COVID-19 Outbreak Update

FASKIANOS: Good afternoon and welcome to the Council on Foreign Relations Conference Call Series. I’m Irina Faskianos, vice president of the National Program and Outreach here at CFR. As a reminder, today’s discussion is on the record and the audio and transcript will be posted on the CFR website.

Today’s discussion will be led by Michael Osterholm and Jessica Metcalf.

Michael Osterholm is the director of the Center of Infectious Disease Research and Policy at the University of Minnesota. He is also the Regents Professor and McKnight Presidential Endowed Chair in Public Health, all among other roles at the University of Minnesota. He served as science envoy for health security on behalf of the U.S. Department of State. And previously, Dr. Osterholm served as a special advisor on bioterrorism and public health preparedness in the U.S. Department of Health and Human Services.

Jessica Metcalf is a demographer and assistant professor at the Department of Ecology and Evolutionary Biology at Princeton University. Her research interests include evolutionary ecology, infectious disease, and public policy. As such, the Metcalf Lab at Princeton University focuses on characterizing the landscape of immunity to support public health and developing a framework for understanding the evolution of immune function.

Dr. Osterholm and Dr. Metcalf, thank you very much for being with the Council community today. I thought we could begin with you, Dr. Osterholm, to give us an update on COVID-19—where we are; the state of preparedness in terms of the PPE, the personal protection equipment; as well as the supply chain.

OSTEHOLM: Well, thank you very much for being here with you all today.

Let me begin by stating the obvious: anyone who is trying to digest information around COVID-19 realizes we’re all drinking from a firehose, and what happens by the hour now is only overtaken by what happens by the minute. So anything we say here today will, obviously, be a temporary statement in the sense of what we’re learning.

Let me just give a very, very brief update on where we’ve been because I think that helps set the horizon of where we’re going. You know, we’ve been following this at our center here very closely since literally the end of December. On January 20 we put out a document to a group that we advise that, in fact, this was going to be a worldwide pandemic, and despite WHO’s insistence that it could be contained we saw no reason that that was going to happen given that we had switched from seeing this as a SARS- or MERS-like situation where the highest level of transmission occurs often after the fifth or sixth day of infection, rather that this looked very much like an influenza transmission model with very early and significant transmission upfront. On February 3 we put out an additional document saying that it was going to show up worldwide, though it would probably take another month because of the time period that it takes for two to four to eight to sixteen to thirty-two cases per generation occur. And sure enough, in the end of February it showed up. And then we had suggested that, in fact, it was—when it did show up in countries like the United States, it would be those initial early hotspots, the kind of epicenter-type things that we saw, where transmission had been going on unrecognized for at least six or seven generations, and then when it finally became apparent that there would be a fair amount of already community transmission occurring in the communities, which has happened.

Now, I tell you this not to say, oh, aren’t we so smart, because it’s to set the tone of where we’re going. At this point I don’t have a clue—(laughs)—what’s going to happen next with this virus. We can go into this more. Anybody that tells you there’s seasonality likely to happen with this virus, they don’t know what they’re talking about. I will just be really frank with you and say that. I could give you all the reasons why that won’t happen. Whether there will be waves with this virus, we’re, obviously, inferring an influenza epidemiology to say that. This is an influenza virus. Even though I just got done saying it has a transmission model like influenza, there are some important differences. And what I can say is that I do believe—and we’re going to hear more from Jennifer (sic; Jessica) on the modeling issues—that this is a virus that likely will continue to be transmitted at some heavy pace, you might say, for as long as we have, you know, less than 40 to 80 percent of the population infected. And I don’t know what that number is in there, but I think that only with that will we see enough human immunologic rods into the reaction.

I do think we have good news in that we’re having some emerging data come forward that, in fact, there likely is some immunity that occurs with human infection that may have some durability. How long that is we’re not sure. Those data come out of animal-model studies where macaque monkeys have been challenged with the virus, recovered, and then re-challenged, and they were universally protected on re-challenge.

And I think that in terms of our preparedness we need—we can talk about that, but we’re quite unprepared. I wrote a piece for Foreign Affairs back in 2005 in which I said we were unprepared for the next influenza pandemic, which of course this is really a coronavirus causing an influenza pandemic in a sense. And I can only wish we were back in 2005 because, frankly, we were much better prepared back then. Our health-care systems had much more elasticity. They were able to expand and take in these patients. They had more equipment. They had more workers. And most importantly, they had more PPE. We’ll, obviously, talk about that today, but I think our health-care workers are clearly at risk. And while not all the health-care workers to date in the United States have acquired their infection from occupational settings, as of this morning we have at least 103 health-care workers in this country who had acquired infection that we know of for sure. And this is a really huge, huge situation that’s going to emerge very quickly, just as we saw in China and in Europe.

As far as the world, I think—I say this, that—and I don’t mean this to be inflammatory, in a sense—but the world’s on fire with this virus, and that’s going to have major implications on when we look at supply chains for things like testing, things like PPE, you know, ventilators, et cetera, because everybody wants this all at once. We’ve never really planned for that kind of event, and we’re realizing the fragile nature of these supply chains.

So I think the transmission will occur—continue to occur for some time. I don’t think we have a national plan. I have not seen a national plan that I think really lays out how we’re going to thread a needle between this physical modeling that showed us we can suppress this and probably keep infections to a minimal, but it will mean totally shutting down society, much as we saw in China. The other side of the coin is that we just let it go and overwhelm our health-care systems with potentially millions of deaths in the U.S. Clearly, the impact on health care would be substantial not just in terms of providing care for COVID-19 patients, but also the collateral damage of those who also need health care for their heart attacks, for their strokes, et cetera, not being able to get that.

