it gives me warning but more importantly, we’re getting reports from epidemiologist around the world that with the HCQ craze, that they can’t get the medication, excuse me, for those patients with rheumatoid arthritis. lupus where it is effective that the Americans pay more in the world market.

So it’s being bought up. And now we’ve just received indications that American physicians for the rheumatoid arthritis patients are having difficulty procuring the medication. So that’s very concerning this drugs been around, I don’t know, 50 6070 years and it was effective against a broad range of viruses some would have shown a long ago.

And I might add that any physician could do an open label study today, just take a series of patients offer them hCQ patients with COVID-19 . Some will take it some won’t. And compare the progress of those patients. We would love to have the data and see the data. It’s not a randomized controlled trial, but nobody’s publishing any data that we can find and we search every day and we search almost every hour for data on HCQ.

Andrew Tisser 11:03
Wow, that thank you again for poring over that data. I know as a as a frontline worker myself, I don’t have the time to look into the studies and just having a reliable source to summarize it and put out what’s out there is is really, it’s great. So thank you again. Do you have any idea as to as a whole how we’re doing as a country? And perhaps some models as to when this may peak?

Lawrence Mayer 11:32
No, I don’t think you can have my there are a lot of models. We discuss them on the epidemiological, the clinical epidemiological discussion group that I mentioned, but it’s much too early to be talking about a peak I think today, we reached 85,000 cases, which means we have more cases in the United States than China had.

So we are the epicenter now of the outbreak and obviously When the virus will peak will depend on how much people socially isolated I need to put a plug out. It’s critical to socially isolate actually physically isolates a better word, because it’s better to be in social contact with other people through computers through telephones, but to remain physically isolated.

Andrew Tisser 12:24
Yeah, fair enough anywhere. Everyone’s trying to get the message out there. But just going to the supermarket the other day, it didn’t seem like people are heeding the warning. But, again, we shall see. I know New York City right now is the Do you feel that New York City’s outbreak is any different than anywhere else or that they’re just testing more and just receiving more positive results?

Lawrence Mayer 12:51
Well, the biggest failure is we didn’t do early testing. So we don’t know how much of the rates are due to artifacts. We don’t know. Even the Simple sensitivity and specificity of the test we’re using, because we aren’t testing enough people. So it’s very hard to tell. There’s an exponential growth in cases, whether there’s a separate parameter for New York City or just farther along on the exponential growth. My cases.

My guess is they’re just farther along. On the exponential on the exponential growth is said to double about every three days the number of patients in California I’ve just seen reports epidemiologist say it’s down to every eight days in New York City. I think it’s even less than than three days. Part of the problem is the CDC has given us no leadership on this and past epidemic.

CDC has always been the leader. We’ve always trusted what they’ve said. And suddenly my friends at the CDC say that they need to be careful not to say anything that is against their secretary or current administration. Are they fear for their job? So they’re being amazingly, amazingly silent. And I’ve heard nothing from the director of CDC whatsoever on the outbreak.

Andrew Tisser 14:12
That’s horrible. The I know the CDC has lost a lot of credibility with us frontline workers due to their statement about wearing bandanas and scarves. It’s truly and unfortunately, a lot of administrators are taking CDC guidelines to heart due to rationing of supplies and we’re really being thrust on on a suicide mission in some of these hospitals. Luckily, my my personal facility is doing pretty darn good job but otherwise, I think across the country, we’re seeing a lot of issues with that.

Lawrence Mayer 14:50
Right, let me let me say in Arizona, which is kind of an interesting case, banner health, which I ran research for through an academic contract for years has actually ordered physicians not in the ICU, including those in the emergency department, not to wear masks. And that’s based on some CDC directive saying that masks are not needed by healthcare professionals and several banner doctors, including one who I know personally and trust, have said that they’ve been threatened that they’ll be removed from the premises.

If they show up with a mask, even their own mask that they can’t attend patient and one doctor. There’s an excellent website physician to physician for physicians to get help from other physicians reports that she was put out of her facility for wearing a mask. And then she they reported to the medical board for patient abandonment. So being forced to see patients. She’s an OB GYN she’s being forced to see patients without wearing a mask.

Andrew Tisser 16:03
I mean, I hear it from my colleagues that I trained with and know across the country, different facilities that they’re being, you know, nit fives on lock and key or there’s three available and it’s got to last you the whole shift or multiple shifts. It’s you wouldn’t expect this out of the United States of America, but unfortunately, that’s that’s where we’re at. Do you do you think this crisis will fundamentally change healthcare in this country?

Lawrence Mayer 16:37
I hope it does, because people want to blame the current president, but over several presidents, we have really downsized the Public Health Service. We’ve downsized the CDC, we’ve gotten rid of so many public health people who monitored this, these kind of events and helped from Line clinicians. It’s really sad. Not only is bad information being put out, but not much good information is being put out. So I hope there’s a change.

