April 06, 2020 COVID-19 and diabetes: what do we know?

Dr. Alice Cheng [00:00:06] So hello, everyone. It's noon. So I think we should get started. I'd like to thank all of you for attending this special edition of Diabetes Canada Webinars speaking about COVID-19 and diabetes. My name is Dr. Alice Cheng. I am an endocrinologist from Mississauga. And it's my pleasure today to co-present this topic with a dear friend and colleague, Dr. Peter Lin, who is a family doctor in the Toronto area. Although I think his face and his voice is quite familiar to all of you already in that he has been a medical correspondent for CBC for many years. And if I may say so, has been probably one of the most prominent voices of reason from our medical community during this COVID-19 pandemic and crisis. So thank you, Peter, for agreeing to be volun-told to be part of this webinar and we certainly appreciate your time. You're welcome. So a piece of some housekeeping things that I do want to share with the group before we get started.

[00:01:16] So first of all, this session is being recorded and and as well, we are going to have a question and answer section towards the end of the one hour slot that we have. For any of you who are having any technical issues related to logging in our very capable technical person, Lindsay is available within the chat room. So therefore, if you have any technical issues, please type a message to her and she will see it and then respond accordingly. You will also note that all of you have been muted and your videos have been turned off for a couple of reasons. One is to avoid any embarrassing moments should any of you guys choose to go to the bathroom. And the other thing is to ensure that we don't have any noise issues as we go through the webinar. I'm afraid to ask Peter if he's actually wearing pants right now during this webinar, but he promises not to stand up during the webinar at all. As I mentioned, there will be a question and answer, period. So please utilize the chat box and type in your questions. We'll make sure we spend enough time at the end to try to address them.

[00:02:23] As some of you may know, we are also doing this webinar a second time live three hours from now so you can again attend again, I guess if you really wanted to at that point. Another opportunity perhaps to get your questions answered. I do want to thank Diabetes Canada and especially Joanne Lewis and Grace Leeder, who were amazing in terms of putting this together very last minute. I mean, this idea came up late, well, towards... actually about a week ago, and we've been able to pull this together. So I want to thank them very much for it. And with that in mind, I do want to say anything you're going to hear today is really the thoughts and opinions of myself and Peter and of course, backed up from the literature wherever we can and do not necessarily represent the official views of Diabetes Canada itself. So with that introduction, I guess we might as well get started. Peter, do you want to share your screen? For those of you, depending on what your platform you're using to watch this if our heads are in the way, even though I actually washed my hair and did makeup for the first time in many days today, you could get rid of our heads if you wanted or you could exit from full screen if you're using the app. And then that way our heads will be above the slide and won't actually on the slide itself. But otherwise, hopefully you can see us and the slides at the same time. So again, welcome to the session that we have here. And I think our first slide is just a disclosure slide for myself and Peter in terms of companies that we have worked with, but none of which would really be relevant to the topic that we're talking about today.

[00:04:01] So, Peter, let me start with you. So can you share with the group briefly what is COVID-19, in case anyone doesn't know yet? And of course, how does it spread and what we can do about it?

Dr. Peter Lin [00:04:11] Thanks very much, Alison. Thanks for setting this up with Diabetes Canada. So welcome, everybody, and it's good for you guys. I want to thank you guys for sharing your time with us today. So bottom line with COVID-19, as you know, it said it's a corona virus and those little spikes that you see in the red spots, those are the ones that are the keys that can get into our cell. So the normal Corona virus maybe has the key that can get into your nose cells. So therefore, it will go in there and replicate and therefore you get a mild, cold, runny nose kind of symptoms. Unfortunately, the COVID-19 has the key to access your lung cells. So very much like the SARS and the MURS virus that we heard from before, they can access your lung cells and therefore replicate within the lung cells. And unfortunately, as it replicates within the lung cells, it destroys the lung cells. And so therefore, it's a bit of a race. And that's why I have the word race up there. So the virus is killing off your lung cells and your army, your immune system, is desperately trying to make an antibody against it. And it's just how fast you make it will determine whether you have a good outcome or not. So in the elderly, for example, perhaps the immune system is not so good and so they can't make the antibodies fast enough. And so therefore, they succumb to the disease in some of the young people. We've now been seeing them getting very sick because it is a new virus. So therefore, your immune system has never seen it before. And so it might take some time for it to start manufacturing the antibody. So therefore, if you don't figure it out fast enough, then you are again going to lose the race and the virus rents and that's why, you know, people that think that I'm young and healthy, they can still get into very much trouble as well. And also the dose. So there is some thought that if we give you a higher dose of virus, then more of them we'll be replicating at the same time.

[00:05:51] And therefore, they will win the race. If there's millions and millions of copies of those viruses entering into you. And that's why the health care professionals seem to be hit the hardest, because perhaps they're getting a much higher dose of it as opposed to other people that might be getting it secondhand at home, for example, or from travel. In terms of people saying this is just like the bad flu. So they put this together. This is the flu in terms of fatalities. So if you look at all ages, it's about point one percent and in the brackets are people that go into a health care facility. So if you're sick enough to go and see a doctor the mortality rates is a little higher at 2.2 percent. You'll see here the seniors are around point eight to one point four percent if you go into a medical facility. So somewhere around 1 percent or so in terms of the elderly. If you look at COVID-19, on the other hand, overall it's 2.3 percent. So you could see it's orders of magnitude higher, at least ten fold higher or more. And if you look at the people over 60 here, you can see that they're at 6 percent, not 1 percent. And if you look at people that are over the age of 80, they're more like 15 percent in terms of mortality. So this is not a flu. This is much worse. And you can see the young people, if you look in this age category of point zero zero four percent. And here is point 1 percent. So it's about 100 fold higher, even for the younger individuals as well. So that's why this is not a common flu. And that's why we have to take it very seriously.

[00:07:13] In terms of symptomatology, is there anything that can identify patients so that we can say they are COVID-19. And you could see here from the 55,000 patients they looked at in China, you could see fever was quite common, but that's common in everything, including flu and colds, you could see coughing about two thirds of the people. Fatigue is sort of nonspecific as well. And you could see that sputum production in about a third of the people. Shortness of breath is interesting. So about 20 percent of the people and as you remember, about 20 percent of the people get into trouble. So perhaps shortness of breath might be a very interesting one because that usually happens early, whereas with influenza and colds, it's very rare that people will complain about breathing difficulties. So this is a sign that the virus has made it into your lungs. We used to use diarrhea as being, if you have diarrhea or GI symptoms that can't be the COVID-19. We now realize that in the United States there are more people with GI symptoms and the receptor for the cells to get ins for the virus to get in exists on the GI tract as well. And in fact, the paper was just published that if you have GI symptoms, you're actually going to have a much worse outcome. So therefore we can't choose to use GI symptomatology to separate people out. Flu, generally speaking, hits like a Mack truck. So within a couple hours you're sort of collapsed. No shortness of breath, but you feel terrible and your body gets pulled apart. Common cold tends to take two or three days. It's very slow. And again, there's usually no shortness of breath. This one will be slow in the beginning, but then you get this fever and then shortness of breath seems to come quickly in the people that are going to get into trouble. In the people that are not going to get into trouble, it will look very much like a common cold. So very difficult to separate out whether it's COVID or not COVID.