I would be very cautious and just say one last statement about suppression to date and what that means. We have taken a lot from the Asian models and have made conclusions about what will happen with this virus. I can tell you I’m in frequent contact with colleagues in Singapore, Hong Kong, and Korea, and I think they would tell you right now that there is a very tenuous period of whether or not they really are going to be able to control this for two reasons. One is that originally there was a stream of cases or potential infections coming in from China, and that was much easier to contain in terms of understanding it, identifying it, and dealing with it. Today the whole world is a source of this virus to any other country in the world, and so unless you’re going to deal with everybody who’s traveling like China’s trying to deal with right now, you’re going to keep getting it reintroduced in even if it has already been eliminated. And at this point I don’t think that we can say any country has.

I think China is in a major experiment right now. As they continue to release the population back into the workforce in Wuhan and Hubei province, to some degree Beijing, I think we’re all still waiting on bated breath what will happen there. I do think the Chinese will be able to respond to it as effectively as any country in the world, but I think we have to be very careful to say this is over with. And I’ve seen far too many people conclude that the—by what they did in Asia it’s a model that we can do in the rest of the world, which I don’t think is true, but more importantly I don’t think that their model has yet been proven to be nearly as successful as people think. This virus is still there.

So with those general overview comments I will be happy to turn it over to Jennifer (sic; Jessica), and we can go from there into, you know, open it up then for questions if that works with you, Irina.

FASKIANOS: Great. Thanks so much, Mike.

OK, Jessica Metcalf, you do a lot of disease modeling, and can you talk about that modeling and what you’re seeing with this pandemic?

METCALF: To start with, I completely agree with my colleague Michael. I think that absolutely we’re still in the trajectory of rapid epidemic growth. I think it’s worth emphasizing that everything we do today—all of the social distancing that’s taking place, all of the interventions—we’ll only see the results of two to three weeks in the future. So it’s worth absolutely keeping that in mind: The effects of our actions are, you know, indistinct and in the future.

I think that everything we do, as well, to flatten the curve is still—you know, despite the long term before we see the rewards of our efforts, it’s going to be valuable in terms of trying to reduce overwhelming the health system, but also the innovations that are happening in looking for treatments, et cetera, et cetera.

I completely agree, also, that there is a question about how we manage a stepdown. Is there a path where we don’t have to move to a situation where almost everybody has been infected, and therefore hopefully has some kind of immunity, but rather we’re in a situation where we can somehow manage infections and contain them? And people have suggested a number of technological fixes—tracking of and testing, et cetera—but I think it’s still very much an open question as to whether these are going to be feasible, as Michael says, in our societies, in the communities we live in.

So I’ll move to the question I think about a lot because I work on demography. As of today, the Johns Hopkins website reports that we have seen more than eight hundred thousand cases and thirty-nine thousand deaths. But of course, that doesn’t tell us about anyone’s individual risk of dying of coronavirus, and that’s because there’s kind of—you have to unpack what underlies the hood there. So for every individual you have to count—account for the fact that we have varying risks of infection. Once you’ve been infected there’s a risk that you have symptoms or severe symptoms, and then on top of that the risk at which you die. And for each of those three levels there’s both the reality and then the data that we have to inform our understanding of that reality, and the data is shaky for a number of reasons at each scale.

So to start with the risk of infection, clearly that’s going to be shaped by both the social-distancing and control policies that are in position in the communities that you’re living in, but also your individual behavior. The trouble with identifying the risk of infection is that everything suggests that the proportion of individuals that show symptoms is actually quite small for this infection. So estimates have ranged from between, you know, 30 to 80 percent of individuals are asymptomatic, so show no symptoms whatsoever. And we can get to grips with this by testing individuals for active virus, but that will only tell us people who are infected now, not people who were infected, say, back in January. An alternative, and one that I think will be very important in thinking about how we move towards stepping down the distancing measures we have in place, is serology, and this is where you take samples of people’s blood and you look for long-term markers of infection. And hopefully that should also provide evidence as to whether individuals are protected or not, and that might give us ways of, you know, releasing health-care workers back into vulnerable settings, et cetera. So that’s the risk of infection. We’re likely to underestimate the fraction of individuals infected unless we really start testing much more widely, but also start deploying serological tests.

And the second is the risk of being a case. And the reality is that many lines of evidence suggest that this is—you’re at higher risk with certain comorbidities, you’re at higher risk certainly at later ages, and you might be at higher risk also if you’re male. Again, the data that we have to inform us is complicated because the way that cases are defined vary from setting to setting. Over the first couple of weeks of the epidemic the definitions kept changing all the time simply because people didn’t know what they were dealing with exactly, but even later on in Wuhan what was defined as a case became much more severe as time went on simply because hospitals had to turn people away and you had to sort of enter the hospital to enter the database. So we are also going to be tending to ignore a large fraction of the iceberg in our definitions of cases.

And then, finally, there’s the point of mortality. And you might think this is a fairly distinct piece of data, but it turns out, especially early on in the outbreak, we were probably missing deaths because people didn’t realize this was a serious risk. There’s people who die at home that might not be entering our registries of COVID-19 mortality. And then a third piece is that there—you know, cases that are occurring today are unlikely to die for two to three weeks, and so if you’re to do the number of cases divided the number—by the number of deaths exactly today you would actually end up underestimating the risk of dying. So all these cases come into play. And then what you see often presented in the press or presented in summaries is going to be either the infection fatality rate or the case fatality rate. So you take all this diversity—all these patterns across age or comorbidities or sex—and you punch it down to a single number. And so, of course, one of the things we see is that—one of the things you might expect is that countries with higher-aged populations will tend to show higher case fatality rates simply because more individuals in the population are old.

