Novel Coronavirus Panel at the Johns Hopkins Bloomberg School of Public Health

[Music] welcome to this special broadcast from the Bloomberg School of Health at the Johns Hopkins University thank you for joining us I'm Brian Simpson editor in chief of the Hopkins Bloomberg and Global Health now we're here to talk about the outbreak of the 2019 novel coronavirus with some of the Johns Hopkins experts who have been at the forefront of the global domestic and university preparedness the corona virus outbreak involves an emerging virus that's deadly and rapidly spreading tens of thousands of cases in dozens of countries including the u.

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more than 50 million people in cities in China in lockdown increasing travel restrictions and currently no vaccine or treatment for this new virus there's a lot we know and a lot we don't know Johns Hopkins clinicians and researchers have been sharing the science and the evidence needed to advance understanding of the virus and to determine the appropriate response they've been advising the public the health community policymakers businesses and others what to do now and how to prepare for what might come next our goal today is to bring their knowledge directly to you we'll discuss the most important things to know about the virus the outbreak and the response this will include answering your questions submitted before and during the broadcast with that let me introduce our panel dr.

Tom Ingoldsby is director of the Johns Hopkins center for health security at the Bloomberg School dr.

Caitlin rivers is a senior scholar at the scene Center for health security and Lawrence our is director of the operations for the Johns Hopkins office of critical event preparedness and response or CPR now to our questions we'll begin with the virus Tom what are corona viruses and why are they so dangerous so this new virus that's causing disease in China and elsewhere in the world is part of a family of viruses called the corona virus family which infects both birds and mammals including humans and in humans there are currently IRS's that cause mild disease and corona viruses that have caused very serious disease in the past including two diseases called and MERS which we'll probably talk about later and what makes it particularly dangerous is that in this case some small fraction of those who get this corona virus developed very serious lung very serious lung disease which can either get them into an intensive care unit on a ventilator or potentially be lethal and when a person is infected at what point do they become infectious so they actually can transmit it to other people we know about most viruses is that when people are most sick is when they are most infectious we don't know enough about this virus to say that that is absolutely the case but we believe that preponderance of infections are going to happen when people are sick there is some information in China that suggests there may be some spreading of the virus before people are very sick and a few studies that suggest that might be a possibility but we don't have a lot of information about yet that yet so just for general purposes we believe that most of the most of the spread will occur around people who are symptomatic and for asymptomatic people if that actually does exist and they can transmit is that like a whole level of great another level of greater concern that would be a very serious concern in terms of trying to get control of this virus on the other hand the one thing that might be somewhat better if that is already occurring extensively is that it would mean that there probably are many many more people who've been exposed and are not developing symptoms so when you would suggest to us that maybe this is more of a mild illness than we're seeing now so we'll have to see what happens great Caitlyn and a question for you from an alum so the reports have been of a say 2 percent fatality rate and the alum wonders like why is that so alarming isn't the comp isn't the flu worse yeah that's a great question and I see that reported a lot but it's actually the case that we don't know yet what the mortality rate is it feels right that you should be able to compare deaths to cases to get the mortality rate but in fact there have been about 24, 000 cases in China right now and half of them were infected in the last five days or reported rather in the last five days those people are still sick and we don't know what's going to happen yet so it's not right to be able to just do that division and so the truth is we don't know yet what the mortality rate is now I see a lot of comparisons also with flu flu is a very serious public health concern that we deal with every year and that's true but we know a lot about flu and we manage it every year we also have vaccines we have antivirals we're really good at planning for and responding to influenza we don't have any of those advantages with this novel coronavirus yet and that's what makes us worried and you touch on an interesting epidemiological challenge in that you we've had a huge surge in reports of cases but there is a dip that's a difference there's a difference with that between an actual surge in the true number of cases so the reporting may be getting better that's right yeah what people get sick especially in the context of a new outbreak it takes a while to sort of move them through the detection pipeline and diagnostic pipeline so just because we see a big influx of cases today it doesn't mean those people got sick today but probably they got sick recently and we're in a question for you so for many of us as we think about