[00:08:55] When will they get symptoms? Around day 5, 50 percent of the people will have symptoms by day 11 and a half, ninety seven percent of the people will have symptoms. So somewhere in that timeframe. And that's why we think that 14 days is good enough for quarantining. However, if you're a statistician, you'll realize that outside of 14 days, if you look at ten thousand people, there'll be 100 people that will have symptoms over 14 days. But the thing is, we can't keep people locked up forever so that's why 14 days became a good enough number to catch 99.5% of everybody. COVID-19, as you know, is just a USB stick. So basically, it's a virus particle. It cannot move. It has no wings, no feet. It needs us to move it and it has no equipment to make copies of itself. So it actually has to borrow our equipment. And the reason why I like putting this slide up is to reinforce how weak this virus really is. And it actually depends on humans, the host, to actually move it around and also to make photocopies of itself. So therefore, if we protect our personal borders, in other words, don't let the virus get into our lungs, then we can avoid this particular virus from getting a hold of us. In terms of how long does it last on surfaces. So this is one paper looking at copper. So you could see the viral count drops off quite, quite quickly. So less than maybe fifteen hours or so. If you look at stainless steel, it'll actually last a little bit longer on stainless steel. So in the hospital, most of the tables are stainless steel and that's why you see them disinfecting them every four hours or so. Cardboard around two days somewhere in that ballpark. If you're getting a package from Amazon or something like that, cardboard box potentially can carry some viruses on there. So people are saying if you leave a cardboard box, leave it somewhere else in about two days, the virus will die on its own. Plastic bags and things like that, you can actually have it for about three days or so. So therefore, from grocery shopping, all the plastic bags should be put into a corner, not near a vent where you may be blowing air across it to make sure that they will die over the next three or four days. And then aerosolization. So we now realize that procedures that do this have dentists that are digging in your mouth, are spraying up this virus. And the virus can sort of survive in the air. It doesn't travel very far, but it can survive in the air. And so that's why procedures that have aerosolization required N-95 masks for them to do. Having said that, we'll talk a little bit about this. But people breathing in and out, there may be some viral counts there as well. So therefore close contact is to be avoided as well.

Dr. Alice Cheng [00:11:23] So in terms of how things look now, I know that we had first talked about this about a week ago and this part has been updated multiple times. And you've probably updated this just this morning. So, Peter, where are we at now?

Dr. Peter Lin [00:11:35] Yeah. So if we were to look at these graphs, I'm just going to orientate you in this particular graph. This is the number of people that are getting infection and this is over the number of days. So they started off by whichever country crossed 100 will make it to this graph. And you can see here that this line here represents doubling every two days. And this line here represents doubling every 10 days.

[00:11:56] This is China's curve. So you could see that in the beginning they were doubling more than every two days. And then eventually by about day 30 or so, they were able to squish it down to sort of like maybe 50, 60 cases per day coming down from about four or five thousand. So this curve tells us that it is possible to actually contain the virus. And that's what the W.H.O. was hoping for, is that all countries would follow this particular curve. Unfortunately, if you look at Spain, if you look at Italy, Iran, all of them took off in the same fashion. And unfortunately, we haven't been able to contain it in many countries. However, South Korea gave us hope because South Korea took off exactly like China. But you could see that they curved it as well. So they had massive testing. And their area was specific, one area of the north where it was related to this church. And so, therefore, they could contain all the people there moving in and out of the area. People were highly regulated and they had apps that made sure that you stayed inside your home and you didn't leave your home with the G.P.S. tracking on your phone. In Canada, what you can see here is this rise. And you could see around the time that March break, people started to come in. People were traveling back. We were doing fine when it was from people coming sporadically by airplanes. We were able to pick those people off. However, what's happened now is that we had people crossing across from the United States. And at that time, United States had a defective test. So the CDC test initially could not give them an answer. They would keep giving them an indeterminate result. And so therefore, they didn't know who had COVID. And also the tests were only in states where there were international flights coming in. So if I flew into San Francisco and then I connected to Milwaukee, there was no test in Milwaukee. So therefore, because they didn't test we didn't know the numbers that were happening in the US. So when all the Canadians were coming back by car, they didn't realize that they were carrying the virus over. And so that's why our numbers spiked up rather dramatically during that March break period. Here is the most recent. So this is the United States total number of cases. As you know, as of this morning, like about three hours ago, it was eighty five thousand people and they've now taken over China.

[00:13:59] So China was sitting at eighty one thousand and was steady. And here we are in Canada at around four thousand forty three. And if you look at 10 percent of the population, we should be at eight thousand if we were doing the same things like the United States. So perhaps our public health measures have cut away half of them. But certainly we're still dealing with the number of patients that are coming back in from travel and the repatriation flights as well. So you have patients coming back in on the repatriation flights, they will all lie and say, I feel perfectly fine getting on the plane. So tell them all to mask if they can when they're on that plane because everybody might have disease and still not admit to it. This slide is old, but I just wanted to show you that this is actually single cases here, not percentages. So this was Alberta. And you could see that the number of people that were coming in, it was basically travel related. And the next curve is the sad part, these were the close contacts. So these people infected these people. And that's why there's just a shift of a couple of days. So basically, we told the travelers to isolate while they had the infection. They were told to isolate, but they isolated within their family. And they just kept hanging out with the family and therefore they infected their family. And you could see that we're basically matching the curve in terms of close contacts, which means that our public health message didn't get out properly as to how to self isolate. And community spread was very low. However, when you have all these people moving around. Therefore, communities spread. Now in Canada, as of yesterday, was 53 percent. So half of our cases were not travel related and were not close contacts. So that's why they said we have to close restaurants, we have to close bars, so we don't want people bumping into each other, basically.

Dr. Alice Cheng [00:15:35] So what can we do as individuals? And then we'll move on to the diabetes link here.

Dr. Peter Lin [00:15:40] Yeah, so in terms of individuals, we always told people it was the coughing, sneezing people. Right. Because that's what World Health told us. But we now realize that the one or two days before you get symptoms of coughing or or sneezing, basically you're making millions of copies of the virus. And as you breathe in and out, there is viral particles inside your breath. So therefore, if I'm very close to you, I might be able to breathe that same airspace and therefore breathe in the virus. Or if I'm giving you a hug, I could do the same thing. Now, the virus doesn't last very long in the air, it'll die. However, if I'm in close contact, that becomes an issue. And so that's why when we started seeing this kind of stuff happening, that's when the sort of the draconian measures came in. You know, we're going to find you. We might give you jail time and everything else because people were still gathering. And the belief is that they thought that only sick people well, sick people won't come to the beach, right? Because only healthy people will go to the beach. So therefore, I'm only surrounded by healthy people. And number two is I can identify a sick person because they're coughing and sneezing either stay away from them. So I think that's why these people believe that they were actually doing something very safe. Unfortunately, those people don't have to look sick, they don't have any coughing or sneezing, and yet they can still transmit virus. So that's why we started hearing stories about people saying, I just went to a family party for six people. Nobody was sick. Nobody was coughing. And I've got COVID-19. And so that's when we started discovering for the first two days before you get symptomatology, the viral load is actually quite high inside your airways and nasal passages. So therefore you can pass the virus. So that's why it's quite simple - no crowds and you have to stay six feet away that way you're not breathing in that same airspace and no hands to your face because that's the other way that the virus can sneak up into your face area and then you can breathe it in. And then we told people to isolate at home, but properly, except people didn't understand what properly means.