So the ground is always shifting, as Michael also said at the start of this. The exact numbers keep moving up and down. But it certainly seems to be the case that we can point to age, comorbidities, and possibly sex as important factors in the risk of dying of this infection. And I think there’s absolutely no question, again as Michael said, that both the footprint of this infection on our demography but also the footprint that comes indirectly through how this infection has perturbed our health systems is going to leave an even more longer-lasting shadow because of all the things it will disrupt in terms of normal health-care functions.

FASKIANOS: Thank you, Jess, very much for that.

Let’s open it up now to questions from the group. We have a very big group again, so please state your—a brief question. Don’t make a statement. And we want to get as many in as possible.

Brandon (sp), over to you.

OPERATOR: Thank you. At this time we will open the floor for questions.

(Gives queuing instructions.)

The first question will come from Nick Turse with the Intercept. Please go ahead.

Q: Can you both talk about the special challenges of COVID-19 in the developing world? Especially Africa, where cases are beginning to spike and supplies like ventilators and PPE are in very short supply.

OSTERHOLM: Well, this is Mike. I would be happy to take a stab at that initially.

Believe it or not—and this may seem counterintuitive—I think many people in the lower-income countries, and even to some extent the middle-income countries, are going to actually fare better in many ways than we do in the high-income countries. And you can say, well, wait a minute; that doesn’t make sense. When you actually look at—as Jessica just pointed out, if you look at the age distribution of the population, many more of these are much younger individuals. Other areas that are really an important comorbidity is the issue of obesity. And while obesity is of somewhat of a problem in the low-income countries, it’s not nearly the same problem. And already I think we’re beginning to see an emerging pattern here in the United States where we have seen an unusually high number of hospitalizations and even intensive-care requirements for people under age fifty-five where the one major factor has been obesity. This is something we didn’t see in China in the elder-aged population. We saw it clearly in younger people in China. But here in the United States, about 50 percent of our population over age forty-five is moderately to severely obese, so that’s not occurring.

But the other thing that’s not the case is, is that in many instances there aren’t the kind of comorbidities you might expect to see that you see elsewhere. For example, in the United States seven hundred thousand people here are living with end-stage renal disease. And that has been associated as a risk factor in previous outbreaks, particularly with influenza, where we saw bad outcomes. I could go through a laundry list of other things like that where we don’t really understand the intersection of age, gender as Jessica just said, and these comorbidities.

So, at the same time, your point is a very good one about the lack of medical supplies, et cetera. Let me just tell you an example. Our center has been following very closely and have been very concerned with drug shortages for some time here in the United States, and we identified 156 different drugs that are needed for acute critical care right now or within hours or people die, or it substantially increases their morbidity. Of those 156 drugs, 100 percent are generic. Of those, almost all of them are made offshore of the United States; and China, India, and ironically the Lombardy region of Italy happen to be major places where those are made. We’re already beginning to see potentially major shortages of these drugs above and beyond what we had already had before, and the unfortunate kind of perfect storm may be developing here. We’re working very, very hard on this issue to try to project which drugs are going to be short and why because the supply chains from China are now finally drying up; meaning that was in the pipeline in December, this is the last of it. And so we’re working very closely right now on this very issue. Those are drugs that in many cases are not even readily available in a low-income country, so they’re not going to miss them as much as we’re going to miss them here.

So I think that on one hand, while there’s every reason to think with the lack of infrastructure, medical care delivery, number of physicians per population, those are all reasons why the low-income countries will have a harder time; but because of the age distribution, the relative infrequency of the same comorbidities we see here in a country like the United States—which, you know, unfortunately, those people have already died in many cases in low-income countries from that comorbidity; they’re not still alive—I don’t think we can quite say what’s going to happen that way, but it’s not an automatic that it’s just going to be that much worse in the low-income countries.

FASKIANOS: Jessica, do you have anything to add, or should we go on?

METCALF: I have a—I have a slightly different perspective. I do think, having done some modeling, that while the—certainly the age structure is going to play out, there is still sufficient—you know, moving into later age classes in many of these settings, especially in urban settings, a little bit of modeling suggests could be profound, and particularly profound since, you know, these are settings in which social distancing may be impossible because of living conditions, because of food access. You have to go to market.

I think there’s a real issue—so I work a lot in Madagascar with spread of trusted information. So health-care workers really have no idea what’s going on and they’ve been sort of, you know, reaching out to ask about which foods they should be eating in order to prevent COVID-19. So engineering efficient spread of trusted information I think will be really important in trying to combat this in this setting.

And of course, you know, even if in—without comorbidities we’re seeing that it is possible to experience very severe symptoms, and certainly there is—this is happening in a tsunami of other infectious diseases in many of these settings. But it’s still likely to be one last straw that might break the camel’s back, and so I think thinking about economic safety nets for families where providers become ill or providers die is likely to be really important.

And I also think, though we do—we’re starting to get a handle—and it’s still very incomplete—on comorbidities that have mattered in China and that matter here, from obesity, et cetera, it’s important not to forget that, for example, hypertension is extremely abundant in places like Madagascar, and we don’t yet know how this virus will interact with the backdrop of infection that is occurring in all these other countries and remains poorly documented. So how will it interact with—for example, with malaria? We don’t know. And so I think it could be a really serious issue and one that we just—there isn’t—there aren’t clear levers to pull to diminish the impact.

FASKIANOS: Thank you. Next question.

OPERATOR: The next question will come from Lawrence Wright with the New Yorker magazine. Please go ahead with your question.