coronavirus the only other ones we have heard about our MERS and SARS and certainly with SARS that outbreak really kind of lodges in our memory the 2002-2004 outbreak which had a you know a good pretty bad number of deaths in cases how would you compare the two between this novel coronavirus and the SAR the virus that caused the SARS outbreak yeah it's a great question so we know that this virus emerged from a virus that is related to SARS and we learned a lot of lessons in the SARS and MERS outbreak so knowing that this virus is related but having some information not there that we now have with SARS and MERS is really important it's also important to remember that we see coronaviruses all the time and they can cause things as as common as a common cold so we do have a wealth of knowledge about coronaviruses so while we can't compare the case fatality rates as Caitlin was mentioning or even the underlying burden of disease we learned a lot about how to manage cases of SARS for example so we know that infection prevention control processes are really important we know early detection is really important so all of the lessons that we've learned about SARS about MERS and even about the more common coronaviruses we can apply in this outbreak so a little bit of history there and that helps us great so Kaitlyn can you tell us a little bit about some more about the knowns and unknowns with this outbreak so we know the virus emerged in China maybe in December maybe in late November and that it's spreading fairly efficiently in the community we think on average one sick person infects two to three other people we also know that some fraction of people do experience severe disease it could be as many as 15% but we're still learning more about that what we don't know is how much spread we will see in the US right now there is very little recognized community transmission actually the only two cases that we know of in the u.

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got them from their spouse and very close contact but we don't know if we're going to see more community transmission more like what is seen in China we also don't have a great idea of severity as I mentioned we're not sure how many people will be severely ill or how many will go on to die and so that what this makes us concerned Tom one of the group here at Hopkins the Center for System science and engineering has created kind of almost a real-time tracker of coronavirus cases and just taking a look at that map what did what jumps out to you what is is anything surprising there or it kind of is this what you would expect for this kind of an outbreak it's hard to say in terms of this kind of an outbreak since this is so unusual and and different from anything we've experienced before it's got its own unique characteristics but the map shows first of all kind of the explosive spread in the Wuhan and hoobae province area and kind of the case finding that's going on now it also shows how it is now in essentially all provinces at some level in China we know that we don't believe that that Chinese public health authorities have been able to test as efficiently in other places in China so we don't really know the case burden in other parts of China I think the other thing that we see on the map is the number of cases that are in small numbers at this point in many other countries a number of countries are just beginning to get testing capability so in some places in the world they wouldn't have had a chance to know whether there's disease in those country in that country is yet and it just shows how connected China is to the rest of the world they have flights out of Wuhan there's something on the order of 85, 000 passengers moving to other cities around the world every month so China is very connected to the rest of the world and we see that on the map katelyn it kind of a quick question for you what signals are you looking for in terms of as this outbreak transitions what are you it's what would you look for in terms of being a signal for a potential severe pandemic that we see is in mainland China and if we start to see chains of transmission outside of mainland China that will indicate to us that the outbreak is really growing beyond what we currently see now the good news with that is that the more cases that we see that we didn't recognize the more that mortality rate is going to go down so I talked about a way the mortality rate could rise if we see the people who are sick now go on to have outcomes hopefully they recover but we can't be sure but there's also the mild the the side that has mild cases and the more mild cases we see then the more the severity rate will go down let's move on to the response and Tom wonder if you could like walk us through China's initial response when they put these first cases what happened there and what might be able to have been improved on so we have a kind of a case study there as compared to what happened in 2003 around SARS and the the Chinese response in some ways was much faster in the sense that the genome was sequenced and that information was shared with the world but now we have seen in the last couple of days some accounts that some of the information that we would have liked to have known early on wasn't allowed to be released so that we'll have to kind of understand that because the earlier we respond the better we're going to be it's it's also the case that there is some information that's coming out in various scientific journals that is really not being discussed ahead of time and it comes out on a Monday and no one in the public health you had any sense that that was happening even the day