Yale School of Public Health Forum On Outbreak of Novel Coronavirus

Yale School of Public Health  Forum On Outbreak of Novel Coronavirus


(ambient chatter) – [Sten] Good evening. My name is Sten Vermund. I’m the dean of the
School of Public Health here at Yale university. I wanna welcome all of you in the Winslow Auditorium this evening, as well as those of you
joining via live streaming. Thanking in advance our speakers who have joined us this
evening on short notice. My only duty this evening other than to quiet the crowd is to welcome this evening’s moderator
and introduce him. Dr. Saad Omer is director of the Yale Institute for Global Health. He is an infectious
disease epidemiologist, a vaccinologist, and a physician. He’s also a professor of medicine in infectious diseases at
the Yale School of Medicine. He holds a Susan Dwight Bliss Professor of Epidemiology
of Microbial Diseases at the Yale School of Public Health and also has a secondary appointment in the Yale School of Nursing. We are lucky to have Dr. Omer here. He is the inaugural director of our Yale Institute for Global Health. And without further ado… (audience applauding) – [Saad] Thanks Sten, and besides being the dean of the School of Public Health, we at the Institute for Global Health are privileged to have a true pioneer in global health, Sten,
as one of the deans here as the dean of the
School of Public Health. And he’s one of the founding fathers of the Institute for Global Health. So it’s a privilege to be here and talk about this important
emerging public health issue. And, just to outline
what we’ll be discussing, we’ll be discussing the academic response of the various parts of the
university, not university, the University and the
hospital as an institution which is located in New Haven, et cetera, and interacts with its communities. It is a part of it, but our focus here is as an expert panel covering various issues from an academic and research perspective. And there have been other
panels in the past few days and in the last week or
so in the university, but this one has a focus. We want to do a comprehensive focus on a few issues ranging from epidemiology, to communications, to
virology, to some aspects of preventive measures and the public health response, et cetera. I wanna, before I start, I will start with a few overview slides. And then, I’ll welcome our
distinguished panelists. And most of the session will be based on questions and answers. I’ll go through a couple
of rounds of questions from the panelists then we’ll open this forum for discussion. We have a really good and
solid, rich base of faculty and students who have a lot to contribute. So please, feel free to contribute. I wanna thank, in terms of
organizing this, specifically, YSPH’s Department of Epidemiology
of Microbial Diseases, especially, Albert Ko,
who was very instrumental, I don’t know where he is,
I don’t see him right now, but I’m sure he’ll come. And he was instrumental
in choosing the panelists, et cetera, and was very
helpful in organizing this. I also want to thank Global
Health Justice Partnership. Gregg Gonsalves, who’s
one of the panelists, and Amy Kapczynski, and a few others who have been really helpful. Yale is very privileged to have
long-standing collaborations with our colleagues in China. And there are a lot of efforts going on, especially, for example,
there’s a coronavirus working group focusing on
a few research questions, which is very driven by
our Starlight Fellows. And I would encourage colleagues
with connections to China and of Chinese heritage, to contribute in today’s discussion. So without further ado, I will start with my introductory slides. So we know that the initial
cases were identified and reported from Wuhan City in China. And it is an unfortunate aspect that some people call
it a Wuhan coronavirus. I’m very uncomfortable, and a lot of us are very uncomfortable, labeling this virus with a place and adding to a little
bit of culture of stigma that sometimes evolves. But it was identified,
it’s appropriate to say, it was identified,
initially, in that place. It has now, as of this morning,
it’s spread to 28 countries. And this is a map, but there’s also, there’s some sobering reflection on the status of the outbreak in the sense that the major chunk remains in China, and the major chunk
remains in mainland China. There have been over
28,000 cases reported. There are model-based estimates that go much higher than that. But, in terms of reported
cases are 28,353, including, unfortunately, 565 deaths. And that’s a very sobering reflection on the status of the outbreak. But when it comes to emerging diseases, it’s not just that we are concerned about what has happened so far. And can you imagine that,
during the holidays, most of us had, in
fact, yes, I was looking at the reports, there were emails
circulating in early January, starting in late December there
was something percolating. But we didn’t know about
this major outbreak. Certainly, it wasn’t common knowledge. It wasn’t a major concern
and how quickly this disease has become a major concern. We think the family of
viruses it comes from, it sort of tells us that it is likely to have the more prominent
host as a bat virus. You know, when you use icons sometimes, they look closer to Batman symbol. (audience laughing) But, you know, take my word, it’s a bat. But there is a possibility
of an intermediate host. Having said that, there
was a lot of rumors~ and sort of preprints that were shared. Someone looked at the receptors
and had some speculation that we have a snake intermediate host. And, no matter what you guys do, don’t call it a snake virus. There was a headline,
not in the Baltimore Sun, in the Scottish Sun– Baltimore
Sun is a much better paper that the Scottish Sun –that
had this snake flu headline. But, obviously, it got
transmitted to humans. And what really concerned us, was the well-established
human to human transmission. Because when things come from zoonosis, when there’s a jumping
of a virus or a pathogen from an animal host to a human, that happens with some frequency. But what really concerns us is when there’s human to human
transmission established. Just to give you a little bit
of a big picture estimate, so one measure of transmit-ability is the so-called basic
reproduction number. Some people call it basic
reproductive number. That’s not a preferable term. Basic reproduction number, meaning, one way of conceptualizing it
is that in a naive population, where everyone is susceptible
to this infection, if there is one case
introduced of this disease, on average, how many
cases they would infect? So that’s one simple way
of understanding this. And this is a measure of transmit-ability. This is not the sole predictor of how big, how dangerous the outbreak will be. But it is an important measure. There’s some uncertainty
about the magnitude of it. But we do know that it is
not as transmittable as, let’s say, measles, which is one of the most transmittable common diseases which has this R0 Number of 12 to 15. In certain outbreaks,
it has gone up to 17. Ebola had this number of two. And this is, the novel
coronavirus is comparable to SARS. It’s more than the flu. And so, this is some
perspective to keep in mind, with a caveat that our
information is evolving. We certainly know a lot
more about this virus than we knew a couple of weeks ago. But our understanding is evolving
and so keep that in mind. Now, this is a natural
phenomenon in all outbreaks that are emerging. So what can we do? So I have thought about it a little bit in terms of the big
picture policy response, and we will be, so the
implicit focus will be, the response, from an academic
and research perspective for the rest of the panel. But one of the things,
those of you who don’t know, that the writers have very little control over the headlines. So there’s separate editors
who do the headlines. So my op-ed was a little bit more nuanced than the headline would suggest. But we certainly have,
I certainly didn’t go, for a call and response
kind of a framework. “Are we ready?” “No.” (audience laughing) But we did talk about certain gaps. First of all, what I
postulated was, and this was, I wrote this a few hours after the first case were identified. The government hadn’t
formulated its response. So some of us were
concerned about the response being handled by the political leadership. Look, it’s not an unreasonable thing to say that our elected leaders
who we elect in a democracy could be at the helm of a major emergency. But this is slightly different and it should vary from
pathogen to pathogen and emergency to emergency,
and here’s the reason why. When you have an outbreak
with substantial uncertainty, we should acknowledge that uncertainty, but the decision-making
process should be structured in a way that the
assimilation of ever-changing and ever-evolving information,
and the decision-making should be very proximal and ideally led by the same set of people, who have the detailed, nuanced knowledge, intuitively of these things. They should be calling the shots. And who are those people? Fortunately, those in this country who are leading our major
public health agencies, the NIH, the CDC, FDA, even the HHS, various entities within the HHS, are mainstream, well-respected scientists or public health professionals. And so, rather than sort
of having this outbreak, irrespective of the political perspective, in this kind of a situation, being handled at the White
House level, for example, it would be best for the
agency heads to tackle this. So similarly, let the scientists and public health professionals lead. But, look, it is hard,
it’s highly unsatisfying. I was on an AMA Reddit half
an hour before I came here, where a lot of questions,