Q: I have just written an article for the New Yorker about convalescents and whether they can be put back into the workforce, and also whether plasma from their blood containing antibodies might be useful as a stopgap measure. And I wonder if you would comment and give me your opinion about those matters.

OSTERHOLM: Well, this is Mike. Since I mentioned it before, I do think that there will be some evidence of durable immunity amongst individuals who are infected and recover. It’s very important that we confirm that. I think Jessica’s point earlier about serology is right on the mark; we absolutely need that. That would be a major advantage if we can tie that back to one’s actual immunity. So I’m confident, I think, that based on other viral diseases like this and with what we’re seeing at least in the initial animal-model data that we have reason to believe that this could be the case.

In terms of the plasma, I think it’s a very important step forward. I’d just caution everyone that, you know, we have a lot of things on the table right now that would appear to be the answer, and I know quite certainly that most if not many will not be, and in fact the toxicities of some of these treatments may be a challenge. I think this one has every biological reason why it’ll work. And I was very involved, just by way of disclosure, in some of the earliest discussions about setting up the national network that Arturo Casadevall and others are working on right now, so I think this is a great idea.

My biggest concern is how applicable it is to how much of the world. And what I mean by that is just doing plasmapheresis, that the very requirement of the kind of materials that, you know, in terms of what do we do in blood banking and so forth, by themselves are already limited. And the question is, how many people can we plasmapherese? How much of this plasma can we actually obtain and how much will be available for patients around the world? I think that’s a challenge.

On the other hand, the—it’s surely an early stopgap. And one of the issues is—(inaudible)—monoclonal antibodies that will do some of the same work that we could produce in much more mass in production. So I think it’s a very thoughtful way to go.

You know, we’re still having some confusion, you might say, about just what is it that’s actually killing people with COVID-19. Early on there was a sense it was a classic acute respiratory distress syndrome kind of picture—ARDS—I mentioned before, which surely immune-modulating drugs may help or play some role. On the other hand, we’re also seeing a major cardiac involvement that is unclear what that is all about. We need much more information on that. And if that actually is a direct impact of the virus on the heart muscle itself, then that becomes a different situation where in some cases the potential use of immune modulators may actually be detrimental. And so we don’t know that yet, and this is a very important point.

But the one thing with plasma, it should basically be helpful regardless of what the condition is that you’re—or the pathology in terms of this disease.

FASKIANOS: Jess, anything to add?

METCALF: And just to add, so on the question of—on the question of duration of immunity, I think it’s an incredibly important question. I think we have lots of evidence from the other coronaviruses. So people did experimental reinfections of humans with some of the other coronaviruses, which the betacoronavirus—these cause, you know, the common cold. They’re very mild. Well, they tend to be mostly mild.

So the alphacoronaviruses, which are closer to the one we’re seeing now, mathematical models have suggested that while there does seem to be immunity to infection, or at least there’s a suggestion of that signature, it might not last very long. So it might last a year or so.

The question of, you know, how we move from serology to identifying whether individuals are immune—and you can be various phases of immune. Are you immune to infection? Are you immune to disease? Clearly, what we really care about in terms of people reentering the workforce would be immune to infection, right, because you don’t want people transmitting to vulnerable individuals. I think that’ll take, you know, really concerted work in the coming months to line up our understanding of what serological (axes ?) are telling us about individuals’ immunity and resisting infection, et cetera. So basically, testing, testing, testing.

FASKIANOS: Next question.

OPERATOR: The next question will come from Emerita Torres with the Soufan Center. Please go ahead with your question.

Q: Hi. My question is related to the supply chains, particularly to the extent you can comment on the ability to make ventilators. I know—I read a New York Times article that mentioned, for example, a Medtronic ventilator has around fifteen hundred parts supplied by fourteen separate countries and we’re already behind in terms of the manufacturing. So I’m wondering if you can give us a sense for our ability to meet the demand, and your thoughts and your assessment on it. Thanks.

OSTERHOLM: Well, thank you. Actually, I cited that information in my op-ed piece with the New York Times on Saturday. And this is one of the concerns we’ve had about the Defense Production Act, that it was basically one where it was somehow if we did this we could, you know, rescue the U.S. from supply-chain shortages, and if not we couldn’t. And I think that, frankly, there was much more political theater behind that then there was reality.

We’ve had companies now step up. I happen to know—(laughs)—some of the back and forth that’s gone on with those. And the challenge we have is twofold. One is we need equipment, but we also need it in a very, very timely way. It’s not something you can gear up.

And I mean, just stop and take a thought about this. I mean, if you’ve been making airplane engines or you’ve been making car parts, what now gives you the machinery to make one of these very finely-tuned/machined pieces that would go into a ventilator? And how do you bring this together? I think most people were surprised to see the more than fifteen hundred parts in a—in this case it happened to be a Medtronic ventilator.

Now, there’s versions of these that can be more crude, you might say—that don’t have all the necessarily bells and whistles, that could be simpler. But the bottom line is you’re really starting from scratch with people who don’t have any real more experience than people who are already doing this. So if we were talking about expanding capability, we’d be talking to the—to the Medtronics of the world in mechanical ventilators, we’d be talking to 3M and Honeywell in terms of N95s—which has been done, by the way, and these companies have been operating largely at full capacity with their ability to extend new lines.

But the machines it takes to make N95s, for example, again, are themselves sophisticated machines. Most people don’t realize that if you take, for example, just the facemask portion of an N95, that’s actually a poured matrix material that dries that creates this very unique ability for air to pass through but at the same time stops these viruses. And so that it’s not just that simple. So I think from a timing standpoint I don’t see really these supply chains in any way, shape, or form being materially impacted by this.