[00:17:28] So this one I just put this slide up here as Friends. OK, so we shouldn't be doing this like sharing everything. Now, this is just my thoughts. Again, this is Peter Lin's thoughts. So this is not an official position of public health or anything like that. I can say a lot of crazy things, whereas they cannot. And so therefore, separate room. And then somebody asked me. But we live in an apartment and there's four of us. How do we do that? And we only have one bedroom. And so therefore, a string. So we used to tie up a string and then put a bed sheet over it. So this half would be people that may have virus. This half would be the clean side. And so therefore, you separate the two sides. So when things come from one area to the other, you have to take precautions in terms of clothing and stuff like that that may be coming from that area. And we want to maintain that six feet distance, including mealtime. Right, so we're not sitting next to each other during meal time. We're going to separate those times as well. And the clothing that comes out of there may have virus. So therefore, you glove and then you wash them in in a normal washing machine and dryer situation with high heat. And that will kill the virus. And then watch out for jackets. You know how when you come in from outside, you take your jacket, you throw it onto the sofa. The jacket could be contaminated. And therefore, now you have virus on the sofa or on the bed. Bags are bad and backpacks, the bottom of the backpack can pick up a lot of viruses off of floor. So therefore, be careful of where you put those things. So nothing on a surface that your hands but then end up accidentally touching and no sharing of anything. So no food, no toothpaste, no towels or anything like that should be shared in that fashion. Now, who should get it? I mean, all the people with symptoms, of course, we do this, too. And the travelers, they have to do this. Now, the next set of list of people. It's just from me, my opinion, so my opinion is that maybe health care workers, because they don't want to bring virus back to their family. Maybe we started separating them out. In Hong Kong and China and things like that, they actually have a separate dormitory for the people that are working in the hospital. That way, they don't bring it back to their family because they realize that 70 percent of the cases in China were spread amongst the family members. It wasn't new contact because they locked down 16 cities and nobody was bumping into strangers. It's all within their own family unit. Working still - so these are the people that are still going out to work. So there's a potential that they can bring back virus as well. So therefore, you have to tell them about clothing and all that kind of stuff. Don't throw your jackets, those kinds of things. And the person that's the designated shopper that's going in and out. So basically anybody that's going outside that comes back. Let's just take some precautions around there. Then we won't be like Italy. Italy has been in a lockdown now for the last 20 days or so and their numbers keep going up by six thousand every day. So where are they getting it from? It's within the family unit. So therefore, separating people within the family, cocooning them might be the way that we get rid of some of these cases as well. Now, Alice, I know that this is all about diabetes and we have even talked one cent about diabetes. So can you help us sort of bridge this gap between the Corona virus business and diabetes?

Dr. Alice Cheng [00:20:16] So I think when we think about the relationship with diabetes, I've been getting a lot of questions, as I'm sure you have, and we need to think about two concepts. The question of whether people with diabetes are more likely to become infected and then if one were to be infected, if you have diabetes, what are the outcomes like? So if we take it, try to answer that first question. We can look at some of the data that emerged from China. The CDC within China, looked, publish some data on forty five thousand confirmed COVID cases. And you can see that the prevalence of diabetes in the confirmed cases was around 5.3 percent. And we think about the prevalence of diabetes in China, this number would probably be, in fact, be a little bit lower or similar to the general prevalence. So this would suggest to me that people with diabetes are not more likely to get COVID-19. But the issue around complications is a little bit different. So if we take a look at the next slide, you'll see that from a mortality perspective, the situation is different. This is looking at the case fatality rate again from the Chinese CDC based on co-morbidity and those with diabetes, the case fatality rate is 7.3 percent, whereas in those who have no co-morbidity, it's 0.9 Percent. Now, diabetes is not the highest you can see cardiovascular disease is 10.5 percent. So therefore, our patients living with diabetes, they're not more likely to get COVID. However, if they have COVID the potential for more severe disease is certainly higher amongst those living with diabetes.

Dr. Peter Lin [00:21:55] Well, can somebody living with diabetes, how should they be preparing? Because there's a lot of scary stuff out there. So what should they be doing?

Dr. Alice Cheng [00:22:02] So one resource that I'm certainly telling them to go to is the Diabetes Canada site that does look at COVID-19 and diabetes and is being updated on a regular basis. In addition, on that web site, there is an infographic, if you will, on the next slide that shows how they could prepare. So things, common sense things like having all their medical information in one place, taking a look at their medications and making sure that they have enough for at least a couple weeks, if not longer. But we don't want people stockpiling. And I'm going to come back to that concept later. And I think very importantly on the right hand side, things around making sure they have hypoglycemia treatment at home and having a glucagon kit available if necessary. And very importantly, things around ketone strips, which I'm going to talk a bit more about later as well.

[00:22:54] The question about glycemic control, right? Is glycemic control an important piece of how they should prepare? And I think the jury is out on that. We do not know for sure. We do not have glycemic control data on these patients who have had COVID. But what we can extrapolate from is what we do know about glycemic control and overall infections. We do know that people whose glycemic control, whose A1C is higher are more likely to get certainly bacterial infections. And we do know in hospital that when patients come in with higher blood sugars, their outcomes are not as good. Now, whether or not that's a direct association remains a question. We do know that overall bacterial infection rates are also higher when one has higher blood sugars. So therefore, the answer to this specific to COVID is not clear. But in my mind, again, this is my interpretation, this is an opportunity to encourage our patients to do what they can, to control what they can, which is the glycemic component in case that is a predictor of who does worse with the infection. So therefore, I think this is an opportunity to discuss glycemic control. But we do not know for sure if outcomes are worse. But if it's similar to pneumonia, regular pneumonia or regular flu, then it would seem like it is.

Dr. Peter Lin [00:24:16] Well, what about people living with diabetes that get sick? So what are the steps that we have to pay attention to?

Dr. Alice Cheng [00:24:22] So if somebody living with diabetes were to get sick, then we do need to very much share the whole sick day management concept. And I think that's a concept that we've talked about for a long, long time already. This is, again, an opportunity to reeducate our patients about sick day management. This is a handout that's available again on the Diabetes Canada website, which looks at sick day management for those with type 1 or type 2 diabetes. Sort of more general advice around remaining hydrated, having sources of glucose, watching out for hypoglycemia and of course, the famous SAD MANS that I've shown here on the bottom right of medication that should be temporarily held if one is no longer able to eat and drink adequately. But I think the group that we're probably most concerned about are those living with Type 1 diabetes. And on here you can see the sick day management handout. And I'm just showing an example and I realize there are many centers that are represented on this call and you probably all have your own but I'm just showing the one that's used at St. Mike's, for example, which is specific for those living with Type 1. And I think reiterating this is important that if they get sick, then they should check their sugars more often. Not stopping their insulin is probably the most important message we can give people. Telling them they may actually need more insulin even though they're not eating and drinking, which is counterintuitive, but we need to preempt and tell them that. And of course, remaining hydrated. And one of the reasons I really want to stress this, and I'll show you the ketone thing in a second, is because just today I got a message from the hospital and things keep changing quite rapidly. But diabetic ketoacidosis admissions are now going to be admitted under endocrinology and not under general medicine because general medicine needs to be freed up to take care of COVID patients.

[00:26:13] Our job in the outpatient space, even if you do not do inpatient work, is keep patients out of the hospital. And this is one group that I think we have tremendous impact on in terms of keeping people out of hospital, because then the hospital can do what the hospital needs to do right now. So please, please, please, I think sharing this message is absolutely critical.