I’m not a political person so I can predict whether or not it will occur. Another issue that I’m concerned about is there quite a few emergency departments where a nurse practitioners are taking care by themselves is where they can practice alone of COVID-19 patients and with all due respect to nurse practitioners, I know they’re well developed in the primary care facilities but I am surprised in particular one where young person come in with COVID-19 and basically the entire course of care. He’s never seen by a physician. That’s very concerning to and hopefully something will change there because I’m worried a bit Do about nurse practitioners moving into specialties for which they’re not trained?

Andrew Tisser 18:05
Yeah, you know, I have great respect for our advanced practice providers and I rely on them quite a bit. But certainly there is a questionable issue right now of proper supervision or just having enough people to see patients. So we’ll see where that where that takes us. I kind of surveyed my listenership a little bit about what questions they had for you. So I have a couple here. First one was, Do you think there’s any efficacy to partial quarantines based on prevalence? Are we too late for that at this point? Should should we be corn should we be locking down the country?

Lawrence Mayer 18:49
Well, I think that’s an excellent question and I’m not really into logistics. There are people to talk about locking down locking down the country completely. At home or even martial law, all of those things have political ramifications. And I’m not sure what they are. It’s not helpful for people to say the country is going to be up and running by Easter, which I believe is in two weeks.

I can assure your listeners, that’s not going to be true. But whether a partial shutdown, which is I guess what we have now, with asking people voluntarily to isolate themselves, even though in California in New York, Chicago, there are stronger stay at home orders. I don’t I don’t know if that’s going to be sufficient. I suspect from the growth we’re having it will not be sufficient. But I don’t want to predict

Andrew Tisser 19:41
that’s fair. I mean, at this point, it seems as though any anyone can have it that the symptoms aren’t really as right you know, used to be if you have a fever and a cough, well, then you’re suspicious. I mean, I had a patient the other day that just presented with diarrhea and had it without anything else. So The fact that people are not are being told not to wear masks in the hallways or anywhere else. I mean, everyone in my purse, but from my perspective, everyone should be considered to have it at this point until proven otherwise.

Lawrence Mayer 20:13
I think that’s a fair statement.

Andrew Tisser 20:16
All right, what other questions we have here? There was a there was a question that there’s been conflicting reports whether or not dogs and other animals can carry the virus particles on their furred and transmitted to other people. Have you seen anything about that? Like, should we be isolating our dogs?

Lawrence Mayer 20:36
I’ve seen that it’s an open debate. That’s all there are no scientific papers. There have been some veterinarians that have weighed in saying that it’s not likely. But again, we’re data driven. I’ve seen no data on the plants. It’s an excellent question. We know very little about the details of the transmission of this virus, which is particularly concerning. There are issues about kit being carried and droplets. How long does it stay on hard surfaces? Can it be carried on the floor of a dog? And the answer is we just don’t have any data yet.

Andrew Tisser 21:12
That’s fair. But Have there been any any very interesting data that you’ve been reviewing lately that just is not widely known that you’d like to share with the healthcare community?

Lawrence Mayer 21:24
Right, probably the most important data is there now, enough cases, which is not a large number about 50, and several page rip papers written about pregnant women. And these papers indicate, again, preliminarily, that pregnant women are at no increased risk of contracting the COVID-19 virus, and that if they do contract it, they’re not at risk of having worse outcomes. This is particularly amazing Because so many of our healthcare workers, including physicians and nurses are pregnant women.

Now out of an abundance of caution, Great Britain has withdrawn all of them from the ICU and a large portion of told to work from home. Some people have suggested that abundance of caution we should do the same and someone suggested we should ban not only pregnant women, but doctors over 60 from working in the ICU. My feeling is that we should give them a choice. Pregnant women are immune compromised to some degree.

They know what the risks are of working in an ICU. they’ve accepted that risk. And if they want to continue to accept it, they should go ahead I think they should be given the the information and the choice. I’ll say also, there’s no evidence in again about 50 cases a vertical transformation. There is some there are some Moms and infants that are positive positive, but those appear to be from vaginal secretions. And all the evidence says that there is no vertical transmission.

Again, preliminary evidence, but it is evidence. The last thing which is interesting to note is that almost all of the positive women have C section deliveries. So I would say, Well, I should say we don’t know whether that was by choice, or has something to do with the virus. I’m trying to get information I can, but I would tell a pregnant mother who has her heart set on a vaginal delivery, then until we know more, we know this is an important bonding experience from mother and infant.

We would recommend that she not be exposed to the COVID-19 virus and if she is And she has a C section. The only other recommendation that comes clear is that the mother and the infant should be separated instantly, not quickly, but instantly to reduce the risk of infection of the infants newborns do particularly poorly as opposed to children with the COVID-19 virus so that would be our recommendation. ACOG the College of Obstetrics and Gynecology, as of yesterday has made no firm recommendations.

The Canadian society which is excellent, has put out guidelines from an expert panel, but have made no recommendation again. Boris Johnson, the Prime Minister of England, who himself is COVID-19 positive, has ordered all pregnant British health workers not to work with ICU patients or even in emergency departments.