If you look at the estimates of what we need right now for N95s, it’s in the hundreds of millions. It’s not in the doubling or tripling what we currently can do, and I think our whole message has been we just have to prepare for that. As a former secretary of defense once said, when you go to war you don’t get to go with what you want; you have to go with what you have. And we are going to be far short, whether it be PPE, whether it be ventilators. And I think that even testing is an issue right now, but we’re seeing major challenges with supply-chain limitations on reagents.

So that while we keep talking about all this new testing, don’t forget the world is on fire. Everybody wants a test. So even if you have a new platform that’s different, you still have to have reagents. And I think that our work here suggests that probably within three to four weeks we’re going to actually see some real challenges. I can tell you that the state public health labs in the United States right now are virtually out of reagents. And even though they have the capability of doing more testing, the private, the commercial establishments, we’ve been working with them to get more information. They are under real pressure in terms of supply chain integrity.

And so I think no one had really thought about all of this. You know, I mentioned earlier about the drugs. You know, here—imagine. I mean, we have the U.S. Department of Defense that is just as vulnerable to these critical key medications for its troops coming from China as anybody else in the general public. They don’t have any stockpiles. They don’t have any unique manner of obtaining this material, or those drugs, in a priority way. So if nothing else we’re going to learn out of this pandemic is the absolute critical nature of supply chains, and what they mean, and how do we maintain them, and what do we mean by actually have elasticity, or redundancy, or backup? And I don’t think we have ever really appreciated that until now we’re in the middle of it and we need all these things and can’t get them.

FASKIANOS: Great. Thank you. Next question.

OPERATOR: The next question will come from Thomas Novotny with San Diego State University. Please go ahead with your question.

Q: Hi. Thanks for all this great information.

I was wondering about the issue of comorbidities, and in particular related to tobacco use. And we’ve got a fair amount of information now from China, and the metanalysis that was recently done show that the progression to ventilator use and death is significantly higher for those who smoke. And we haven’t seen a recommendation come out about smoking cessation. And also, the consideration of whether tobacco sales might be kind of eliminated even as non-essential in this particular situation. And I just wonder if anybody has any thoughts about that. It hadn’t been mentioned as the comorbidity issue.

OSTERHOLM: Well, can I—just for the sake of the call—I just have to say, it’s good to talk to you, sir, doctor. I just—the questioner who just asked that actually has been one of the people who’s been leading the anti-smoking work in this country for a number of decades and has probably saved more lives than a lot of general practitioners. So my hat’s off to you. You have been a hero for a long time.

The second thing is your point is right on the mark. I mean, smoking clearly is a major issue. It was in China. Although, it was interesting the differential, as you know, Tom, the difference between males and females in China is also very, very strikingly different by age in terms of smoking. But this is a primary issue right now in terms of warning, advising people on how to reduce risk that surely should be top and center for this disease as well as others. But, yes, it’s a very important point.

FASKIANOS: OK. Next question.

OPERATOR: The next question will come from Jove Oliver. If you would please announce your affiliation.

Q: Hey. Thanks. I also serve as a senior advisor to the International Union against TB and lung disease and wanted to go back to the comorbidity thing around TB. You know, last year nine million cases, one-point-seven million deaths, a lot of that in sub-Saharan Africa. Wondering, you know, as well as post-TB lung disease, so folks that have come back from TB and are no longer active. But wondering about the data you’ve seen on that comorbidity with COVID. And then as the sort of rumor mill around chloroquine has heated up, my organization is hearing reports in Africa and other places of people not being able to get their malaria meds, the chloroquine. So wondering both, I guess, thoughts on the efficacy or how much that’s a fantasy and the reality of that sort of depleting supply chains where malaria patients need it.

METCALF: So I’m not—I’m not aware of that many places that are still using chloroquine actively for malaria, but I’m not up to date either. My sense is that there was resistance in the malaria threat in many parts of the world, but it’s used in other treatments as well, and there certainly seems to be supply chain issues around that. My sense as well, although as Michael said at the start of this call is that the information changes every minute with this infection, is there is very little evidence to support its use for this infection. I completely agree with you that I think we need to better understand the impact of things like TB and malaria on outcomes for this infection, but also we need to really keep our eye on the ball in terms of maintaining treatments that are in place at the moment even in the face of this onslaught. I don’t know quite how you do that, but I mean, I think it’s incredibly important.

OSTERHOLM: Yeah, this is Mike. I would just second that and say that that is a very important issue. The CDC will coming out today, if it hasn’t come out already, a report on the preliminary estimates of the prevalence of the selected underlying health conditions among patients of the coronavirus disease here in the United States up through the end of the month. And I have had a chance to review that. And I’m not aware that there is any suggestion for any data. And it really, I think, is data relative to the low-income countries of the world in terms of interaction between TB and COVID-19, as we’ve seen it so far. But I surely wouldn’t want to conclude that that were the case for the low-income countries, where it was going to be much more of a problem. But it has not been noted, to this point, at least in China, EU, and the North American experience, that I’m aware of.

FASKIANOS: Thank you. Next question.

OPERATOR: The next question will come from Judith Miller with Manhattan Institute. Please go ahead with your question.

Q: Hi, Mike. And long time no speak. (Laughs.)

But I wanted to ask you about your statement earlier that you haven’t seen a national plan. We keep hearing these 5:00 briefings from the White House saying things are stupendous, terrific progress, everything going on. Would you evaluate the efforts to date and tell me, all of us, what you think are the vital elements of a realistic national plan for this country?