it’s easy to speculate. It’s very tempting to
say, provide certainty. We certainly know a lot about
this outbreak than before. But we owe it to the general public to convey what we don’t know. But also, what is knowable
and what will never be known. And so, therefore, yes, saying that what is happening right now, you
shouldn’t be walking around in a spacesuit on College Street, it is reasonable to say that. But on the other hand, we don’t know the future
risk of this outbreak. We have some things to go by, and we’ll flesh that out a
little bit in more nuance. So don’t provide false assurances,
don’t alarm, certainly. And the other thing that has happened, as look universities have a
unique space in our society. Which is we are the guardians of evidence. Lux et Veritas is not an accident. And when we are guardians of evidence, we should think about
not just what knowledge is being generated and how
it’s being implemented, but the quality of that evidence. And so, the preprint server movement, where open science requires and nudges us to share our
data and our academic output very quickly on these preprint
servers without peer review. Overall, is a really positive development when it comes to speed
of sharing knowledge and can serve us really well. The genomes were posted very
quickly and very robustly, in the sense that, in terms of the number, obviously there was a
proportion there was a lag. But we should also be careful about how valid that information is. So one way to thread that needle, and there have been incidents that things have been retracted, even
in the New England Journal. So it’s not just the new preprint servers that have been vulnerable. There have been other
things on preprint servers that have been revised, et cetera, and people have changed their perceptions around the outbreak based on that. So one of the proposals I discussed there is to have a preplanned
rapid peer review system that is already set up
to evaluate information on a quick turnaround basis. I’m not going to go into
the details right now. But just to remind you of the response, this is a public health emergency
of international concern declared by the WHO. There have been travel
restrictions, et cetera, and there have been quarantine, various measures akin to quarantine that have been implemented. We will discuss the matter to the value and sort of nuances of these
responses in a little while. These are a couple of
things WHO recommends in terms of preventive measures: covering mouth and nose when
you’re coughing and sneezing, if you’re using tissues into closed bin immediately after use, cleans hands, hand-washing
is a very important preventive measure, it’s not a panacea, that’s gonna take care of all our wolves when it comes to respiratory disease, but it is something that you can do now. It is evidence-based and this
is something we can do now without any further
technological development. And then, there are
certain recommendations, without going into
details, on the WHO side in terms of staying
healthy while traveling. So I’ll pause here and
I will then introduce our panelists one by one. But before I do that, I wanna
thank one of my postdocs who helped with some of those slides, Amyn Malik, and I already
thanked Albert and others for helping organize this session. I’m gonna call the panelists
in alphabetical order. The first one is Ellen Foxman. She’s an assistant professor
of lab medicine and immunology at the Yale School of Medicine. Her research focuses on
understanding the natural mechanisms that protect the airway
from respiratory viruses. And you can see how that is relevant to what we are talking about right now. And one of the interesting
things that she’s working on is rapid diagnostics for these
kinds of emerging diseases for mass screening. So that straddles individual
and public health response. And that’s one of my
favorite kinds of responses. The second panelist is Gregg Gonzalez. He’s an assistant
professor of epidemiology and associate adjunct professor of law of Yale Law School, and
he’s the co-director of the Yale Global Health
Justice Partnership. So he has two homes, Yale
School of Public Health and the Law School. And he’s a perfect example
of an activist scientist. He’s a solid activist, a
very passionate activist, he has the fire in the
belly that we all felt on our first day of grad school. (audience laughing) Some of us get jaded, others stay enthusiastic and passionate. And he’s also a top-notch scientist and models impact of
decisions and operation instead of using quantitative techniques, which are really fascinating. The third panelist is Nathan Grubaugh. He’s also an assistant
professor of epidemiology of microbial diseases at the
Yale School of Public Health, and he has done some very interesting work on genetic epidemiology
and has be co-curating with his colleagues these viral genomes that have been posted or have been shared, and sort of creating this, if you will, the map of this genome as it evolves. And this is realtime public health that takes advantage
of important immediate information sharing and brings
it together for, hopefully, decision-making and response
to an emerging threat. Then, we have Lisa Sanders. Dr. Sanders is a clinical educator in Internal Medicine and
she’s a primary care provider and an Emmy Award-winning
producer of CBS News, as well as an author. And the other thing that
I like, as a House fan, she was one of the inspirations for House. Is that correct? – [Lisa] My column, nothing
personal, I’m way nicer. (audience laughing) – [Saad] Because I was trying
to look for the resemblance with Hugh Laurie. – [Lisa] Sometimes, I win. (audience laughing) – [Saad] And then, our last
panelist is David Vlahov. He’s the PhD program
director and professor at the Yale School of Nursing, and then he also has a joint appointment with Epi here in the
School of Public Health. He was involved and he did
some very fascinating work in early 2000 when SARS
broke and anthrax happened on the response of healthcare providers or the public health workforce, including school nurses, et cetera, who can be the tip of the
spear of a mass response, and was involved from that perspective. But also, as a professor of nursing, has thought about and
would provide his expertise on some of the healthcare and workforce decisions, et cetera. There are a couple of people
who are in the audience who are not official panelists, but I may sort of put them on the spot. One is Dr. Paul Genecin. He’s the director of Yale Health. So if there are any questions that come from that perspective,
I will point to you. And Albert Ko, who’s an
overall smart person, (audience laughing) but also, in all of it, has long-standing links
with Chinese colleagues. But, equally importantly, he’s involved with a WHO working group
developing interventions and evaluating interventions,
more importantly, developing a common
protocol so that we are not have a different playbook for
developing counter-measures against this outbreak. So with that, I’ll switch to
the question and answer phase of this forum. So my first question will be from Nate, “So where did this virus come from?” And I think our best
bet to figure this out is not to send Hugh
Laurie and investigate, but to look at the genetic
data and look at other viruses, et cetera, that could
tell something about that. Could you elaborate a little bit on that. – [Nate] Yeah, sure, thank you. First I would just like to
say that it’s really great to see so many students in the audience, so many people that are interested from a lot of different backgrounds. So the question really gets at something that I’m very interested in with outbreaks and that is misinformation. So, if any of you are on Twitter or are reading some columns, maybe you see a lot of
misinformation about the origins of this outbreak. For a second telling you this
is not a deliberate release from a laboratory. Some of the evidence that
people present for that is a paper that did some, I’m
gonna say, “shoddy” analysis, to say that there is elements
within the coronavirus genome that had an, “uncanny resemblance to HIV.” And therefore it was man-made
and released from a lab that they say there’s a
high-containment virology lab in Wuhan which is actually perfect for being able to respond to these events but then people are suggesting
that the virus was manmade and came from this lab. That is absolutely not true, there is no evidence to actually say that, and the analysis was faulty. Where this actually came from
is like with Saad’s slide, is the group of viruses that this virus belongs to
are beta-corona viruses. And they’re ancient origins are in bats, there’s some 200 different known species of beta-corona viruses in bats, and from what we know there
are seven of these viruses that have spilled over
into human populations that caused outbreaks. Four of ’em cause common cold, they’re right here in New Haven. One of ’em is SARS, one of ’em is MERS, and one of ’em is now
this novel coronavirus. So the question really is then, looking at these genomes
and looking at this data of when and where did this happen? So the when part of it, if we
look at all the genetic data that we have, we can
estimate that the origins of the outbreak was about early December, maybe late November. And there are some questions about whether this came directly from a
live market that was in Wuhan, it’s sort of uncertain if
that is actually the case, the most epidemiological
evidence would suggest that. But it certainly came
from a mammal of sort, so beta-corona viruses infect mammals and this gets into another point
of misinformation out there that maybe this was a snake virus, or maybe this actually
spilled over from fish. We don’t know of any of
