ISPP 2015

Career Opportunities in Pharmacy
Novel Coronavirus Panel at the Johns Hopkins Bloomberg School of Public Health

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 Public Health Magazine 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 coronavirus outbreak involves an emerging virus that’s deadly and rapidly spreading. Tens of thousands of cases in dozens of countries, including the U.S., 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, policy makers, 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 Inglesby is Director of the Johns Hopkins Center for Health security at the Bloomberg School, Dr Caitlyn Rivers is a senior scholar at the Center for Health Security, and Lauren Sauer is Director of the Operations for the Johns Hopkins Office of Critical Event Preparedness and Response, or CEPAR. Now to our questions. We’ll begin with the virus. Tom, what are coronaviruses 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 coronavirus family, which infects both birds and mammals, including humans. And in humans there are coronaviruses that cause mild disease and coronaviruses that have caused very serious disease in the past, including two diseases called SARS 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 coronavirus develop 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? What we know about most viruses is that when people are most sick is when they’re most infectious. We don’t know enough about this virus to say that that is absolutely the case, but we believe the 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 the at that yet, so just for general purposes we believe that most of the 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– 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 it 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. Caitlin, a question for you from an alum: so the reports have been of, say, 2 percent fatality rate, and the alum wonders why is that so alarming? 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 is 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 we’ve had a huge surge in reports of cases but 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, when 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 the 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 Lauren, a question for you: For many of us as we think about coronavirus, the only other ones we have heard about are MERS and SARS, and certainly with SARS that outbreak really kind of lodges in our memory, the 2002, 2004 outbreak which had a pretty bad number of deaths and cases. How would you compare the two, between this novel coronavirus and the virus that caused the SARS outbreak? Yeah, that’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 outbreaks. 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 common as the 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 the infection prevention control processes are really important, we know early detection is really important. So all the lessons that we 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 that helps us, great. So Caitlin 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 percent, but we’re still learning more about that. What we don’t know is how much spread we will see in the U.S. Right now there is very little recognized community transmission. Actually, the only two cases that we know of in the U.S. got them from their spouse in 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’s what makes us concerned. Tom, one of the– a group here at Hopkins, the Center for System Science and Engineering has created almost a real-time tracker of coronavirus cases, and just taking a look at that map, what jumps out to you? Is anything surprising there, or a kind of is this what you would expect for this kind of an outbreak? What’s hard to say in terms of this kind of an outbreak since this is so unusual 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 Hubei Province area. and kind of that 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 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. And 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 that countr and that country as yet. And it just shows how connected China is to the rest the world. They have flights out of Wuhan, they’re 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. Caitlin, kind of a a quick question for you: what signals are you looking for in terms of as this outbreak transitions, what would you look for in terms of being a signal for a potential severe pandemic?
Right now, the most of the community transmission 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 were covered but we can’t be sur. But there’s also 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 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 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 we’ll have to kind of understand that, because the earlier we respond, the better we’re going to be. 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 community had any sense of 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 responding to take this as seriously as anything they’ve ever done before and also 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. Great, so as part of this outbreak, we hear a lot about preparedness. What is preparedness exactly, and how well are most countries prepared? So one working definition of preparedness is the collective work that’s being done to prevent disease, detect outbreaks, and respond to them in the outbreak detection realm, outbreak detection 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 our center worked with another organization called NTI 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 preven, to detect, and respond. We ask them a series of questions and try to gauge capabilities in countries around the world. And bottom line in what we saw was that there’s a wide range of capability in that area of capacity 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 U.S. health care system. How prepared in general is U.S. health care? And specifically what about Johns Hopkins Hospital, what’s happening there?
Yeah, I think there is a wide variety of levels of preparedness across the U.S. health care system, and I think it’s important to note that the U.S. health care 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’re 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 people in beds throughout the health care system, throughout the hospital, that couldn’t necessarily be moved or leave the hospital system, if we have a massive influx of patients. That being said, here at Hopkins and nationally, we are firm believers in preparedness, and I think it’s important 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 CEPAR, 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 or 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 WHO guidelines is a perfect example of that. Making sure that were 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 our ambulatory care centers, or even just messaging to staff, students, and faculty.