before so I would like to see more information being shared before publication there could be many reasons for that on the good side we do know that even at the top of the Chinese government there is a direction to all the people who are in responding to take this as seriously as anything they've ever done before and also to be sharing information internationally so there's a clear direction from the top to share information it's just the challenge of getting that out mm-hmm great so as part of this outbreak we hear a lot about preparedness what is preparedness exactly and how do our most how well our most country's prepared prepared so when working definition of preparedness is is the collective work that's being done to prevent disease detect outbreaks and respond to them in the outbreak detection realm outbreak detection and response realm and there's a whole community of Public Health responders emergency managers clinical experts around the world in every country that have as their job the work of preparedness and one in our our Center worked with another organization called NCI and The Economist Intelligence Unit to put together the first global health security index which tried to assess the ability of countries around the world to prevent to detect and to respond we asked them a series of questions and try to gauge capabilities in countries around the world and bottom line and what we saw was that there's a wide range of capability in that area of expertise and expertise and that every country has a lot of work to do and you can see that there are many vulnerabilities to this kind of outbreak so Lauren let's talk about the US healthcare system how prepared in general is US healthcare and specifically what about johns hopkins hospital what's happening there yeah I think there's a wide variety of levels of preparedness across the US healthcare system and I think it's important to note that the US healthcare system is operating at capacity almost every day if you think about it across the country we have a lot of people in and moving through the hospital system every day and here at Hopkins we are operating very close to capacity all the time so the idea that we would have an outbreak like this and need to expand the hospital capacity whether here at Hopkins or nationally is concerning we have we have people in beds throughout the healthcare system throughout the hospital that not couldn't necessarily be moved or leave the hospital system if we have a rep of massive influx of patients that being said here at Hopkins and nationally we do we are firm believers and preparedness and I think it's important that to note that preparedness is significantly less expensive than response and so it goes a long way but it's also really hard to prove when it works so making sure that people are invested in the preparedness activities that we do daily and not just immediately after when that sort of muscle memory of the response has not passed is really important here at Hopkins we use CPR the office of critical event preparedness and response to ensure that our preparedness activities are streamlined across the institution so we're not giving different messages to our health system or our University whether here abroad and making sure that everyone has consistent messaging on how they can be prepared and what they should do and I think the idea of employing the CDC guidelines and the w-h-o guidelines is a perfect example of that making sure that we're absolutely up to date on what the nation is doing and what the nation's experts at the CDC are recommending and putting them in place here whether it's at our student health clinic at our emergency departments or ambulatory care centers or even just messaging to staff students and faculty and in in the eyes of the public there's a fine line between preparedness and stepping up actions at a hospital and overreaction and oftentimes the public expects a lot immediately but that may not be appropriate how do you sort of divine that line there and then and what what is Hopkins saying to its community as well as what other institutions should be saying to their their people yeah I think in this situation and it can extend more broadly the most important message is to go with what the facts say and use the information that's available available to you to make informed decisions so following the guidelines that are put out whether it's at the institutional level or at the CDC or at the w-h-o acting rationally and calmly and and remembering those things we've learned from previous outbreaks and previous responses we know what we're good at and we learned from previous responses what we're not good at and we try to make improvements in between I think the mask example that is is all across the media is a perfect example of this so we have had a run across the country and I think globally on the use of face masks and purchasing face masks and we know and the w-h-o and the CDC tell us that the evidence doesn't support healthy people using masks out in public to protect themselves and what's important is for us to message to our faculty staff students and community that the masks that they see out in the community are for sick people to protect themselves from spreading to vulnerable populations who they might encounter so taking that information and applying it more generally is a is a microcosm of a broader preparedness message we know the evidence doesn't support it so how can we implement it at our facilities and one of the one more question for you one of the most important parts I think of preparedness is building up the diagnostic capability can you let us know where the u.