these viruses that have ever infected anything other than mammals. So what exactly that
intermediate host was, if there was an intermediate host, before we had a human
outbreak is sort of unknown. – [Saad] So that brings
me to the question about the viral pathogenesis, so
Ellen, do you mind elaborating a little bit on that part of
how the virus effects our cells and us as humans? – [Ellen] Yeah, sure. Hello everyone, it’s great to be here. So my life study’s respiratory viruses and there’s a lot of those
as we were all familiar with the common cold, the flu, and
these viruses that we get, year after year. And so I thought I’d talk about this virus in the context of that,
what are similarities and what are some differences? So as many of you probably know, the way a virus causes illness
is it is able to enter a cell or several cells of your
body and hijack those cells and basically turn those
cells into factories for making more virus, which
can be damaging to the cells. But then your immune system
realizes that’s happening and comes to that area
of the body to fight it, fight the virus and get rid of it. And wherever that battle is going on is where you get the symptoms. So if you get the common
cold virus in your nose, the immune system’s
fighting it in your nose, you get the symptoms of the
runny nose and so forth. If that battle’s going on in the lungs, then you’re going to get lung symptoms, breathing problems and whatnot, the things we associate with pneumonia. So this virus can do both of those things. It can effect the nose or it
can effect the lungs or both. So you might ask, “Well,
why are we more concerned “about this, we get
these viruses every year, “they’re going on in New Haven right now. “We’ve got lots of other
respiratory viruses.” And the main thing is,
is the fact that it’s new to the human population. So as I’m sure many of you
are also familiar with, is the idea that when
our body fights a virus there’s a memory immune
response that’s formed, that makes it so if we see a virus, that virus or a similar virus again, our body is much better at blocking it before it even gets into cells. So that’s always the
concern about a new virus is that none of us have that pre-existing immune
defense up and going. And that makes it potentially
easier for the virus to spread from person-to-person and also
if it gets into your body, you don’t have that first line of defense that could maybe prevent disease as well as if you had
seen the virus before. And that’s why, like a new virus, is always a cause to be alert,
it’s a cause to be vigilant. Just because it’s new, doesn’t mean it’s worse than
other viruses that we know, that we’re familiar with but
it means there’s a potential and that’s why there’s a reason for the heightened vigilance about it. – [Saad] That’s a very
important point to remember, that just because it’s new,
doesn’t necessarily mean it’s worse, unless it’s a disaster movie. (audience laughs) You get that, it’s not- – [Ellen] Yeah, we just don’t know a lot of those things yet. – [Saad] Yeah, exactly. And so Lisa, you’re practically a doc and tell us a little bit
about what preventive measures we can take now and perhaps
if the outbreak expands in the community. – [Lisa] Well, it seems
now, we all know what to do, hand-washing and coughing into your elbow and things like that. Not probably getting too close to people who have obvious infections,
giving them their space, there’s probably pass-through fomites or other kinds of
respiratory-borne particles. So I don’t think there’s
anything particularly wild that we can do, I’m not sure that, certainly if you had a cold perhaps it might help if you wore a mask. But certainly there’s no
evidence that wearing a mask is going to keep you from getting it. Nor does there seem like
there’re very many people who have it now to get it from. So I think having ordinary
levels of precaution makes sense. I mean, I assure you, most people don’t wash
their hands nearly enough. So if people just washed their
hands just a little bit more, it would probably go a long way. – [Saad] Yeah, that’s
certainly aligned with CDC recommendations and specifically, at least at this point, CDC doesn’t recommend wearing face masks. It’s probably perhaps one of
the reasons people wear them is for self-efficacy, they
want to feel in charge. It’s a situation of helplessness, when there is a lot of uncertainty. So perhaps those of us
who, there’s a few who work on health behavior and communications, perhaps we should have a
message of self-efficacy in the form of saying,
“You can wash hands.” Which is not going to
take care of everything, you can practice some
level of social distancing without being paranoid about this, especially when you have someone infected, social distancing doesn’t
mean that start discriminating against people willy-nilly,
it means if you have someone, if you are specifically in
that kind of a situation, you take some of these precautions. And also, the original prevention
to public health response David, do you have any thoughts
in terms of the response at the mass level and some of the things that you were involved with earlier on, in previous similar outbreaks? And the second part of that question of some of the things
that have been employed by various countries, including
China, including the US, and some of the others. – [Assistant] Here you go, sir. – [David] Oh, okay (laughs). Thank you for the question. In terms of what’s going on in China, there’s quite a bit of discussion
about whether quarantine makes things better or makes things worse. And the idea of having people that are separated and protected, seems like it would be a good idea, but it also has a stigmatizing effect where people can under report,
go underground, if you will. And if we take the example of Ebola, which again’s a very different, it’s an analogy that doesn’t
work at a lot of levels, but again just that
stigma of being confined and not trusting in a
particular environment, there’s a lot of discomfort
and anger and acting out that can happen with that. So what’s the process that
can be a middle ground. And the approach that
I think seems better, although you have to look at
what is the local situation, what are cultural considerations
that go with that, are to be able to have a
conversation with people, in terms of what is your
likelihood of having been exposed given what we know and taking that person to have
the individual responsibility for staying at home, for example, right? Secluding oneself for a period of time, that’s a social contract that happens, and for many people that
seems very reasonable and there’re going to be others that may need a little bit
more assistance in that area. So I think that’s one of the
larger issues that comes up and has certainly been in the news, is quarantine or cordon sanitaire, right? What are the different levels
of protection one can have? Now another part of the question is what is a public health response? And Robin Gershon and Chris
Korechi were doing a study of nurse preparedness in New York City and found that if there
was some sort of disaster that was about to happen, what barrier, how many of you would
have at least one barrier, that would stop you from
showing up to work, whatever? So turns out it was 90%, like a childcare, all those different issues and
then, it was not by design, but the Anthrax, hit New York
City and they followed up and they found out that
every single person, every single one of the
nurses, showed up to work, and did what their job was, right? So part of it is recognizing
that people will rise up to what that challenge is, what their professional
responsibilities are, and part of that also is having
the education and support to be able to do that. So I’ll pause, ’cause I
could keep going, I’ll pause. (audience laughs) – [Saad] Yeah. No, so very insightful. So you mentioned quarantine and Gregg I want to sort of switch to you, there was some really interesting work, I wasn’t here in New Haven
in the area at that time, but there was Ebola-related
quarantine, as I understand, in the area and even as an outsider, as someone who looks at these issues, I found Yale Law School’s and
some of the people who were involved in the Global
Health Justice Partnership, collaborated with the ACLU, on a report that came
out of that experience. Which is a very, very
helpful, very pragmatic tool, that a lot of public health practitioners should pay attention to. Could you elaborate, in
terms of, if we quarantine or whatever the parameters
of quarantine should be? And if we do that, how
should that look like? – [Gregg] So if you
were here in 2014, 2015, in wake of the Ebola
epidemic in West Africa, several governors across the country, decided to quarantine
individuals returning from, West Africa healthcare workers,
in absence of symptoms, confine them under quarantine. Including two Yale students, who were not infected with Ebola, and including a West African
family from Westhaven, who were not infected with Ebola, this was done by former
Governor Dan Malloy. We’re still in a lawsuit, the law school’s immigration
clinic is partnering with us in a suit against the State of Connecticut against these quarantines, but we wrote a paper with the ACLU and Doctors Without
Borders that talked about what would happen, the
epidemiological and the legal implications of the Ebola
quarantine on healthcare workers in the wake of the Ebola epidemic. And Dan Bausch who was one
of our evening speakers two weeks ago was one of the
scientific advisors on that (murmurs) illness and helped out. You can see the report on the GHJP website at the Yale Law School,
but the back of the report has recommendations about
what happens next time? Guess what, it’s next time. A couple of things to remember, one is to use the least