[00:26:37] Here, this is again from St. Mike's, what we recommend about ketone testing. Each place is going to have it a little different, but the concepts remain the same. If their blood sugars are elevated, they ought to do blood ketone testing. And remember, if they are taking an SGLT2 inhibitor (off label) in type 1 diabetes, then even if the blood sugar is not that high, but they just feel crappy, then ketone testing does in fact make sense. And then here on the next one you can see that the the recommendations, again from St. Mike's, each place will be a little different, but the concepts remain the same. The blood ketone numbers we're interested in less than 0.6 - you're fine. Between 0.6 and 1.5, then that's when action is required. And between 1.5 and 3, even more action is required and certainly greater than 3, they need to be going to the hospital or I think this is a part we can very strongly play is be available to our patients. Certainly even above 1.5, there's recommendations to at least contact a health care provider so we can try to walk them through what they need to do to again minimize the need to go to the emergency department. So this is an example from St. Mike's. But on the next slide, I have an example from Mt. Sinai as to what they recommend. And again, you get to see those numbers, 0.6, 1.5. And then the very important message about those on an SGLT2 inhibitor (off label), if they get sick, they ought to be holding that medication. But in them in particular, even if their blood sugars are okay, but their ketones are positive in these numbers, then they need to eat and take insulin. Because remember, insulin is the tool to prevent DKA from happening. So question to you then, Peter, and this comes up, right? So patients with diabetes or should be on RAAS blockers, ACE inhibitor, ARB? Questions about NSAIDS, aspirin. What's the deal?

Dr. Peter Lin [00:28:36] Yeah, so there were news articles that came out talking about maybe we should be stopping all RAAS inhibitors on people. So where did that data come from? So here's the thinking process. So remember, we said that the COVID virus comes in here. And basically, if I were to zoom in right here, this is the receptor, the doorway in which it gets into. And that's known as the ACE-2. OK, so this is the same ACE that you're thinking about, ACE inhibitors and things like that. This is the thing that we're trying to block in an ace inhibition. But this is the receptor that's sitting on your lung cell and coming in. So therefore, people quickly said, OK, so ACE inhibitors and ARB actually increases ACE-2. And so, therefore, does that mean we have more doorways for these viruses to come in? And if that's the case, then that's a bad thing. So therefore, little articles came out and said we should stop all ACE inhibitors and ARBs because then we can protect them from this entry point. So therefore, it was a article. It wasn't even an article. It was a correspondence, it was a letter to the editor. And basically they went all the way to recommending we should switch everybody to calcium channel blockers on this theoretical consideration. So therefore, all the cardiology divisions around the world started to say, is this real or not real? And are there other things that we should be considering? So this is one aspect. What about other aspects? Here is that ACE-2 that's sitting in the cell in your lung and here is the virus attaching. And what people have now pointed out, there's other research that says there's a soluble ACE-2.

[00:30:05] So this stuff is floating around in your serum, in your blood, and it could actually act as a decoy. So therefore, this thing can now bind the virus and therefore the virus is not available to go and bind onto the lung cells. So therefore, they said, look, if I give you an ACE inhibitor in ARB and I increase the soluble version of the ACE-2, that actually acts as a good decoy. So therefore, ACE inhibitors and ARBs are a good thing and may be protective against these infections. And there are animal models that they've looked at where if they give an ACE or an ARB, they can protect some of the viruses from attaching. So that's why they're getting this data. The other thing to remember is this angiotensin. Remember ACEs and ARBs play with the angiotensin molecule. And it turns out we always said angiotensin-2 is a bad guy. He's not a bad guy. He's a repair molecule. So therefore, when it operates on these receptors, it's kicking in a repair process. In other words, it's causing scarring. And so therefore, that repair process is very important. If you have a hole in the wall, you need to call the repair guy to come and patch up the hole in the wall. So angiotensin-2 is a hormone that says if there's damage, I'm going to come and repair it. And in our body, repair usually means fibrosis scarring, just like when you cut your hand, you get a scar there afterwards. So therefore, angiotensin-2 is related to lung fibrosis or scarring in a normal person. Now who's stopping this is the ACE-2, so the ACE-2, as long as it's healthy sitting on the lung cell, then basically ACE-2 will break down angiotensin-2 into nice chemicals that are healthy for the lung. So therefore, as long as the ACE-2 is happy and there, then the angiotensin-2 gets broken down so then you don't have lung fibrosis. So the repair man just keeps going and doesn't stop to put in any of the repairs. Now the problem is if you have lung damage and you get rid of ACE-2, then basically this one disappears. So therefore angiotensin is available and therefore you get scarring and repair. Unfortunately, the COVID-19 attaches to the ace two and pulls it into the cell. So effectively, the ACE-2 is now gone from the surface of that cell. And so therefore you have less ACE-2 on the surface of the lung cells, which now means there's nobody to break down the angiotensin-2, which then leads to fibrosis in the lung. And so that's why people that are doing research during SARS days, because SARS also goes through the ACE-2 system. And what they notice is that in animal models, if you give an ACE inhibitor or ARB, you increase the ACE-2 that's floating around. Therefore, you block off this guy and you have less lung fibrosis. And so in animal models, if you infect them with the SARS virus, for example, which pretty much mimics our COVID-19, you have much less scarring if you'll give an ACE inhibitor or an ARB as treatment. So therefore, there might be some benefits of this as well. And so therefore, when you look at the totality, there are some people that say, well, you might increase the number of doors that the virus can come in, but then there's all these other benefits of taking these agents. So let me give you two scenarios. Your patients has COVID-19 already, which means the virus has already entered the cell. So therefore, what should I do with the ACE or R. Well, the virus is already in the cells. So I don't care if you have extra doors or not. It's there. So therefore, you stay on the ACE and ARB. Perhaps we can get less lung fibrosis and damage and definitely will still protect your heart and your kidneys. Let's say you don't have COVID-19 yet. Well, I still want you to stay on your ACE and R because it's going to protect you from cardiovascular and renal problems. And so therefore, in both situations we would not be taking you off the ACE or ARB. And so that's why the CCS guidelines came out very quickly. And they said if you are a person taking an ACE inhibitor or an ARB, you should stay on taking an ACE or ARB. If you have confirmed COVID infection, you should still stay on the ACE or ARB. And in terms of aspirin, there was some concern, should you still continue to take aspirin? The answer is you should stay taking aspirin if you don't have COVID-19 if you have an original indication that you should be using aspirin and if you have COVID-19, you should still stay on the aspirin as well to protect the cardiovascular system. The NSAID story is a little complicated. There was some original data that came from France that says NSAID patients do much worse and so therefore the recommendation was stop all NSAIDs, don't use NSAIDs, however, once they looked at the data, they said it wasn't very convincing. And so therefore, the World Health Organization backed up and says you can still use NSAID, but we would prefer acetaminophen first to treat any fever or pain and then if you have to, you can use an NSAID. And so therefore, right now the recommendation is preference is acetaminophen. If you have too, you can still use NSAID. Now, part of it might be when patients are sick, they take acetaminophen. That doesn't help them. Then they may be moving on to the NSAID. So could it be that sicker patients ended up on NSAID and so therefore it wasn't the NSAID causing it? So this is the problem with some of these small databases. So we will await further information as we start collecting more data on people and seeing how many people with and Saids got into trouble versus how many people did not. The Diabetes Canada has a very similar statement. I won't read this all out to you. Bottom line is stay on your ACE inhibitors and ARB at the current moment.

[00:35:25] Now, Alice, what about insulin supply? You talked about this hoarding and all that kind of stuff. And then we certainly saw that with toilet paper. But what about insulin? Because that's life. I don't I'm not sure why there's toilet paper hoarding, but it's not a diahrreal disease. But anyway, what about insulin supply?