OSTERHOLM: Well, if you have a day—(laughter)—I’m more than happy to do that. But let me just summarize it briefly. Yeah, I don’t think we do have a national plan, that I’m aware of. And you know, and I continue to be very struck by the fact that what is being said or done has really been in the absence of CDC expertise. You know, we all recognize the CDC had a moment in terms of the testing issues that, you know, is going to one day be clear what happened why, and what could have been done differently. But CDC possesses some very, very talented people in the pandemic preparedness and response area. They understand frontline public health, which I’ve seen many people who are well-intended and who really care about this just don’t have any understanding of frontline public health in this country and where it’s at.

For example, I will go so far as to say I think one of the best things we could do right now in most areas of this country is stop all contract tracing. It is not helping. It is basically fixing two of the five screen doors on your submarine. On the other hand—and I mean, that’s because there’s just so many people out there. Just know that there’s two kinds of people in the world today, those that are in quarantine and those that will be. And I think that what we need to do is concentrate in high-risk populations and help them. We need to bubble all the long-term care facilities in this country the best we can right now. There are so many long-term care facilities that don’t even have an N95 within a block of their building.

And we’re seeing that those can often be explosive events, when you get an outbreak in one of those, that actually does have a big impact in communities, and into the hospital. We know that right now we could be doing much, much more in the way of syndromic disease surveillance, which in the absence of more uniform testing or availability of a test is very helpful. This is a system where you’re actually surveying a randomly selected group of medical clinics—random in the sense that they are throughout the community but they’re the same ones week after week. And you look for influenza-like illness.

And in New York, it was very clear and compelling that you could see influenza-like illness reports as a percentage of the visits seen by week was dropping through February until the very end. And then you saw it increasing. And it was really indexing the earliest days of COVID-19 in New York. And the health department did a great job in that. And how do you use that? We’ve seen the same thing here in Minnesota, just delayed by about two weeks. That’s the kind of information that can give a community the sense that, OK, now is the time to really put the pedal to the metal and to basically make sure that you’ve got the most you can to bubble your community down, not just a long-term care facility or any other congregate living area.

I mean, I could go through a list of things like that, that are actually in the end going to have more impact getting us through this. Now, there are plans that have come out from individuals. Zeke Emanuel put one in the New York Times in his op-ed piece on Sunday. Scott Gottlieb and colleagues did yesterday. I think these are aspirational plans, which I surely welcome. I think they’re very important. They’re staged plans. Phase one, two, and three. Neither of them, I thought, were realistic in their phase one because they just said: Go buy more ventilators. Get more—(laughs)—you know, PPE. And do more testing. And do contact tracing. All the things of which I just said, from a standpoint of supply chains, isn’t going to happen.

But that doesn’t mean that the principle isn’t there. And what I proposed in my op-ed piece right now is I would love to see a Manhattan Project-like approach, with bringing together some of the best minds right now in public health, in medical care delivery, in public policy, in business, medical ethics, et cetera. And give them forty-eight hours, maybe seventy-two at most, to come up with a detailed plan of how are we going to take each step of this, and how are we going to assimilate new information as it comes in to help judge where we’re going to go next, instead of basically almost a day-to-day kind of, well, this is where we’re at today.

And I think that’s exactly what we need. I think that’s what’s going to help the business community understand what their measures are. I mean, we’ve been ringing a lot of bells in this country and we don’t have a clue how to un-ring them. When we shut down—I keep asking, if we’re going to shut down a community how do we know when to un-shut it down? What are we going to do? What’s the measure? And that’s what I think would bring more clarity. It would bring more, you know, outcome-driven approaches. And, you know, it’s the kind of thing also that people like Jessica, and the group that do modeling and so forth, will have more data to then help inform it, if we have the planned into the system. And I just don’t see that happening right now.

So that is my personal view. And I’d love to be dissuaded of that in some other position.

FASKIANOS: Jessica, any—your perspective on that?

METCALF: So I completely agree with Michael. I mean, from my perspective, you know, one of the pieces that might help thinking about how we step down from shutdown would be serology. There’s like a bajillion efforts going on all over the country and there’s no coordination. It’s extraordinary. I mean, there’s no—there doesn’t seem to be a leadership in that space.

OSTERHOLM: Yeah. And I just want to reemphasize that. That’s exactly where we should be, is setting up these systems for data like this. And again, this is where CDC is missing. We need them because that’s what they’re really good at. And you know, right now we’re led by fifty state governors and we’re being led by fifty state health commissioners. And what we need is that national approach. So as Jessica just said, we should be assimilating serology data from any number of different places, and learning, and bringing into together. And so that, I think, could come from a national plan that would be very, very important. And it would be kind of game plan we’d at least all understand too.

METCALF: Thank you. Next question.

OPERATOR: The next question will come from Ed Cox with Patterson Belknap. Please go ahead with your question.

Q: With respect to Belarus and Sweden, they seem to be taking a different approach at the opposite end of the spectrum, if it is a spectrum here, than the four tigers of Asia approach, which we’ve already discussed. Would you comment on what they’re doing? I know the Brits tried the same thing, and then they decided they would—they would not go that direction. If you call it a, what, protect the vulnerable, the elderly, and otherwise life goes on as usual?

OSTERHOLM: Well, let me just say, we’re going to get through this. We are going to get through this. And that’s what we have to keep remembering. And I think the challenge is going to be how we get through it. You know, what is the morbidity and mortality going to look like? You know, what it is that we’re going to do to economic disruption and ruin? You know, how many people are going to commit suicide because of the fact that they are in such dire economic straits with no future that they see forward? I mean, we have to look at all the damage, both directly and collateral damage. And I think we’re not yet quite there yet of getting a plan to understand how we do that.