restrictive measures possible, so not to overreact. So in the case of the Ebola
epidemic the quarantines were absolutely unnecessary, unjustified. As David is saying, there
may be self-isolation and staying at home if you feel sick or quarantined if
necessary, but really to use the least restrictive
measures for a start, rather than sort of going
full-steam ahead for quarantines. The other thing is to ensure
robust procedural protections. You have rights, under
the US constitution, to bodily autonomy and due process. So when our students
were put into quarantine, we could appeal their cases
immediately to the courts, but it was a 14 day quarantine
and we ended up saying, afterwards because the
time-period was too short. But you do have robust- you do have rights under the constitution to due process. Kaci Hickox was a nurse, with
MSF, who came back to the US and was quarantined by Governor Christie, a republican in New Jersey, her quarantine was overturned
by a judge in Maine, who said it was
epidemiologically unjustified. So in one case the law worked out. The other thing is ensure humane
conditions of confinement. Now I saw on the news today
that China is thinking about quarantining or taking
all the infected people, in Wuhan and other places, and putting them into quarantine camps. What are the conditions
going to be like for them? Are they gonna get adequate health care? Is there gonna be adequate
infection control? We’re thinking about the risks to us here in the United States, but think of the thousands
of Chinese patients with coronavirus now whose health status is going to be put into
precarious position if they are isolated in these facilities that we have no idea of who’s
overseeing their quality and their ability to
prevent onward transmission from these sites. So there’s lots of things we can do, I’m not gonna go through
all the recommendations, but follow the science, as Saad said. Follow the evidence. If you hear the words,
“abundance of caution,” beware, because it means, “Damn the
evidence and we’re gonna do “what we want to do.” And that’s what Governor Daniel Malloy, Governor Chris Christie, and
Governor Andrew Cuomo did in 2014, 2015, which was
bi-partisan stupidity. (audience laughs) – [Saad] On that note of
bi-partisan Kumbaya, I guess (audience laughs) So I want to switch to a lot
of those decisions were made in a communications
environment, in a public, in the view of an
interesting, to say the least, public discourse. So, Lisa, as someone who has
been involved, as an author, as a producer, obviously as a physician, on top of all of this, what do you think, what is your initial impression
of what is happening now? What are some of the nuances, what are some of the adequacies, what are the things that
we should have learned from previously that we could do better? – [Lisa] Well, if you, I
don’t know how accurate a representation of
the country Twitter is, but you don’t have to
look very deep in Twitter to start seeing real crazy
about this proliferate. And to some degree I think
that’s completely natural because of the disconnect between
the messaging that we have “You’re much more at risk of
the flu, just wash your hands, “don’t worry about it,
it’s going to be okay.” Versus closing the country off to people from different
countries, who’ve been to China, imposing quarantine, sending
people to concentration camps when they’re diseased. I mean, that suggests a level of concern, that doesn’t really match
what we’re told to do, right? So we’re told to calm
down and yet everybody in the government seems
to be extremely excited. And nobody’s really trying
to make that connection and when you have big gaps like that, it’s inevitable that crazy creeps in because people are worried and
that’s how people express it. I think that we need to
acknowledge that we have to try to make sure that nothing bad happens, while saying the risk
right now seems limited, and acknowledge that we don’t
know what the future holds. I mean, I think that those
are the reasonable steps. But this kind of “pooh-poohing”
concern, of course, makes everybody crazy and really worried and I think it’s completely natural. As journalists, of course,
we need the snappy headline, it’s essential, I mean,
maybe the New York Times doesn’t need a snappy headline, although I think they have been tempted by that once or twice, but
certainly other publications need that, television needs that. I mean, people are, this is
a competitive environment. So some of that is understandable, I don’t know that it’s forgivable. But as public health
people, we have to step in and try to make it make sense
to the people around us. We can’t depend on the
media necessarily to do it. – [Saad] So the frontline of
this response, in this country, because of the way certain
powers are given to the state and local health departments,
a lot of people don’t realize that yes, CDC provides technical guidance, but actual action, in terms
of outbreak prevention and control, on the ground happens at the state and local health departments. Over the past 20 years, there
has been a lot of investment. The investment in terms
of resources have stalled. Should we be reassured, in
one way, by the headstart we have had, since SARS and
Anthrax and the 2009 epidemic and/or should we be
concerned because of the cuts that the public health system
has seen over the last, at least, six, seven years? So any thoughts on that, David? – [David] I’m not sure except,
how best to start on that. You know it’s a crisis like
this that can be a stimulus to get the public health funding. I mean, we certainly saw
that in earlier crises, it may be delayed, but I think
there’s a opportunity here to say we’ve gotta take the
public health preparedness very seriously and to
generate the resources to be able to respond to this. – [Saad] But isn’t that,
usually vanished after, sort of we get this bolus,
this sugar rush of investment in global health and then we have this seven years of crankiness after that sugar rush dies down. In terms of where we,
the public health system, after building up, having this surge, then suffers from these consequences. Any thoughts on a sustainable way of investing in public health this way? I know Sten, Development
had a very good op-ed, in terms of the global health investment and not having these boom, bust cycles and sustaining the infrastructure. But domestically speaking,
sort of any thoughts on how to maintain that
infrastructure that doesn’t go through these cycles? Sten, do you want to contribute? – [Sten] Sure. The reality is that public health is faced with an inherent challenge. It’s hard to convince
policy-makers to pay you to do something to prevent
something from happening. It’s much more intuitive
to invest in hospitals, to care for the ill, than it is in public health infrastructure to prevent the illness to begin with. So that is part of the
theme I think this evening of all the panelists, that we’re up against tremendous
communications challenges. How do we advocate for infrastructures for disease prevention,
for rapid response? To be prepared for something
that might or might not happen? And there’s so many compelling demands, in a developing country you
advocate for public health and you’re up against
the minister of defense, you’re up against the minister of tourism, you’re up against the
minister of education. Where we have more resources
and high-income settings, it’s almost equally challenging. The NIH budget is in the neighborhood of $33 billion dollars a year and the CDC budget is a fifth of that. So people understand disease,
research to treat disease, tremendous investments in clinical trials, the prevention budget is far more modest. So I think it’s part of our duty, here in the school of public health, to work more diligently
on how to communicate with lay audiences about
public health and prevention. How to communicate with policy makers so that they appreciate
that an ounce of prevention is worth a pound of cure, which I suspect our grandmothers told us. And at the end of the day,
integrating acute care settings, with chronic care maintenance, as with the HIV investments in Africa, where a tunnel vision approach, that these are for HIV,
HIV and nothing but HIV, when people may be dying
of untreated hypertension, where there may be an Ebola
virus epidemic around the corner in which those infrastructures
could be helpful, a coronavirus epidemic. I think we need to be
broader in our thinking, less siloed and more attentive
to how infrastructures can be very potent, they
can serve a function today, for an investment today, but keeping in mind that there may be an investment in near future, for which these infrastructures
can be highly valued. Ultimately, that’s a
challenge we’re facing. I know that the Bloomberg
philanthropies are investing in precisely that with
Tom Friedman’s initiative in New York City and the whole
philosophy of that initiative is chronic disease care,
upgrading that care globally, but having each chronic
disease investment, be prepared for acute responses to outbreaks and I think that’s a very wise philosophy. – [Saad] That’s a really good point. In terms of, coming back to
a little bit more science, and one of the misconceptions and one of the more frequent questions some of us get asked by the press is, “Is this virus mutating?” And that’s such a general question, I’m not gonna go into the details of why is that a non-specific
question because we have someone who knows a lot more about
it than I do, so Nate, would you like to elaborate
on the various layers of that question? – [Nate] So this is one
of my favorite topics of misinformation during outbreaks and the answer is, “Of