Dr. Alice Cheng [00:35:40] So the issue around insulin supply, I think, has come up in the last week or so and the situation is as follows. Even today, I got a phone call from a patient. She went to the pharmacy to get her insulin vials for her insulin pump and was told that she was only allowed to get one vial every two weeks and no more than that. And clearly that caused a lot of concern for her. So what is the story? That the story right now is that there is a move about to ensure that people do not stockpile insulin. Insulin is clearly a life-saving therapy and if people behave with insulin as they did with toilet paper, we are going to have a very big problem. So therefore, the pharmacists, etc. have already started to think about just providing 30 day supplies, not 2 week, but 30 day supplies to patients of their insulin and then requiring them to come back to get their next 30 days supply. Now, Diabetes Canada is aware of this. Diabetes Canada already sent a letter out to various stakeholders to make the point that if this 30 day rule were to apply, then there are implications to patients in terms of physically going to the pharmacy every 30 days and potentially prescription renewal fee. So all of that is under discussion. But I think there are some important messages that we need to get out to people. A very important one is that, as far as I know, speaking to the various insulin manufacturers, there is zero anticipation of an insulin shortage. So the various manufacturers have reassured us that they do not see a supply chain issue. So there is no expectation of there being a supply issue. However, there is a preemptive actions to try to avoid hoarding. So in fact, there's an infographic that has been created for both the people living with diabetes and for the health care professionals. And on the next slide, I've sort of blown up the important parts a little bit more. So for people living with diabetes, it's to have insulin at home, of course, certainly have enough for at least two weeks. I think it is reasonable to expect a 30 day supply from your pharmacy. But above all else, do not stockpile your medications or your supplies because we do not anticipate a supply chain issue with any of those things. And I think for us as health care providers, particularly our pharmacist colleagues that are out there, the next part of this slide would tell us just to use clinical judgment and common sense and to ensure that that we do provide that 30 day supply and recognize that your patients are going to be anxious about this and explain it and reassure them that you're not going anywhere and that you will be available in 30 days to provide the insulin to them. The patient that called me today, the pharmacist did tell them that from a government perspective, they were told to limit to two weeks - really should be 30 days. And then the other piece that they also said was, but you could buy it and pay for it out of pocket if you wanted, which of course, is completely inappropriate, because if this is meant to be a supply chain or a supply and demand and just being responsible, then that's obviously not the right response. So I think the message to us is to tell our patients that when they go to pharmacy, they may be told about the 30 day thing, but the manufacturers do not anticipate a problem. There is no problem, but it's just to avoid people from stockpiling.

Dr. Peter Lin [00:39:09] What if the patient asks if it's safe for them to work? OK, so there's been a lot of people saying I've got diabetes, am I allowed to go to work? What do you say to them?

Dr. Alice Cheng [00:39:18] So this one, I have no slides here because this is a philosophical answer. And I've certainly had that question quite a bit. What I do explain to them is what I said earlier, those with diabetes are not at higher risk of getting COVID. But if you were to get COVID, your disease may be more severe. So I think it is very reasonable to ask employers, if possible, to be placed in positions whereby you are at lower risk of exposure. So maybe not the store front, maybe not as much public exposure. Working from home, if that's an option. And those kinds of things. So I personally have not written notes for people just to be off work completely on the basis of this. But I think this is very much a philosophical conversation. I think educating is the key. Again, this is my opinion. It's not an official Diabetes Canada position, but that's been my my take on this issue.

Dr. Peter Lin [00:40:11] That's very useful.

Dr. Alice Cheng [00:40:13] So, Peter, we've talked a lot about sort of the current issues. Can we talk about some perhaps happier stuff about the cure and what the future may hold?

Dr. Peter Lin [00:40:24] I know, I hope that we have happier stuff one day. I'm sure everybody saw this picture, this is Kaiser Permanente. This was the first injection of vaccine on March the 16th. And just to explain, this is a mRNA vaccine. So what does that mean? So normally in a flu virus, what we do is we grow the virus in a chicken egg and then we take out the proteins and beat it up and we take the little spike proteins and we inject that into our patient. And then we tell the army, go and find that protein and then make an antibody against it. In this case, the mRNAs, we inject the RNA, which is the blueprint on how to make the spike protein. So that little red thing that I showed you in the beginning. And so the idea is that we inject that into you and we get your body to make the protein, and then we hope that your army recognizes that protein as being foreign and then makes an antibody against it. So you can see that it's a different method of doing things, but it's much quicker because you don't have to grow it in a chicken egg like the flu - the influenza shot. That one, we need about six months before we can actually produce enough vaccine. And so this way we can get each person's body to make that protein. But you can understand that I now have to show "does it work?" because your body made the protein. Will your body realize that it's foreign? And number two, is it safe? Will it continue to make this protein over time? And what happens if it continues to do this? Is there a safety concern? So that's why these vaccines will not be coming to us anytime soon. It'll take about a year for them to do the safety and efficacy trials. And so it's not going to help us for this crisis. But if this virus does become seasonal, it will help us in the future seasons. If these viruses actually work and this is the direction that they're pushing vaccines to make them faster in terms of development.