But let me also say, we want to be a little bit more cautious about conclusions. I feel we’ve jumped to conclusions that are far too soft to have arrived at. For example, I was asked by a major medical journal to review a paper that was submitted by a group of researchers in a country where the virus had been recently introduced into. And they made conclusions about what was happening. Well, by the time they got the paper written and got it submitted, the virus had continued to spread in that country. And I can tell you today that the actual epidemiology of that disease has changed when it moved from a group of young people to a group of older people. But at the time the paper was written, it didn’t have the older people.

And so one of the things I feel like we’re trying to do is we’re trying to finish the game after the first inning, and say it’s done. OK, here’s the final score. And I’m sitting here saying, no, there’s probably at least eight innings left, OK? And it doesn’t mean we don’t want updates from the first inning, and it doesn’t mean that they’re not important in helping us understand where we’re at, or whether we need to change pitchers, or whatever. But the bottom line is, is that we’re all in a learning mode. And countries that seem to have had a certain set of circumstances, findings, et cetera, today, follow them for six more months, six more weeks even, and you may have a very different set of circumstances.

So this is what we have to be constantly willing to look at new information. And, you know, if in fact the first inning, the second inning, the third inning, and the fourth inning all look pretty much the same, you know, then you can start to say, well, maybe that’s exactly what it is. But, you know, we’ve seen this happen already in Europe. Let me give you a better one. In Korea, you know, we have everybody commenting on this very low case fatality rate that was occurring in Korea. And any of us who looked at that said, well, wait a minute, you know, the median age of this religious sect, which was the group that was contributing most of the infection there in the country, was about forty-two years old. That was it. Now that we’re beginning to see cases occurring in the community that are not tied to that, the case fatality rate’s going up because of an older population.

So I think this is where an epidemiologic perspective helps because it’s adjusting. And that’s what Jessica said earlier, about how important this is to be able to understand that. And so if you pick any one country and ask me today what’s happening, my first response will be, seriously, well, can you give me six months and I’ll really give you a better answer—which of course I know I can’t. You want an answer now, and we all want one. But I think that’s what we have to also understand, that this is an evolving pandemic that we’re leaning from, and that don’t hold any piece of data too close to your heart right now because somebody may rip it away from you in the next month.

FASKIANOS: Jessica, anything to add?

METCALF: Yeah. I think just to add, you know, what mathematical models do is they allow you to kind of draw a line through the data that we see, and see what makes sense, and prove our assumptions about what’s going on. And they also allow us to predict the future to some degree, right? But, you know, it’s very hard predicting the future, it turns out. (Laughs.) So much policy has been grounded around our forecast of what’s happening. I mean, that and the evidence from Wuhan, the evidence from Italy projects that this is not completely unlikely.

I think that there—as Michael says, there’s so much opportunity to learn that we’re just squandering as this epidemic progresses. We’re not—we don’t have leadership and coordination in terms of data collection, but neither are we piloting policies—and potentially extremely difficult and damaging policies like closing schools—in a way to evaluate what’s going on. I mean, I think the precautionary principle is absolutely clear here, but we could be much more thoughtful about how we proceed and how we learn from what we’re doing. And we’re just not doing that.

OSTERHOLM: And I completely agree. Well said. (Laughs.)

FASKIANOS: Next question.

OPERATOR: The next question will come from Susan Levine with Castle Rock (sp). Please go ahead.

Q: Hi. Thank you.

Today’s New York Times talks about how we’re seeing countries in Asia shutting down again because they’re worried about new infections coming from elsewhere. So I’m wondering how it will even be possible for us to stop sheltering in place until we see real progress in both treatment and vaccine?

OSTERHOLM: Well, first of all, you know, I think it’s important to understand that this is going to play out for likely months ahead. This is not going to be over with soon. And you know, where people come up with this way it’s going to happen here, and this way it’s going to happen there, you have to understand that the data are limited. And we surely can talk about a wave, but knowing that that wave still only, in a sense, impacts 20 or 30 percent of the population, you still have a lot of people left to go. The next wave or an ongoing transmission is going to continue to occur. And that’s where I think the statistical modeling has been very helpful, because it’s kind of helped demonstrate that. You know, a vulnerable person’s a vulnerable person until they’re not a vulnerable person anymore. And how many of those are will dictate where transmission goes.

At the same time, we can’t stop living life. You know, we need our groceries. We need—you know, if you’re in New York City and you’re living above the fortieth floor, I bet it’s kind of a big problem for you when your elevator goes out. You need your elevator repair person. You know, I look at what it’s doing right now to first responders. As you said yesterday, NYPD. Look at that. You know, over nine hundred members of the force are how positive. Thirteen percent absenteeism yesterday. New York Fire Department, very similar picture. We need to keep those going. How do we—we just can’t tell them, you know, you can’t do your job, you’re going to get infected.

I could go through a laundry list of people like this who are essential to our everyday lives. I still haven’t, as I said before, figured out how you do remote working in picking up garbage. And so somehow we need to craft what that means, and how—who’s at lowest risk, potentially, of having an adverse outcome. I want to be really clear, you know, in epidemiology we deal with numerators and denominators. In life, it’s all about numerators, because these are our family. These are our loved ones. These are the people we work with, the people we care about. And so we’ve got to somehow blend both of those too in a way that says, you know what, people under age twenty are going to have some bad cases, and some may even die. But if you look at the risk overall, compared to those are the upper age group with these underlying risk factors, it’s very different.

So I think this is where I talked earlier about trying to thread the needle with rope. We got to do this. We got to find a way not to let society just collapse. At the same time, we’ve got to do whatever we can to minimize the impact. And I must say, just parenthetically here, you know, last week I was on one of the talk shoes. And it was really a tough time for me, because one of the lieutenant governors of one of the states said: Well, you know, well, maybe it’s just time for the old people to step aside, and get infected, and so we don’t ruin the economy for the younger generation. And if you really believe that, that’s one thing. I don’t.