course, it’s mutating.” But go back a second. So mutations sort of conjure
up these inherent fears of something unexpected
and some major change, think of American pop
culture – X-Men, right? These mutant humans have
these extraordinary abilities. You think about, have your
ever read “Andromeda Strain” or watched the movie “Outbreak”? As soon as a mutation is
introduced into the picture, something new is happening. So of course, the people
that grew up on this, when you hear the word mutation, right, this is what you’re thinking about. You’re thinking about these
crazy changes that can happen, not about the fundamental
evolutionary processes. So every time a virus replicates,
when it copies its genome on average about one
mutation is introduced. And most of these mutations
don’t do anything to the virus, some of ’em make the virus
worse than their loss, and some of them provide a benefit. But what we’re actually
thinking about, I think, when people ask about mutations are actually natural selection. So are these viruses becoming
better adapted at something. So I think it’s a perfectly
reasonable question to ask, “Is this novel coronavirus,
adapting to humans?” So during the Ebola epidemic,
in West Africa, we found that early on in the outbreak, there was a mutation that appeared and through a lot of
experiments and everything, we found that it eventually
dominated the outbreak. And it looked to be a human adaptation. But when we look at the
epidemiological evidence, so that people who are
infected with this mutation, or with not, there wasn’t a
difference in the death rates, there wasn’t a difference
in how much virus you had. It was a human adaptation that
didn’t really have a major epidemiological impact,
the same with SARS. SARS, after it was introduced, we found these changes that happened that looked like they
were human adaptations, but when you look back at the data you can’t actually determine
if this had any major impact on the overall epidemic. So could this novel coronavirus adapt better to infect humans? Sure, possibly could. Will it have a major
impact on the epidemic? Will it cause more deaths? There’s not really any
evidence to suggest that. – [Saad] So my last
question of this phase, before I open up, is from Ellen, and I want you to talk about a
little bit about diagnostics. So our ability to detect this, especially from the perspective
of being Global Health, you always think about inequities. For example, in Africa,
one of the questions is, the fact that we haven’t
detected a lot of cases, is because is it the absence of the virus or the absence of detection, et cetera? So could you talk a little
bit about our ability to have these diagnostics
and it’s implications for an equitable response
through knowing the burden and the ability from a
scientific perspective, to detect these viruses in populations. – [Ellen] Okay, sure. (alarm rings) So one thing that was really quite amazing about this outbreak compared to other ones is how quickly the actual genome sequence of the virus was online. It took about a week,
I mean, it was amazing and so advance in technology, we all know that it’s much
easier to sequence genes than it used to be, but this is really a
great example of that, where as soon as that
outbreak was recognized, that scientists were able to actually, right from the patient sample, get the whole sequence of the virus. In the past you had to try to grow it and there was a many steps. And that was really an
example of the application of a pretty expensive technology actually, but in a way that’s gonna benefit a lot of people very quickly. As far as diagnostic
tests, that’s discovery, that’s virus discovery and
this has really been quite like a poster-child for
amazing infrastructure for virus discovery. As far as diagnostics,
having that genome sequence online immediately, the
way that we detect viruses, here in our hospital right here in Yale, is often by doing a detection
of the snippet of the genome. And having that genome
sequenced that quickly means you can quickly make a diagnostic test. Which the CDC has done. But then the other issue comes of if you do a diagnostic test enough times, on a population that
doesn’t have the disease, you’re gonna get some false positives. Any positive would be a false positive. So right now what’s happening
is, there’s a lot of criteria, before people will be tested by the CDC, that they actually have a
chance of having the virus, before they will be tested in the US. As far as around the world,
I mean, these kinds of tests are not super cheap. These PCR based tests, it’s
a little bit complicated, you need a special machine, you need people who are
trained to perform the test. So for all those reasons, it’s
not something that you can quickly and cheaply get
out to tons of people. So there are a lot of efforts now to say, how can we use our new
technologies that we have now, that we’re developing on a research scale, to make cheap, quick tests
that could be distributed and could allow people to
be diagnosed more widely. – [Saad] Before I open up for questions, I just want to remind
everyone that outbreaks, as the plague in Europe
or the 1918 flu pandemic or more recent Ebola outbreak, et cetera, can bring the best and
the worst out of people. It’s extremely important
for us to treat each other with dignity and respect and compassion. Dignity and respect and
tolerance is somewhat passive ways of looking at the world and in my short time at Yale,
I think I can fairly say with some confidence, this
is not a passive community. So it also demands that we
are active in our compassion, for our peers, for our students,
not just when the outbreak is in China, but when we have a scenario, that your mom or uncle or
cousin from Colorado calls and says, “I’ve heard
this thing on Twitter” and there is that tone
of concern and fear, that is part of that conversation. So as part of the Yale community, it our responsibility to in
these kinds of situations, I’m not saying this is gonna happen, with this and uncertainty doesn’t mean that it’s gonna explode, it means that it could go
on the other side as well. But if it does happen, my
hope is that all of us, would look back on this year, as part of the Yale community,
most of us who are here, and we’ll be proud of our
response as a group of people. So let’s just remember
that before I open this and have no doubt that
it’s not gonna happen, absolutely gonna happen. But my hope is that we
go one step beyond that, we bring the same passion and compassion and lack of passivity to
this as we bring to the other parts of our endeavors at this campus. So the way, there is a
microphone somewhere, yes, there’re a couple of
microphones on either side. So please ask your questions,
state your name, et cetera and if you have an affiliation
one way or another, if you’re comfortable
please state that as well. Please raise your hands. Yes, this one here. – [Mark] Hi, Mark Russi, Yale
School of Medicine and also Yale health system. In 2003, there was a lot of
discussion about the phenomenon of a super-spreader
(mumbles) of Hong Kong, the index patient at the Metropole Hotel. Are you seeing, perhaps this is question for Nathan and Ellen, are
you seeing anything, either potentially ascribable to
host factors or to some combination of low levels of
humidity, directional airflow, et cetera, that leads you to
believe that there are cases where there is a substantial
excursion from the R0 that we’re seeing of about two
and a half for this disease? – [Ellen] I will start by
saying I don’t really know the answer to your question. The only thing that comes to mind is this. There was a report in several
Chinese media outlets, that they tested environmental samples, at that Wuhan market, and there was a good number of them tested positive for the virus. So that suggests that
at least at that market, there was a spot where there
was a lot of this virus. Why that was is not clear,
but there was a spot where there was a lot of this virus. Was it from an individual
who was shedding it? Was it from an animal? I don’t know the answer to
that, but that’s the only thing that I can think of that I’ve read about or heard about that would suggest
what you’re talking about. I don’t really know the answer
to that with regards to any, I have not heard of any
reports of super-spreaders or anything like that at this point. I don’t know if anyone else might know. – [Saad] Do you want to say something? So there’s a question at
the back, right hand side. – [Wu] Hello, Wu from School Of (murmurs). Okay so I have some
questions, first one is, is there any scientific
way to learn the quality of the data published
by Chinese officials? And the second question is
emphatically, if the initial outbreak is happening in New York, which has the closest resemblance
to high-insurance filled population and mobility and
if the public health official was notified two weeks
after the initial outbreak how can things handle different? – [Saad] So I will, so
Nate, you have thought a little bit about sort
of information quality around this Rpeg, do you have
nay thoughts to contribute to on this? – [Nate] You can start it, I’ll join in. – [Saad] I’m sorry? – [Nate] I said you can
go ahead and start me. – [Saad] So I can start. So that’s a really good question,
so we don’t have a direct sophisticated way of saying
that what a given paper is saying is valid, other
than we do have tools, they are tools that have been
with us and have served us overall well, but not
perfectly, for decades, if not centuries and that,
the most effective tool, is called peer review. And that’s where someone
else, who’s not involved with this whole process, says, “But there’s something odd about this.” And then they sort of, they