[00:42:06] We've all heard about chloroquine from the president saying that this is the big game changer. So let me just show you some of the data around it so that we can sort of make sure that we tell the patients the right thing because people were starting to ask doctors to prescribe them these. Please do not prescribe them. Please do not prescribe them for your office use. There's been a report coming out that they're going to hunt you down if you're trying to hoard chloroquine or hydroxychloroquine, which is plaquenil, which we use to treat lupus patients and all these other folks that are running out of medications. And just to show you the data, this is French data. China was using it. South Korea was using it in sick people admitted into hospital, not for prevention or anything like that. So this is the people, control group in terms of viral swap. So this is not outcomes. This is not whether they got better or not. This was just viral counts that they were doing. This is the hydroxychloroquine. That is about 10 times more powerful as chloroquine itself. So it gets into higher levels. So that's why they usually use this. And in France, they use that along with Azithromycin, an antibiotic. And you can see that when has the fastest viral clearance. So this is not the greatest data in the world. However, everybody jumped all over it. Look at the numbers, 20 people on the hydroxy hloroquine, 16 controls, and look at the type of patients. Six patients were asymptomatic. Twenty two had upper respiratory tract. Eight people had lower respiratory tract. So it's a mishmash of people and they don't tell you which one belongs to each group, unfortunately. So this is not great data. They are doing larger trials with this, so please don't encourage patients to do this. And please tell them the stuff that you buy from the aquarium is not the same because an Arizona man took that and then died. In Nigeria, they had people taking it and overdosing on it. And people are stockpiling. So please do not prescribe. Do not tell patients to go get this stuff. And in China, they did not use Azithromycin because of liver toxicity. So therefore, they chose not to use this over there. So you can see that's a lot of issues. You can tell that I'm going to The Guardian for my medical information. So this is the drug in Japan made by Fujifilm. They said that four days they can clear the virus as opposed to eleven days. They said that they have some lung x-rays that say that there were improvements. However, the Japanese health ministry, they said, yeah, we tried this drug on our elderly and it didn't work. So therefore, the health ministry is saying it didn't work. The Guardian is saying it did work. We'll wait for the studies again. Please do not try and look up this thing and try and buy it on Amazon or anything like that. In terms of HIV, you probably all heard about in India they had 16 people that they treated, 15 got better with this concoction of HIV drugs along with chloroquine and things like that. And when they did the final study to say, does the HIV drug really work, the answer is no. There's no difference in outcomes. And so, therefore, we don't have to waste the expensive money on these medications here in Canada. There are good studies going on. If you go on to clinicaltrials.gov you can search this. This is rRemdesivir, which is an antiviral that was originally used for Ebola. It did not work in Ebola. It's an intravenous version of things and they've got a severe study and they also have a moderate study. So this one, data will come out maybe May 20th, somewhere in the beginning of summer we might get some information on this one. This is the big one, three thousand some odd patients looking at using an HIV drug on patients along with hydroxychloroquine and then for their contacts, they're going to just use hydroxychloroquine to see if they can protect the contacts. So this study will come out in the middle of the summer so maybe we'll have some data about how to protect the close contacts as well. So we'll look for that data as well. Antibodies: there was a lot of talk about taking convalescent patients, patients that have recovered from this. They're producing lots of antibodies, siphon off their antibodies and then fire it back into the sick people. So John Hopkins, they're spearheading this. So hopefully they'll have some data also around the May area if they're lucky to get everything lined up. But first, they need people to convalesce. So in the United States, they do not have very many recovered people but in China, they have about 60,000 recovered people. So perhaps they can get the blood from there and there is a Chinese company that's working on that. And of course, somebody is trying to make the antibodies so that you don't need patients. So these are the things that people are working on. You're going to hear about this one, which is a Montreal based Dr. Tardiff, which everybody knows from the cardiology world. They're using colchicine. You're going to hear it in the news. Please do not run out and buy colchicine. We use that to treat gout and things like that. But it stops your immune cells from dividing. So therefore, in very sick people, what happens when they don't make the antibody is that your immune system decides I'm just going to use whatever method I can. So I'm going to release cytokines. So cytokine is kind of like napalm. You just burn everything up. So therefore, you're going to burn the whole forest up. And so during ARDS, what you see is the cytokine storm. And the thought is that could we give colchicine to stop the cytokine storm? Right now, what we're using is high dose steroids and that seems to have some benefits. So they thought that perhaps this is a different way. So when you read about colchicine, this is not for prevention. This is not for you and I. This is for the sickest sickest people that are in the intensive care unit. So just in case your patients read about it online and they start coming in saying, I want colchicine, just tell them, for your gout is OK, but for everything else, don't use it. So, Alice, what do we do as health care professionals for our patients with diabetes? Like how how should we manage seeing them or discussing things with them?

Dr. Alice Cheng [00:47:41] So, Peter, in the interest of time, can you just jump to slide 60 for me?

Dr. Peter Lin [00:47:46] 60?

Dr. Alice Cheng [00:47:51] Just punch in 60.

Dr. Peter Lin [00:47:51] Hang on, just a second.

Dr. Alice Cheng [00:47:51] So I think when we're having conversations with our patients, we do want to, especially the ones who are quite anxious about this, maybe help them sort out what they can control and what they cannot control. So as this particular handout, which again, I think what we'll do is we'll be able to post some of this stuff onto TimedRight hopefully and people can access it. But I've sort of split up this one pager. But I love how she laid it out as to what you can control and what you can't, which is probably good for all of us, but also for people living with diabetes to get a handle on things. And I think for us as health care providers, virtual visits is going to be a huge part of what we are already doing. So just a few hopefully helpful tips. I think preparing the patient if possible. So if you do have front staff who are calling people ahead of time to let them know and having the patient know when when you're going to call and what time you're going to call approximately and also how long the call will be. Because one thing I certainly noticed is in the absence of visual cues of body language, sometimes people can talk a lot. So trying to maintain that, given that we obviously want to get to all of our patients. And utilizing technology and resources. So is available now to take a look at people's blood glucose levels remotely, as well as other resources like videos and things that are available online. I think actively asking them if they have concerns about the COVID piece is good because they may or may not bring it up. Hopefully this webinar has been helpful for some of the things you can say to them and then reassuring them and sending them off to resources, which again, we will post on to TimedRight as some of the really good websites that are, in fact, out there. I think it's an opportunity to re-emphasize glycemic control and sick day management, sick day management, sick day management, particularly in our Type 1 population. Let's do everything we can to keep people out of hospital and this is one opportunity to do so. But Peter, the reality is sometimes there are some patients you still have to physically bring in. So what's the guidance around that?

Dr. Peter Lin [00:49:53] Yes, so something just came out from the Family Physicians College in Ontario. But I mean, many other colleges have put out things. In other words, screen the patients ahead of time. Do they have COVID symptoms or not and then redirect them. And they said even outside your clinic. So you might have booked the appointment for two days from now. But then as they come talk to them on the phone and say, did the symptoms change? Don't touch anything from them. So even the health card, we should be careful about doing that. Two metres distance in terms of patients and your staff members. Space the chairs apart at 2 meters as well. And try and space out your appointments so that you don't have a lot of people sort of sitting in your office and then just minimize the number of rooms, so just keep using one room so you only have to clean up one room and keep contact to one person. So doctor, patient and that's about it. So don't have the nurse going in to take the blood pressure or anything like that. And in-person visits basically just go directly to what you're going to do. And in Hong Kong, they stand six feet away to take the history and everybody is masked. And then you just go in to do your examination at that time. And then if you have gloves, mask, you should be using those. Patients should be masked as well. And if you don't have the gowns, just take a patient gown, just reverse it so that you have something covering the bulk of your clothing and then, of course, when you go home, you're gonna change and wash out all of those things as well. And then once the patient leaves clean the surfaces, countertops and things like that, they've been touched and try and get rid of everything on the countertop. Put them inside the cupboard so that you don't have so many things collecting virus particles potentially.

Dr. Alice Cheng [00:51:23] So I'm going to quickly summarize and then we'll open up for questions. I think we're allowed to go about five minutes beyond as well. So COVID-19 droplet print, primarily droplet based and community spread is here. Peter taught us a lot about how to protect ourselves and how to protect others. For our patients with diabetes, no increased risk of getting it as far as we know but if one were to get it, complications can be more severe. So therefore, it's an opportunity for us to re-educate. Glycemic control is important overall. Don't know specifically about COVID, but overall it absolutely is. And therefore sick day management, sick day management, sick day management. For us in the outpatient space there may be a sense of, well, what what can we do? What use are we in this entire fight? Well, I think that's the utility that we have - to keep people out of hospital and to keep people well while they're out. And telling our patients not to stockpile. The last thing we need is a an issue with insulin supply. And hopefully the future is, in fact, bright. And this last quote I will read out, and if Peter is willing, he'll do a little dance that comes with it. Hard times are like a washing machine. They twist, turn and knock us around. But in the end, we come out cleaner, brighter and better than before. So let's hope that's the case here. And maybe what we'll do is we'll stop sharing a screen. And Peter, what I'll do is I'll read out some of the questions. We'll keep our answers as brief as possible in hopes of getting to them. So a question here. Half of those who tested positive in Iceland are non,  are asymptomatic for COVID. What are your thoughts on the trends in Canada? Do we have a sense of that?

Dr. Peter Lin [00:53:05] None because we don't have asymptomatic testing, because we've been discouraging that, because we didn't have enough tests. So in certain countries like South Korea, they tested massive numbers of people. So they would test like two hundred thousand people in an area. And so they actually have numbers that say there are people carrying this thing and they don't have a whole lot of symptoms or they have minimal symptoms, maybe a little bit of fever, a low grade or a little bit of body ache. But the thing is that they're not coughing or sneezing. And that's why that distancing, the physical distancing is so important, because you can't tell whether somebody is sick or not.