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is right now in terms of Diagnostics and where it needs to be in the coming weeks yeah absolutely it's a great question and it's so important for for sort of protecting our health system and its capacity right now anyone who is identified using the CDC criteria as a person under investigation for the novel coronavirus has to have their tests completed their confirmatory test completed at the CDC and that's a labor-intensive process so it means identifying that person either at a health system or through a call-in line taking their sample packaging it sending it possibly to the State Health Department first and then shipping it on to the CDC and we've heard reports that this takes from 2004 hours to 5 days maybe even more depending on where that person is located in the country and in the health system and then that person has to sit in isolation until their test is complete I believe it was yesterday we got FDA approval for emergency use authorization of a new real-time rt-pcr test for this but that'll take some time to implement at the Health System or at the Health Department level and so getting that on board making sure we understand what the results mean and how to interpret them and training people on how to use it how to validate it is the it is a really important next step how soon do you think that will that those Diagnostics will be expanded and accessible by other other centers yeah I think it's sooner rather than later and I think every time we have an outbreak like this the technology speeds up and we're seeing that here with the diagnostic side as well hopefully within the week we'll see we'll start to see these tests maybe not the art the real-time rt-pcr but we'll see the tests that the CDC is using at the State Health Department and then that real-time test will come online shortly to follow so Caitlin we received many questions from our alumni about travel and they're asking about near-term domestic travel travel to countries that may have a handful of cases are there I know each case is kind of specific but are there general recommendations that you would provide through folks yeah the two places to look are with the State Department and the Centers for Disease Control both of those institutions issue travel recommendations and they're very good at keeping up with the latest guidance and weighing kind of the risks and the benefits to traveler so anyone considering a trip should check those two resources great so another kalyan another question that we received Sept from several people is all around vaccines obviously vaccines are a very powerful public health tool and apparently there are at least a dozen research projects underway are these are these projects are they are they connected at all or is this kind of more the Wild West where everybody is doing their own thing and how soon do we think actually a vaccine will be able to be tested developed and then so manufactured and distributed what's that timeline look like you know there's a lot of interest right now in identifying vaccine candidates and trying to move them through the pipeline the US government and important nonprofit organizations that help to coordinate these efforts are putting a lot of energy into figuring out what our best vaccine candidates are and how we can expedite that and so I expect to see a lot of exciting news coming out in the coming months but that being said it's unlikely that a vaccine will be ready for use in the general public in months many months potentially it just takes a really long time to get the science to do the clinical trials to manufacture products distribute them it's a long process and so I think we do need to be thinking about what we would do what we will do without having a vaccine on hand and what is what is some of those options look like for you know for a country in terms of a country country level response yeah I think preparing the hospital system to accommodate an influx of patients is really important some countries have implemented travel restrictions or recommendations around quarantine and that's something that each jurisdiction weighs in in their own context but these are the sort of general actions that can be considered great so this is a question for the whole panel here what are some like concrete steps that people should be taking to protect themselves people in as individuals but then also sort of yeah at that country level as well can we do a start sure yeah this is a great question because it's also flu season and so the answers are broadly relevant hand hygiene is always a good idea coffee to kit which is coughing into your elbow and not into your hands is always a good idea and as Lauren mentioned if you are experiencing symptoms regardless of what the cause is if you want to wear a mask when you visit the doctor's office that can help protect people in your area from being exposed I think that it's just Lauren Lauren already mentioned it before is that in most places in the country there's a good state health department or city health department that is very is working hard to stay very current so I'm checking in with a health department about guidance for your location CDC is changing its guidance on a regular basis as they get new information so it's a good source of information for the public both about travel but also about infection control and and the general things that we do to prevent ourselves from getting flu in a season Lauren Andy you think to add no but coming from the emergency department I'll just reiterate what Kaitlyn said washing your hands is absolutely critical and definitely get your flu shot I'm sure okay great we're gonna shift now to some live audience questions and I'll just go ahead and ask the question and then feel free to to jump in so some people coming from China or putting themselves under a voluntary self quarantine for 14 days is this necessary I don't think we have evidence that people like their quarantine in this way has is proven to work I think people are the government has issued new new policy around the just over this weekend about putting people in quarantine we should say the quarantine in the way we're talking about now is taking a group an individual or a group of people who are well who might have been exposed and keeping them out of circulation for a period of time that's different from isolation and the term isolation is used to take to mean taking people who have symptoms and have been diagnosed or under investigation and having them be in isolation for a period of time the latter isolation is proven public health intervention which we use all the time for people who have contagious disease these larger scale quarantine are of less proven value it is now part of