question, they push back, and if the responses are not satisfactory, then sometimes the paper doesn’t
get published, et cetera. So that has changed, we
are in a very different communications environment now. Scientific communications environment, in this kind of situation,
the results of these products, intellectual products, are
being shared on Twitter before they are even submitted they are on preprint servers, et cetera. Which is okay, which is overall sharing the viral genome quickly
and publishing that has a lot of value. I think we’ll have to
compliment that with a rapid, standing peer review system. That looks at that and says, “We are gonna perform peer review. “You have posted it on a preprint server.” The preprint server flags it, sends it out to this group
that has signed contracts, maybe pay them to have this commitment. Say, I’m gonna turn around
because there’s a finite types of people that you would need in an emerging pathogen
kind of a situation. You would need epidemiologist,
you would need virologists, you would need a few clinicians
who would pay attention to these kinds of things. So you can have them on a
retainer in future situations where you say that this paper is submitted to this preprint server. We evaluate quickly and we say
does that make sense or not before you know while the
information is still out there we give it a stamp of
approval or otherwise. So that would be a way to do that? Any other thoughts, Nate? – [Nate] Yeah, I’ll just say something on the quality of the
data that’s coming out. So one thing that’s really
important to keep in mind here, is the sheer number of cases
that are being reported a day now into like the 3 thousands. Those are at least then, 3000 tests that are being performed a day and probably not all of them are positive. So you gotta think about some of it may, the quality it may not really
reflect what is happening, I don’t think it has anything
to do with the quality of the reporting per se. It’s just like, how many
tests can you actually do in some of these places everyday, to get that information out. So there’s going to be
under-reporting that’s happening, that isn’t necessarily
deliberate by any means, but it’s just sort of a
function of overloading systems. – [Sten] I mean, the
only thing we can say is that data-sharing is
important at this moment. It’s like, whoever has
data needs to share it at a global scale among
the scientific communities. ‘Cause it’s not just what
you see in the publication that’s important, it’s the raw data that people can run re-analysis on and there’s some question
about whether all the data’s being shared in sort of a transparent way at the current moment. – [Saad] That’s a very important point. – [Ellen] One more comment about the preprint servers
though, it is quite amazing that Nate talked about
that sort of wrong analysis misconcluding about the HIV present in the coronavirus
genome, but I have to say that went up on a preprint
server, many scientists read it, many scientists commented
about it, and said, “This is a problem.” And the authors took
it down and apologized. And that all happened
like within a few days. So actually in a way, the
system is, there is sort of this informal peer review going on. Likewise, with the New
England Journal article that was retracted. So there is sort of an
informal process that’s kind of coming out of our global connectivity, which is sort of encouraging. – [Saad] So I’m generally a
glass 10% full kind of person, It’s always something to be hopeful about. With this exception, after
having worked in vaccines, I’ve interacted with
a few swamps of 4chan, where these conspiracies
live and thrive and multiply and my concern is, even
after all the retractions, some of that stuff will
find a life of its own. But it is, there is always
these kinds of things have trade-offs. I think having access
to especially raw data, but also some of the analysis quickly, my tendered objective
is, it’s a net positive. A net positive not by
sort of close margin, but substantially, but it
has had, to quote Batman, or actually, Spider-man, “With great power, comes
great responsibility.” Voltaire said it, but he probably didn’t
say it wearing tights. (audience laughs) But so with the power of
sharing that information, it is our responsibility
to guard the veracity and the quality of that information, through the full scientific process. – [Ley] I can talk without
the mic, I’m Ley Chen- – [Saad] So we have broadcasting, so – [Ley] So I will wait. – [David] Who was the person in the back that was there first. – [Lay] Should I wait, Lay
Chen, School of Medicine, Department of Pediatrics. I have a question about the, seemingly the difference in mortality between Wuhan patients and those outside. Do you think that’s simply
a question of not knowing the denominator of how
many people are really sick outside of Wuhan or
it’s something specific about the environment? – [Saad] So, Albert, do you
have any thoughts on that? – No, go ahead, I don’t know. – The mic right there. – [Albert] So I think
that of course the numbers coming out of Wuhan are very concerning, especially because of the number of deaths and the proportion of deaths. But this is kind of very much
like many epidemics that occur at the epicenter, the cases
that were identified were primarily severe cases. You can tell by the age, the
average age is around 60, in cases that were reported. If you compare that to what
we’re seeing among travelers or evacuees that are being identified, we’re seeing that all ages and many of them are having mild symptoms. So this is probably as
you’re suspecting, we call it case ascertainment bias,
in that many of the cases in the initial part of the
epidemic were more severe. – [Saad] So I’m gonna
come back to the question that was asked, it was
a two part question. And one of them was what would
happen if something like this was reported in New York City? And I think that’s an important question, and we should keep it in mind
before we criticize other entities, countries, in Africa
or in Asia or in wherever, in terms of what would happen. Both in terms of, it’s
a good counter-factual, both positive and negative as well. So any thoughts on that? – [David] Well, in New York City, you have quite a bit of history, and it’s also a major, in
New York City I think there’s greater preparedness based on a history and certainly a recent history
of events that have happened. So there’s memory, if you
will, and preparedness that goes along. The second part is that the
information and decision-making, is much more de-centralized and so that decisions
can be made much faster than what’s being reported overseas. So again, how much preparedness is there? The experience with it, what’s
the level of decision-making, I think those would be
three of the bigger buckets and we could probably flesh that out more. – [Saad] So we were
fortunate to have folks from the health department or
experience with health department so as the mic goes there, I want to talk to Paul a little bit. Dr. Jensen, any thoughts
about hospital preparedness in this kind of a situation? – [Paul] For Yale? – [Saad] For Yale. – [Paul] Yeah. Well, first just to say that the Wuhan hospital is full, the capacity for surge is a real question. We have a fairly elaborate
preparedness plan, including the capacity
to setup a field hospital at the Lanman Center at
the gym in a case of need, but the concern about how
we would be able to respond to a large number of pupils
with serious illnesses, is a real one. I just can’t say, but there’s
a balance on one hand between trying to balance anxiety and concern, which is predominately
what we’re dealing with now over against the issues of
what would really happen in the event of an outbreak. And then just speaking to
one point that she made, a little bit tangential
about self-efficacy and the need that people have to feel like they’re doing something, anyone hasn’t had their
flu shots, please get one. (audience laughs) – [Drew] Sir, I’m Drew Hadler,
I was a former Connecticut state epidemiologist. For the last 11 years I’ve
been working in emerging infections program here,
but also as a consultant to New York City Health Department. So I think I came from a
control perspective, I can’t say what the reaction would
have been, but I think from the information-gathering
perspective, it would have been much, much more focused and the information will be out there a lot of the information that we need. So for example, I was there
when pandemic flu hit in 2009 and New York City had a
huge high school outbreak it was one you could see through the city, where four or five kids came
back from vacation from Cancun, turned out they had H1N1 they
went to the same high school and within two weeks, there were 900 cases in that high school and at
least that many family members. That was a fair amount of
resources went into that, it was fully described,
transmission issues were described, speculant disease within
that context was described, the city also setup surveillance for hospitalized cases of H1N1 right away, ’cause they didn’t have
it going on quaran, and quickly had counts of am I
in trouble, is this going on. They also had mortality
surveillance and so within a month we had a full spectrum of
really good information to say that H1N1 was no
more (mumbles) can sense, then any seasonal influenza. We do know it was effecting
children more than older adults, which the (mumbles) seem to believe there’s good explanations for that, because older adults, people in their 50s, 40s, 50s, and older,
actually it turned out did have some immunity to H1N1. And weren’t quite as severely
as effected as younger people. So basically we could
put it in perspective and then base control measures on that. Again, I don’t know what the