Dr. Alice Cheng [00:53:38] So there's a question here that I'll take on type 1 versus type 2. I did not address that specifically. We do not have data to that level of granularity. All I can say is there was one published case report that came from China in the early days of a young man who was admitted to the ICU but ultimately recovered and was sent home who sounds like he had Type 1 diabetes. That's not really evidence of any kind but clearly, I would imagine both types would be susceptible, just like everyone else in the world is in fact, susceptible. But we have no better data than just diabetes is a broad category. OK, so then another question to you, Peter, I think is important. Is there any interventions with nutrition, vitamins or minerals and with evidence to support improving symptoms of COVID and I'm going to add to that maybe preventing COVID.

Dr. Peter Lin [00:54:28] So unfortunately, no. But there's been a lot of people trying to sell these things like the special teas and all that kind of stuff. There was a fellow that they did a little expose. He was sending a letter saying that we have a special tea and these 200 doctors went to Wuhan to help and they drank the special tea for six days before and they never got the virus. And therefore, everything is based on this tea. So in other words, you're gonna hear a lot of things about tea, eat this, eat that and if they're selling it to probably it's not real because if there was anything that could prevent it, I'm pretty sure the Chinese with their huge population over there, any herbal teas or anything like that, they would have used that on their population. And there has been zero. So I don't think that there's anything that could help in this fashion. Good nutrition, always helpful for your immune system and things like that. But remember, this is a race to make a new weapon. So therefore, if your immune system can't make that new weapon, it doesn't matter how healthy you are, you're still going to get sick. Good nutrition is great, but it's not going to stop the COVID-19.

Dr. Alice Cheng [00:55:26] OK, so I'm going through these questions here. We've addressed some of them. So there were some questions about immunity. So a few of my patients are asking if they get COVID and they recover, are they immune? Are they at risk of getting COVID again?

[00:55:44] Yeah, so the hope is, is that basically you're immune. So you will have antibodies against that particular COVID. But the COVID-19, as you know, is about 80, 85 percent similar to SARS, the original virus that we saw, you know, 15 years ago. And that one mutated. So we know that there's at least two versions of this COVID-19 floating around. One is slightly worse than the other. And so they've been tracking the genetics of this thing or the RNA of this thing, because every time we make a copy of it, it may not be perfect. And the question is, will it mutate enough that now your antibodies will not cover, you just like the flu, right? You get one flu, you're not protected against the newer versions as it mutates along. So we're worried that perhaps there may be newer versions if we have this wide spread within the community, whereas when it was a small number of hosts, then the mutation rate is going to be smaller. Whereas if you have so many people making copies of it, the mutation rates may be higher. So right now for this version of COVID, you are going to be probably OK with your antibodies higher. But unfortunately, there may be a second version or a third version, let's say, next year that people are worrying about.

Dr. Alice Cheng [00:56:48] So there's a comment here that maybe I'll take and it's around potentially insulin starts or starting on the Libre and things where people are being sent to the community pharmacies to do that. I think for the community pharmacists, it's the same concerns with respect to trying to stay two meters away from people if possible. So I think if there is an option to delay some of those starts, then we should seriously think about that. If, however, it does need to happen, some insulin starts are happening remotely, virtually. Given technology that we now have. So you're watching, talking to the patient. They're watching and they're going to do it themselves. And then for those that you absolutely must see, I think the advice that that Peter provided is true in that we minimize a number of people to see them. And yes, you're still going to need to get close to that person, but then that's where the hand-washing is going to be so critical. But we do still need to take care of our patients and for someone who we feel needs to start now, they really should, because otherwise we don't want them going to DKA and then landing up in the hospital, which is obviously just bad patient care. So figuring out systems and ways to do it safely is going to be, I think, most important.

Dr. Peter Lin [00:58:02] The other thing is that, you know, how in the past we kept saying no mask, no mask unless you're sick. Because now we have community spread that's quite high. If you have a contact with a person like that, that's when both sides should be masking. So you'll notice that the change in tone in terms of the masking will be more freedom of masking now, just because the virus is in the community, whereas before when it was just travelers, the majority, the population that you would see would not have the virus. So therefore, we really didn't need to mask. So you'll see the tone changing about masking, like, for example, these repatriation flights there, as I was saying, that perhaps all of them should be masking because everybody might be sick and lying. And so therefore, the virus count inside that plane is very high. So you'll see that the threshold of masking is going to be much lower now.

Dr. Alice Cheng [00:58:46] An important comment here from Atlantic from pharmacy, that even if they're trying to order more from the wholesaler, they're being sent one vial/box of cartridges per day. So for some patients, that may not even be a 30 day supply. So I think being aware that there are steps being made on multiple fronts to ensure that stockpiling doesn't occur. And I think it's it's everybody's responsibility. Health care providers informing patients, patients, wholesalers, pharmacy colleagues, etc., etc. So thank you very much for that comment. Peter, a question to you about men versus women. Just about COVID. Let's stick to that particular topic. So from a COVID perspective, men, women, what's the difference?

Dr. Peter Lin [00:59:29] In the China database, it seemed to be a bit more men, but then that doesn't tell you anything, because over there men tend to smoke more. They tend to be older and they tend to be, I guess, more in that market. So it could be that men were just hit more because they were working in the market and stuff like that. So I don't know whether there is a truly difference between men and women, but at least in the China database, it seemed that men would get hit more or the percentage of patients were more men. But I'm not sure if there's a genetic component that's tied to the X chromosome or the Y chromosome. I don't see that, but we'll see once we start looking at the data from Italy and also from the United States, because now they'll have huge numbers of people. And the United States the one thing that we've noticed is that there's more young people getting it. So the proportion of young is actually quite high in the US and we're not exactly sure why that is. Maybe because they didn't care and so therefore, they were intermingling more. In Italy, we think that the death rate is so high because their population is much older. So the number of people over the age of 70 and 80 is quite high. And so that's why when you look at the death rates, it's the 70 and 80 year olds that are that are just out of proportion to any other country in the world.

Dr. Alice Cheng [01:00:42] OK. Let me just see what other questions we've got here. What about people with emotional issues such as anxiety? How do we manage with stress levels, coping with social distancing and other measures to manage prevention of the COVID-19 outbreak? Maybe I'll throw in my two cents. And Peter, you can add that as well. Perhaps I'll talk about selfishly as a health care provider and probably our mental health, which is equally important because if we're not well, we can't possibly help others. And I think sessions like this, where there's a chance to kind of chat a little bit are helpful. Certainly our own friends and colleagues are critical at this time. And for me, what's helped a lot is what can I control and what I cannot. And as long as I sort of remember those things, it makes it a little bit easier to sleep at night. Peter?

Dr. Peter Lin [01:01:33] A couple of things. One is health care professionals are burning out. So therefore, I think all the clapping and everything else was very helpful. You saw that in Barcelona, you saw that in Vancouver, you saw that in England, where people during shift change at the hospital, people are out there with pots and pans. I think that helps to boost people. If we could decrease the workload on the hospital, so keep all the heart attack patients from having heart attacks and things like that, keep your diabetes patients from getting into trouble and needing to go into hospital. I think that would be very helpful. But in terms of how to make people feel calm, one thought is that USB stick idea, right? In other words, tell people this virus cannot move on its own and it cannot replicate on its own. It needs to find a body. So once you explain that to people, then it becomes a very weak agent as opposed to this sinister thing. That's sort of like Voldemort trying to find the next victim kind of thing. It actually needs us to move it. And so therefore, if we stay six feet away, we don't put our hands to our face and we isolate ourselves within the family properly, then the virus cannot cross our personal borders, right. Because now the virus is in our country's borders. But it certainly cannot cross our personal borders. And we protect this border, it does not get into your lungs on your hands. It cannot do anything. It can't do anything through skin. It's only when it reaches your lung. So I think those kind of commentaries may be helpful in keeping people calm and giving them some sense that they have control over their destiny.