And 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 what is Hopkins saying to its community, as well as what other institution should be saying to 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 to you to make informed decisions. So following the guidelines that are put out, whether it’s at the institutional level or the CDC or the WHO, acting rationally and calmly, and remembering those things we’ve learned from previous outbreaks and previous responses. We know what we’re good at and we learn from previous responses what we’re not good at, and we try to make improvements in between. I think the mask example that is all across the media is a perfect example of this. So we have had to run across the country, and I think globally, on the use of face masks and purchasing face masks. And we know and the WHO 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 microcosm of a broader preparedness message. We know the evidence doesn’t support it, so how can we implement it at our facilities. One more question for you, Lauren. One of the most important parts I think of a preparedness is building up the diagnostic capability. can you let us know where the U.S. 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 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 test 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 of this takes from 24 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 a really important next step.
How soon do you think that those diagnostics will be expanded in and accessible by other other centers? Yeah, I think it 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 at with the diagnostic side as well. Hopefully within the week, we’ll start to see these tests, maybe not the real-time RT-PCR, but we’ll see the test that the CDC is using at the state health departments, 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 for 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 the risks and the benefits to travel, so anyone considering a trip should check those to resources. Great, so another, Caitlin, another question that we received 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 projects, 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 also manufactured and distributed? What’s that timeline look like? Yeah, there’s a lot of interest right now in identifying vaccine candidates and trying to move them through the pipeline. The U.S 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 does some of those options look like for, you know, in terms of a 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 their own context, but these are the sort of general actions that can be considered. So this is a question for the whole panel here: What are some concrete steps that people should be taking to protect themselves? People as individuals, but then also sort of at that country level as well? Caitlin, do you want to 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, cough etiquette, 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 the only thing to add is just — and Lauren’s already mentioned it before — is that in most places in the country, there’s a at a good state health department or city health department that is working hard to stay very current. So checking in with the 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 the general things that we do to prevent ourselves from getting flu in a season. Lauren, anything to add? No, but coming from the emergency department, I’ll just reiterate what Caitlin said: washing your hands is absolutely critical and definitely get your flu shot. Flu shot, 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 are coming from China are putting themselves under a voluntary self-quarantine for 14 days. Is this necessary? I don’t think we have evidence that people– that quarantine in this way is proven to work. I think people are– the government has issued new policy around it just over this weekend about putting people in quarantine. We should say that quarantine in the way we’re talking about now is taking a group — an individual or 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 mean taking people who have symptoms and have been diagnosed or are under investigation, and having them be in isolation for period time. The latter isolation is a proven public health intervention which we use all the time for people who have contagious disease. These larger scale quarantines are of less proven value. It is now part of the guidance of people returning, that if they’ve been in China in the last two weeks, they’re now supposed to be in home isolation and that’s the guidance that’s supposed to be followed if that person came in, I think, Sunday night or later. That’s the CDC guidance. Okay, and obviously with with quarantine, 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 it’s the least restrictive thing you can do while still protecting public health an individual health, and so that’s really important for public health practitioners to evaluate. Are there less restrictive options that would still be effective? Is it sound, is it evidence-informed? Sre we making this decision out of fear versus out of science 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 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 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. We say hand hygiene, you mean washing your hands.
Washing your hands, frequently, always a good idea.
And what about the sort of the different antibiotic ointments or solutions that you can put on your hands? Are those effective, or should we actually be using 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. If 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 percent 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 that there are a number of very well-respected modelers in universities in different parts of the world who do believe that there are many more cases that we’re seeing. I mean, 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 the depend on the data. 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 at a complicating factor. Yeah and that’s why the epidemiologic piece of the investigation tool that the CDC has set forth is so important. So the travel history is an important element because otherwise you would be testing everyone who came through with, you know, with flu symptoms or other respiratory symptoms or fever. So that’s why we’ve really focus on honing that travel piece a little bit better.
Great, 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 happens. 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 it’s clear at least in China that were 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 this outbreak could peak, cases could be dropping off, but then six months later, another, a second wave, as in with the 1918 flu, would you say?
We know that for some coronaviruses, there is a seasonal component. The coronaviruses that we live with every day have a seasonal component, but two 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? That’s a difficult question, I think nature is constantly creating new strains of virus in animals, and they’re constantly moving between animals and people, so in terms of a strategy for preventing all of that, 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 twenty years along those lines. If we’re still 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.

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