immediate control measures were dealing with this
but there would have been surveillance setup that
would have attempted to find, full measure of the disease,
how severe it was, and CDC would be invited in as it was then. Which actually helped the
CDC (mumbles) station because we can see the life department anyway and so there would be a lot
of communication with CDC, daily conference calls with
jurisdictions around the country to explain what would be
happening if New York City is the one that was affected
and we’d have the information we need to try and have a
rational response to it. Not one that’s sort of all desperate. – [Saad] There’s someone
in the back, there. – [Thatcher] Thank you, Thatcher,
School of Public Health, New (mumbles) Health. So my question is about the
large number of patients so since the outbreak a
large number of patients, with mild or severe, no
matter mild or severe, they rush to the hospitals
so I believe the number is quite more than 10 times, 10 times more than the hospital can feed. So my question is, so would
you recommend people with mild symptoms not to go to hospital
and just to stay at home? – [Saad] So I can start the response, and if anyone has anything to add or you have any thoughts on that. So this is very important. So at the big public
health response level, in an emerging situation, having clear evidence-based communication, is extremely important. So talking to people that at
certain stage of the outbreak and response, certain kinds
of symptoms, need to stay home for the “abundance of caution”
in terms of the individual response may require, if
there is a judicious use, to self-isolate without
disrupting the more old-fashioned society in that sense. But also, so Dr. Jensen
mentioned, Paul mentioned, something very important,
getting your flu shot. And the reason why you say
it’s not biological, is that flu shot doesn’t protect
against the coronavirus. But it does protect against
a major respiratory illness. So it helps in two ways. First of all, it has it’s
own benefits in terms of reducing morbidity and
mortality in several age groups. But also it reduces, if
you are reducing symptoms, of respiratory illness in a population, then unnecessary visits that were not caused
by Coronavirus go down. So again, we’re not
helpless, passive, spectators to something that is unfolding. We have inherent
self-efficacy in the form of for example, hand-washing,
which is evidence-based measure for all respiratory
illness, flu shot, and some of the other measures. Do you want to say something
more, Paul or Albert, any thoughts on this? – [Paul] Yeah, I think
that’s very important. Also just to, a less likely
influenza is in the community, the more likely it is to be able to assess people with
respiratory infection quickly and efficiently in the event that we do have an
outbreak of coronavirus. – [Sten] That’s an interesting
point, I did it in a study awhile back, looking at if you
have syndromic surveillance in New York City, looking for outbreaks, can you immunize people enough so that you have greater specificity. And the challenge of getting
enough people immunized is there, so from a population
perspective as a concept, I think it’s great, but that
could also add to the case that we want to make,
is that’s another reason why we should be encouraging immunization. – [Saad] Yes, there’s a question there. – [Hadjur] Hadjur from the
(mumbles) So as a Chinese, all my family is still in China and my friends share me all
these information all day. So my question or wondering
is when will this end? I think the correct question
is when do you expect the turning point will be? Some experts say we have
incubation period of two weeks, and since the quarantine
of the whole, has seen a lot of quarantined have been taken, there is roughly 10 days or
two weeks already passed, So if you’re doing some modeling
or forecasting when do you expect this (mumbles) will show? – [Nate] I’ll just start
with something basic on this. So just based on one model that I’ve seen, and I don’t know necessarily
if this is going to be the most accurate prediction,
but it was looking like mid to late February would be the peak. But there’s a lot of
things that can happen, between now and then, that would
even change those estimates and then you have to wonder, the data that this is all based on. So I don’t know if we
have a really great handle on when this is going to be peaking and when it’s going to start coming down. – [Saad] An enough
providing false assurances, I think it’s reasonable
to share experience with other corona
viruses, especially SARS, but there does seem to be
a seasonality associated with those viruses. And they seem to be more
transmissible using the term loosely in this kind of a situation, the peaks are higher in winter. So there is, again, tentative
hope that some of those months will have a positive impact. But again, it’s tentative,
we are dealing with, I would be providing false
assurances by providing some certainty around that. – [Sten] I think the fairest thing is that we don’t know,
during the Ebola outbreak there were multiple mathematical
models that predicted wide sort of trajectories of the epidemic. So I think that information
is trickling out, to parametrize these models,
so until we have more data, until we have more sort of examination of how these parameters were put together, I think the safest thing
is to say, we don’t know. – [David] I taught with Alex
Langmuir, who was the founder of the immunologic intelligence service. And the one thing that we
used in class was Farr, right? Farr’s law, and it’s the first
law of epidemics which is, “Whatever goes up, must come down.” So we don’t know where that point is- – [Saad] Sorry, did you
say that you sort of talked to Langmuir himself? – [David] We taught together. – [Saad] Oh, you taught together, okay. So you were professor at
the age of 12, I guess. (audience laughs) (mumbling) – [Jerry] Hi I’m Jerry
Friedlander, School of Medicine, School of Public Health. So one of the real unusual
characteristics of this is how rapidly it’s spread globally and in a month’s period
of time this is (mumbles) so many countries. It’s very
different (mumbles) precipice. Unfortunate time in which this occurred and people traveling. So I wonder what we know about
the response in other places? We’re most concerned
about what happens here in the US, but this is
a global epidemic now, of some magnitude that
we don’t really know. The response will be
different in different places and that’s gonna have
consequences actually for the global nature
of this and (mumbles) and the future. So is there any coordination,
on an international level at this point? Can we, somehow or
other, advocate for this if it’s not going on in a way
that’s actually functional and important and the
information coming from other places will be very, very
important in terms of what we understand and how we can respond. – Albert might- – [Saad] Albert, you wanna? (mumbling) – [Albert] I think this
is being videotaped. (audience laughs) So the politically correct
answer is that, of course, there is coordination, and that coordination
is being done by WHO, on many different levels in
terms of operating response, in terms of training,
capacity and so forth. But we all know the situation with WHO has been essentially neutered because of the lack of
multi-level funding. Much of the funding is
bilateral and which is really incapacitated some effective
responses and coordination. So I’m being a little harsh
on that, but I think that is a gap and that’s why we have
this myriad of bi-lateral responses which are potentially
not well-coordinated. And I think the concern and
I’m just gonna jump on to, I think what Kai said, and others, is that I mean, this is I think we’re
still in the exponential phase of the epidemic in many of the cities of the 5 million people
who left Wuhan before. We don’t know the exact
proportion of who’s effected but I think it’s fair to say,
with regard to provinces, Shanghai and Guangdong are
in the exponential phase. And that delay of models, which has been modeled three days, and maybe much longer, so I think we’re in for the long-term. I think the big question is, is that in places that have weaker
surveillance systems, I’m thinking about Southeast
Asia, South Asia, maybe there’s only three cases, but
how many kits are available? And so the concern is
we can go all the way back to the beginning of what Nate said, this is probably one of
seven pandemics or so, of the coronavirus, it would
be good to be optimistic it would be good to think
that we can push this into a season that has low-transmission. But I think we have to tie
it on this being, spreading and not necessarily peaking early. And I think we also have to
plan on what’s gonna happen in the most vulnerable
populations around the world. And what happens when it gets there, and this is a case fatality
rate, that may not be as high as MERS or SARS, but it’s not going to
be negligible either. – [Participant] It’s
going to be heterogenous in different parts of
the world, seasonally. – [Lisa] So, I want to go back
to a question that was asked earlier about the people
going to, with mild infection, going to the hospital. And I think that a lot of
that could be prevented if we had a very good sense
of what the natural history of this disease was
and what it looked like when it was bad. Like, does it start off
mild and become bad? That’s one disease pattern. Or does it start off bad and stay bad? If it starts off bad and stays bad, then if you got a mild
case, then you shouldn’t go to the hospital. But until we know what that
is, until we can describe it and make that public, people, of course, are going to go to the hospital with even the mildest