Dr. Alice Cheng [01:02:57] OK, so there was a question about those who get influenza and pneumonia vaccines. Is there any, I guess, protection from that? Is there anything better about people who have gotten those?

[01:03:08] No. So there's no cross protection because the spike proteins are very different looking. And we know that even the flu vaccine is only for the three strains that they put in. So it doesn't really cover every single influenza, even. However, if they've had an influenza shot, they've had a pneumonia shot, then at least two things will happen. One, they're less likely to have co-infections. So we started noticing, especially in kids, they tend to have co-infection. They got the COVID-19 plus something else. And in the elderly and perhaps our health care workers, sometimes they'll have two infections at the same time. So by getting the vaccine for influenza and pneumonia, then we get rid of those risk factors. And also, it allows us to maybe think more about COVID-19. So if they've had flu shot and they've also had pneumonia shot, then at least we know those are low on the priority list. And that the COVID-19 is more likely. So it does help the confusion portion of it and the co-morbidity. But it doesn't help with lessening the COVID-19 infection itself.

Dr. Alice Cheng [01:04:05] And just a few quick questions and comments that maybe I'll just take quickly. There was one question about vertical transmission. I think there was a paper published either today or yesterday looking at vertical transmission of pregnant women in China who then delivered. And bottom line that the neonatal overall did okay. There was some infection that cross but they they did OK. There's a comment about what other resources and partners that we should think about. So pump companies, CGM companies, they're all still around. They're there. They're still providing service. They're providing support any way they can. So we should reach out to them as well. They often have a lot of video resources that our patients can sense, so that continues. And remember, our job is to keep our patients calm and healthy and re-assured and giving them as much service as we can. And there was also a comment about home deliveries for pharmacies. Yes. So remind our patients that many pharmacies will do home deliveries, which will lessen their need to come in. And in an important question around wounds. So diabetes foot care and wound care and whether Diabetes Canada has a position on that. Well, from a COVID perspective, I don't think Diabetes Canada officially does but I would say as health care providers,especially in the outpatient space, our job is to keep people out of hospital. Always has been and particularly now continues to be the case. So if there is care that can, in fact, be provided on an outpatient basis that will help keep that patient safe and hopefully not infected bacterially, needing to go to hospital and take up the bed, then that's what we're going to need to do. Will there be precautions we will need to take to do that? The answer is absolutely yes. But if it's a hands on thing, then it's a hands on thing. And then the precautions that Peter said, I think is what we need to do. But as much care we can provide by phone or virtual is very much our job at this point.

Dr. Peter Lin [01:05:57] Yeah. One thing is that we have a lot of PSWs that are moving from one place to another. I think they're pretty good at hand-washing and things like that. The one thing just to remind them is their coat. So when they come in, a lot of times they just throw the coat onto the sofa or onto a chair. So that process has to stop. So that coat has to be hung somewhere else away from the patient. And number two is if they're carrying a bag, that bag should not go near any table tops or beds or sofa surfaces because the bottom of the bag can be carrying things. So if we can limit that, then some of our more vulnerable people that are getting services being provided will continue to get the services without having an infection being brought in.

Dr. Alice Cheng [01:06:35] So another question, cloth masks. A lot of questions about cloth masks, surgical mask, N-95. Peter, do you want to give a quick lowdown on that?

Dr. Peter Lin [01:06:46] Yeah. So N-95 will be health care personnel that are looking after COVID patients or if you're doing a procedure where you have aerosolization - dentists and people that are digging in places. So then they have to have an N-95 that's fitted properly so therefore no virus can get through. The surgical mask, they leak on both sides, but then they're still useful because they stop you from touching your face. And it reminds you not to do that because your hands coming up to your face is the other big reason why we pick up the virus and if we mask the people that are sick, then that's very helpful. So that was the past. But now because we have asymptomatic people or people with very little coughing and sneezing, having the virus now in a health care facility, you'll see people more liberally using that surgical mask on all patients as long as we still have supply. OK, so this is governed by supply. In terms of the cloth mask, they don't really filter out anything. However, what it does do is it stops you from touching your face. So if they abide by the six foot rule and they want to wear a cloth mask, it just reminds them not to touch your face and they can't touch their face. So that's helpful. But the cloth mask, you must make sure that they wash and clean it properly. Otherwise, you develop all this mold and fungus because you have this moisture and everything else collected within there. So they have to wash and clean them properly otherwise they will get sick from all the stuff that they're breathing in. But certainly in terms of blocking anything, they cannot get close to people because they don't filter out anything. You've seen all sorts of weird ways to make masks out of Lysol sheets and stuff like that. Please, please don't do any of those things because you don't know what breathing in Lysol all the time it's going to do for your lungs.

Dr. Alice Cheng [01:08:20] I think we've already got past time, but we're probably allowed two more minutes. But there's an important question about lab work. I've had many a patient call my office and say I'm afraid to go to the lab so I can't get my lab work done. Usually what I've been telling them is for at least the labs that are locally here in Ontario, you can call ahead and make appointments. So if that's an option, then make an appointment online. Therefore, you're more likely to go in and out. Labs just like everywhere else are not allowing, you know, 50 people to be in that waiting room. They're also spacing people out as much as possible. So I think making appointments is the most important thing. They continue to be open. They need to stay open again to provide outpatient care, which is our job to keep people out of hospital. So if they can just call, call ahead, book online, have an appointment in and out, wash hands, everything Peter talked about earlier. We should encourage our patients still to do the blood. If it's something that's really not that important, of course it can wait. But if we're talking about routine diabetes care in someone where you are concerned about glycemic control, I think it is still worth encouraging that. But with all those safety precautions in mind. Unfortunately, we're going to have to log off at this point, but there are some remaining questions and I apologize to those who didn't get it answered. I think on TimedRight, you could certainly throw in, I don't know if I should be saying this publicly, but I'm going to say just put those questions onto the COVID track. And then Peter and again, I'm volunteering your services, and I are going to do our best and others to try to address those questions when we can. And again, as I said, we are doing this again at 3:00 p.m. Eastern Daylight Time. So some of you may wish to log in for that. This was recorded. So for your colleagues who were not able to join, then they can watch this as well. And we may very well need to do this a little more regularly. Again, I'm volunteering you Peter, depending on how things go over time. But I do want to thank all of you for joining. Hopefully this was in fact, helpful. And I very much want to thank Peter for his his time and his expertise and for his incredible explanations. And Peter, I'm going to give you the final word.

Dr. Peter Lin [01:10:33] Thank you. And I want to thank all of you for joining. And I know it's an hour of your time, but hopefully we can all get through this if we do the right things now. So we don't have to be an Italy, we're definitely not a United States right now. We're much better equipped in terms of that. And I want to thank Diabetes Canada and Alice Cheng for taking on the leadership or putting this thing together, because without them and all the support staff that is behind us, we wouldn't have this connection. And I'm just glad that we're allowed to share some information today that might help us all. As we look and manage our patients.

Dr. Alice Cheng [01:11:06] Thanks, everyone. Bye.