Andrew Tisser 24:58
Fair enough. Yeah, that’s that’s a very interesting point. I think so many so many of our nurses and physicians are pregnant at various stages. So yeah, that’ll hopefully that can be disseminated more widely. So, anything else you want? You want us to know?

Lawrence Mayer 25:18
Sorry? No, go ahead. There are there is a paper that came out this morning when I say came out. Now we’re looking at pre printed post on acute and from Lancet. That indicates that CT is a very limited value in diagnosing COVID-19 is from a very respected group at the University of California at San Francisco. They’re not only excellent radiologists, but they’re also excellent analysts. And they say that looking at what we call Bayesian decision analysis, unless your prior suspicion is high, because of other tests that they argue that there is no diagnostic power to the use of CT.

The other question we’re asked often and repeatedly is what about the sensitivity and specificity of the tests? We really don’t know what they are. First of all, there’s several competing tests. We’ve not seen any data except data put out by the manufacturers. And I want to warn people that I don’t believe the manufacturers are cheating. But when they apply these tests, in order to get sensitive specificity, there are under ideal conditions.

The samples are collected by very careful professional people. The analysis is perfect, and often we find their estimates of sensitivity and specificity are much higher than what we will get in the field. The last common mistake is there is considerable concern about isolation, the effect on mental health and I encourage all healthcare providers to monitor their own mental health and mental health and seek help. Many of them are isolating from their families. They’re certainly isolating in large numbers from their parents. And this, of course, takes a huge toll on people mentally. So I encourage everyone to try to get help if they think they need it.

Andrew Tisser 27:21
Thank you. The last question I had that just came in was, so presumably once we start, you know, who knows when from now but once we start relaxing isolation, there’s still going to be people walking around with COVID-19 . And in regards to our elderly, people, our parents and grandparents what you know, do you do foresee there will be a time that it is safe for them to go out and out and about like they always have, or where the, you know, there there may we don’t really know but presumably people will develop some of these to it but could be asymptomatic carriers at that point. I know there’s most definitely no data on that. But But what is your opinion?

Lawrence Mayer 28:08
Well, you brought up an interesting question. We don’t have any data on whether there is reinfection of there are people magazine type publications that said there are cases of reinfection we don’t know whether infection provides immunity. So that’s number one. Number two truly elderly patients people in their 80s and 90s are doing extremely poorly, as reported by the ICU, particularly just pointed out to john Murray, the discoverer of ARDS died yesterday at nine years old from ARDS associated with the COVID-19 virus and he’s of that generation.

You know, his parents fought world War One, he fought World War Two. He’s a generation of parents to the baby boomer and grandparents to Generation X. And I would be cautious before I would let any exposure for elderly people, particularly this the very elderly, I don’t know what the cutoff would be and also people in skilled nursing facility in assisted living. We get reports from epidemiologists and these facilities that spread very rapidly in these close communities.

So that’s a that’s a concern. I know grandparents really want to see their grandchildren and great grandchildren. But that’s a good question. When will it be safe? I don’t have any prediction except it’ll be there’ll be quite a while because after this peeks Of course, if it’s a usual epidemic, there will still be outbreaks of it in various areas, various regions and we don’t know when people will be saved.

Andrew Tisser 30:01
Fair enough. Definitely good warnings for everyone. Dr. Mayer, I really want to thank you again for coming on the show and taking the time and for everything you’re doing.

Lawrence Mayer 30:14
I get a lot of get a lot of mail directly to me from rural physicians, saying that they don’t have enough case scenario to take this seriously that people are still congregating that they’re still having problems. And they’re having Friday night football games and things like that. That’s the nature of exponential growth. It starts very slowly, and then it goes up very quickly.

So I encourage them to monitor our website, or I should say our Facebook group COVID-19 , clinical epidemiology discussion group or get information somewhere, but there are people in these communities, telling people that they don’t have to worry about And that’s simply not true, particularly if their health care facilities are limited. a limiting factor here in terms of turning number death is obviously the number of ventilators and a number of ICU beds.

Many hospitals have turned whole floors into ICU beds. Their short two things are short medical staff. So I’m concerned about the pregnant healthcare workers going home and their short equipment, particularly masks and ventilators which are going to be critical.

Andrew Tisser 31:34
Yeah, people really need to take this seriously. That is that is the absolute point. If people wanted to find out more about you or get in contact with you, is there a preferred way?

Lawrence Mayer 31:48
Sure, the best email is [email protected] I’ll spell that phonetically. It’s Lincoln, Sam, Mary, Mary David. Paul Henry [email protected] or I’m in Facebook under under my name, and I answer as many, as many questions as I as I can. And I really want to thank you for inviting me on this this show. This is the only interview I’ve given and the fact that you have a significant outreach to healthcare workers, really is the deciding factor for me to come on board. And of course, the fact that you do an excellent job.

Andrew Tisser 32:30
Oh, thank you. Thank you so much. But thanks for all your work and stay safe out there.

Lawrence Mayer 32:37
Thank you very much. Again, bye bye.

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