symptoms ’cause of course they’re worried. And rightfully so perhaps, but I think that’s one of
the pieces of information, that we really need to get out to people. Is what does it look like when it happens. Like, is it bad all the time? Or does it start off mild and get bad? That’s an important distinction. – [Saad] So, in the interest of time, I want to finish on time, I’ll
take only a couple of more questions and there were a
few questions on this side. We spent some time on
this side for awhile, so you had a question for awhile and then there was one more in there. So unfortunately we will have to stop here and I’ll be happy to stay
back and maybe others will also stick around. – Hi I’m (murmurs) from the
department of internal medicine and herbology. I was wondering, you mentioned
seven of these corona viruses some causing cold and yet some like SARS with a lot of fatality
do we know, biologically, what is different about the SARS versus the ones that cause colds and causes this without fatality and can use that information when we’re studying mutations
in this current coronavirus to predict potentially what
might be more of a problem? – [Saad] Start? – [Ellen] I can start,
I can start on that one. Well, one interesting thing
is there’s a coronavirus, the corona viruses that
circulate every year in New Haven and throughout the US,
sometimes cause colds and they can cause serious illness, particularly in people who
have other health conditions kind of like what we’ve seen a little bit with this virus too. As far as the receptor the
virus uses to enter cells, this virus uses the same receptor as SARS and the same receptor as
a different Coronavirus that causes colds, so
that’s not the key thing. With SARS there was some
information about it suppressing the anti-viral response pretty well, which you can imagine
would allow the virus to get to a higher level in the body. But as far as this virus,
I really don’t know. So it’s interesting that
people have studied already where those receptors are
found, the receptor the virus uses to get into cells,
they’re in the upper airway, they’re in the lower airway
where the gas exchange occurs in the lung and also in
other tissues of the body, like in the liver and the blood vessels and things like that. But I think there still
needs to be more work on the pathogenesis of this
one to figure out exactly. It’s not totally clear, kind
of getting back to something that was said earlier is at the beginning when a lot of people who are presenting to a
hospital are very, very sick, a lot of those initial
people were also people with other medical conditions, who you might expect to get ill. More ill than somebody who’s
perfectly healthy and young. So it’s still not totally clear, how that factors into the
pathogenesis we’re seeing and the mortality rates too. – [Nate] Really quick, so we
can go to the next question. So it does seem to be, if the virus can use the ACE2 receptor, it can infect humans, if it cannot use it, then it can’t infect humans. That’s one of the parts of it, but whether this is gonna
be SARS or a common cold? We can’t just look at the genome
and sort of gaze at it yet. We don’t have the tools
or enough data to say how bad this is gonna be,
that’s not quite possible. – [Saad] So there was
another question from there or that has been answered by? So I’ll come to Evelyn
and then I think we have, I said two or one more, sort of time for one more question, et cetera. So Evelyn, do you want to? – [Assistant] Michael can we
do this question and then I- – [Saad] Okay. – [Evelyn] So I know China
just finished building a thousand person hospital isolation ward. What do y’all think? Is this an efficient way
to contain the outbreak or are we gonna end up with more issues than we started with? – [David] I’m curious about the
construction and the quality and the resources that go into that, supplies that are available,
what’s the access? Really don’t have enough
information about the specifics. But I am gonna turn it
over to Gregg, who does. (audience laughs) – [Gregg] No, but that’s not
the point, the point is that we can’t abandon our
Chinese brothers and sisters and say like, “Let ’em do what…” The point is that the
conditions of confinement have to be clinically suitable and meet human rights norms. And if they’re being dumped in a hospital with poor infection control and without sufficient clinical capacity to take care of people, it’s
not the right thing to do. We all have friends in China and we need information to get out so that people are taken care
of both in their communities and in any facilities
they might be sent to. – [Evelyn] Hi, Evelyn Shay
from the School of Medicine and Public Health. I actually wanted to follow
up on Jerry’s question and hear from Albert, when
you said there are myriad bi-lateral initiatives, is
that countries with China? I’m curious to know sort
of the degree to which there’s a partnership with China, whether it’s CDC or government and how effective that has been? How much are they doing this
on their own domestically? How much is their engagement,
it’s a little bit hard to tell from the outside. (presenter chuckles) And I think this goes along
with what Gregg was saying, to what degree is there- – [Albert] So I’d very much
like Sten or David to answer this question. (presenter laughs)
(audience laughs) – [Sten] My authority is my
friends in China on WeChat. Who’ve been lighting up my phone all week. And it does seem like the Chinese are pretty much on their own on this one. There isn’t any substantial
international help infrastructure in Hubei
province in Wuhan city. The US CDC has a presence in
Beijing but I’m going to guess that there isn’t a coronavirus
control expert in the group. But they do have good, solid (murmurs), just that it’s not improbable
that there’s communication with the China CDC. China’s CDC’s a pretty
sophisticated operation. They have a sort of a command center for outbreak investigations
some I visited that reminded me of the CDC command center
and was modeled after it. And I am thinking that the Chinese are largely tackling this on their own. I have no evidence to the contrary and my friends at WHO
are not deeply engaged. I know people high up
in the state department that I talk to and they’re
helping the Chinese, but they’re helping them
from Geneva and from Atlanta. So I think there’s a lot of communication, a lot of consultation, but on the ground, the Chinese are handling
this on their own. I think that’s fair to say. – [Evelyn] Can I just… – [Sten] Yeah. – [Evelyn] Sorry just to follow-up, if this is helpful at
all, but I was speaking, I was in Beijing recently and I was speaking to
a documentary filmmaker about a film she made
about emerging epidemics and she was focusing on the Ebola virus but when she was in Africa
she said that the best makeshift hospital that she
had encountered were the ones built from China so I think
that if that’s reassuring that’s great infrastructure-wise but I understand- – [Sten] Just put things in perspective and I think there’s a lot
of issues coming around freedom of information and
dissemination of information. As I said, the Chinese CDC is a very
sophisticated organization and once, and I think this is up to debate and this is all speculation, but once the outbreak was shown, I mean it was identified. And there are probably
policy reasons why it wasn’t the early warning system didn’t work as it had worked with H7N9. And they detected other
emerging pathogens, in the interim time between
SARS and are very efficient, why it didn’t work now is unclear. And that’s something that I think we really don’t
have a good answer, but once they had detected
it, and once it went into the early warning, through IHR. They followed all IHR
regulations very sophisticated responses, they sequenced the genome, they are now doing, many randomized controlled
trials for treatments, many of those are probably
gonna come out with information in the next one or two
weeks about how to cure. So very sophisticated
responses on many fronts. I think we have to just put this all kind of into perspective. – [Saad] Yeah, so I’ll then
wrap up, I wanna wrap up exactly at seven. I know there are other questions and that’s an indication of
the importance of the issue and the engagement so I’d
be happy to stay back. I can’t speak for other
people, but I’d stay back if you have other questions, et cetera. But I don’t want to wrap up
as we wrap for seven on time, colleagues who put it together
and helped to organize on a quick notice. I’m not going to be able to
go through the full list, but specifically Ros and Alyssa
and Mike Skonieczny and Jen and many others from different
parts, and Colin and others from YSPH and YGH et cetera. Who made this possible
at a very short notice. But I will wrap up, as I wrap
up, I want you to remember the intensity of response,
mounted by health workers, both clinical workers, but
also public health workers in China as we speak. They keep all of us safe, they have risen up to the challenge. Set aside all the politics,
individual health workers and the health system,
folks on the ground, have responded, not just on
behalf of their own community but on behalf of us. And if there was any
doubt of the sacrifice, we should remember one of the physicians who was initial canary in
the coal mine, passed away. There are reports that he passed away. There were mixed reports, but
I think it’s now confirmed, that he passed away today. On that somber note,
we should also remember that we are not helpless
observers, we have self-efficacy, both as humans and as compassionate beings and as scientists, public
health professionals-

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