the guidance of people who are returning and then if they've been in China in the last two weeks they're now supposed to be in home isolation and that's the button the guidance that's supposed to be followed if that person came in I think Sunday night or later that's the CDC got instant and obviously with with quarantined there are massive ethical dimensions to that what are some considerations that public health officials should have in mind when they're making this kind of determination and evaluating the need for a quarantine I think one piece is is that the least restrictive thing you can do and while still protecting public health and individual health and so that's really important for public health practitioners to evaluate are they're less restrictive options that would still be effective is it sound is it evidence informed are we making this decision out of fear versus out of science and and policy and I think those questions are questions that we can't just ask once we have to ask them repeatedly as we get more information great so another question from our audience so we've talked about the use of masks which cover the nose and mouth can someone be infected through the eyes or from a droplet on food I don't think we have a great understanding yet of how this pirate all of the possible ways that the virus can infect someone we know it's a respiratory virus and in general respiratory viruses are transmitted through droplets through the nose and mouth also touching things and then touching your face is usually not a good idea and there may be other routes of transmission as well but I think it's important for the public to really focus on the primary modes which is droplets and hand hygiene when you say hand hygiene you mean washing washing your hands frequently oh it's a good idea and what about the sort of the different like antibiotic ointments or things solutions that you can put on your hands are those effective or should we actually be using water soap and water soap and water is the best option if you have it available but alcohol-based hand sanitizers can also do the trick great so another question from our audience how do you think the number of actual cases compares to the number of reported cases I wish we knew we knew that we would have more questions answered I don't think we have a good sense right now of how many cases we're not seeing it's the sense that there are probably a lot which sounds alarming but it's also a good thing because right now we're seeing about 15% of cases reported in China are severe if we assume there's a large burden of cases that we're not seeing that means they're probably mild and so that means the disease on average is probably less severe than what the numbers reflect but right now we just don't have a good sense of how many more are out there the only thing to add to that is just that there are a number of very very well-respected modelers and universities in different parts of the world who do believe that there are many more cases that we're seeing I mean some some estimates are five times as many cases as have been now reported or more are already present in China but those are all models so they depend on the data and we don't know if they're correct it also speaks to the particular challenge of fighting a respiratory outbreak like this during flu season right I mean that's got to be a complicating factor yeah and that's why the epidemiologic piece of the investigation tool that the CDC is set forth is so important so the travel history is an important element because otherwise you would be testing everyone who came through with a you know with flu symptoms or other respiratory symptoms or fever so that's why it's we've really focused on honing that travel piece a little bit better right and one more question when when is the peak of an outbreak like this when do you know you've reached the peak you don't really know until after it's happened there could be a seasonal component and if so that may change the dynamics a little bit we don't know for sure but right now we're it's clear at least in China that we're in the expansion period and so the peak does not seem to be behind us and when you talk about seasons there's a possibility where the this outbreak could peak cases could be dropping off but then six months later another second wave as in with the 1918 flu would you say we know that for some coronaviruses there is a seasonal component of the coronaviruses that we live with every day you have a seasonal component but to other coronaviruses that are very important to us SARS and MERS because they're quite severe don't seem to really have that pattern so we don't know for sure okay great one last question how can we prevent pandemics in the future so that's a difficult question I think it's nature is constantly creating new strains of virus and animals they're constantly moving between animals and people so in terms of strategy for preventing all of that and preventing the next virus to jump from animals to people I think that's probably unrealistic but what would be more realistic is improving the capability of the world to respond to them quickly with early diagnosis early understanding of the virus but then a much stronger ability to make vaccines and medicines very quickly we've come a long way in the last 20 years along those lines but if we're still at the point where it takes a year or two to make a vaccine for a new disease that's really not acceptable in this world and isn't fast enough so overall I think we need to move towards a much stronger capability of responding early with the tools that we can create great thank you so we're unfortunately out of time I would like to thank our panelists and all of you for being part of this broadcast a recording will be made available soon and we'll be getting that out as quickly as we can and we're happy to share some links to resources to help you stay informed so to stay up-to-date on the university's guidance you can visit the johns hopkins coronavirus information page on the hub and to get the very latest analysis from the Johns Hopkins center for health security visit the center's website and sign up for their situation reports they come out daily they're comprehensive and I want you to know we read them all the time great to stay up and informed and you can also subscribe to global health now the daily global health newsletter produced by the Bloomberg School we're covering the coronavirus every day in our smartly curated newsletter of the most important news in global health and I want to make sure everybody knows we have launched a coronavirus expert reality check that answers key outbreak questions thank you again for joining us [Music].

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