But more importantly, that says, oh, and by the way, we don’t care about all those health-care workers—who are also young—who are basically being sent into a viral machine gun with no vest on and no bullets in their own gun. You know, we’re going to lose a lot of very, very young and dedicated health-care workers. And so I think what we’re trying to do is find out how do we not overwhelm our health-care systems? How do we provide the best care possible for COVID patients, as well as non-COVID patients? And how do we, at the same time, minimize that, but at the same time allow our economy and society to continue to move on?

And I hate the term economy, only in the sense—and I said this in the op-ed piece—is that people then assume you’re putting a price on people’s heads. How many—how many dollars are you losing because this many people died. That’s not what we’re talking about at all. We’re talking about making sure that we can live in a world today where people do have jobs, where they do have financial support, where they do have access to health care, they do have access to mental health care. That, to me, is what means keeping this economy going.

FASKIANOS: Jessica.

METCALF: Just to add, I mean, I think it’s—like Michael said—it’s incredibly sad imagining what we’re asking our health-care workers to do. It’s really, you know, extraordinary. I think that the—one of the ways in which we’ve got to start thinking about this, is we’ve got to think about innovation. Is there something around serology? Can we learn about who’s immune? Can we develop ways of tracking at-risk individuals that don’t invade privacy, et cetera? So I think there’s going to have to be some really interesting changes in those sorts of ways in which we function in our societies, because, as Michael said, we’re not just going to let a bunch of people die.

FASKIANOS: Next question.

OPERATOR: The next question will come from Peter Katona with UCLA School of Medicine. Please go ahead with your question.

Q: Thank you. Wanted to know, regarding the shortage of PPE, what you thought of the machines that do vapor phase hydrogen peroxide or ethylene oxide are using, like, to kind of mass-sterilize these PPE.

OSTERHOLM: Well, thank you. We actually have a major piece going up on our website, that’s CIDRAP.umn.edu, on that very issue tomorrow, I think. And CDC has actually been leading the way, again, trying to provide information. And one of the challenges of this, of course, is what is the integrity of that device after it’s gone through these different areas? And right now, FDA has basically released a certain element of opportunity here to do things to these devices in such a way that you can do this and still use it. NIOSH and others have not. And so what we’re trying to do is get a comprehensive U.S.—and for that matter international—understanding of what can you do with them or not, so that you don’t lose the capacity to protect you?

And so as I said, we will have a major comprehensive document coming up tomorrow on our website which addresses that. And it’s clearly part of conservation. But we can do other things in conservation. You know, I mentioned earlier that, you know, here we have 3M making thirty-five million a month. We have one hospital in New York last month used two million, just by that one hospital. And so in terms of conservation, we’ve got to look at better ways to do that. And that doesn’t mean trying to put people intentionally at risk, but if you only have so many N95s, what do you do to reduce the risk as much as you possibly can?

And I think that’s something to do. For example, people say, what do you mean? Instead of having fifteen private rooms, where every time you go in and out you have to doff and don, put all fifteen people in one ward, where with air engineering assurances you’re not blowing that air into another part of the hospital. And then once you’re in that ward, you’re basically in and you don’t have to doff and don between patients. You know, what are the creative ways that we can start doing more with less? And I think that’s what we’re all looking for right now. But in addition, we’re looking at how can you refurbish these N95s from a standpoint of contamination and in such a way that they still protect? And so it’s a very important topic, and one that is probably too complicated to get all into this call. But there are—there is information out there. And it’s coming out more every day.

FASKIANOS: Great. And, Mike, we can circulate a link to that report tomorrow once it comes out to everybody on the call.

OSTERHOLM: Great. OK. Sure. Good.

FASKIANOS: Let’s go to the next question.

OPERATOR: The next question will come from Tim McDonald (sp). Sir, if you would please announce your affiliation as well before taking your question.

Q: Hi. Yeah, thank you very much, guys. It’s really helpful. Really appreciate it.

I just wanted to follow up on this conversation we’re having about serology tests. And I’m wondering if you could comment on the use of serology tests for diagnostics. And I was seeing today there was a company that looks like it got an emergency use authorization from the FDA for a diagnostic serology test. But I know there’s some concerns about how accurate those might be. And yeah, I wonder if you could talk about that. And, Jessica, I was wondering if you could say a little bit more about the lack of monitoring of the data that could come from those tests, and what you would like to see as more of these tests are administered.

METCALF: So I think Mike might be able to better speak to the issues of using it as a diagnostic. My understanding is that the chances are you’ll miss individuals during the first few days of infection because it takes a while for seropositivity to come up. So that might be one of the main issues. And then, of course, there’s all the issues—I’m not sure what the sensitivity and specificity of the test discussed might be. With serology you always have the question of whether, you know, the immune reaction that you’re detecting is actually an immune reaction to a related virus, so, say, one of the other coronaviruses. These are all challenges in developing serology in general.

What I know of at the moment is that just about every other academic I know is trying to work to pull together some sort of serological sampling, you know, with the firm constraint that it must in no way impeded any of the health care activities that are underway. And yet, this information is so valuable that if we can reasonably and ethically get it, we should be getting it. But I mean, it’s all, you know, Google Docs floating around on the web. It’s all, like, extraordinary dedicated people doing it in all of their spare time. There’s no sort of CDC person, or there’s nobody who is coordinating this that I can see. Maybe Michael knows more. My sense is that there’s a very informal network that is working together, and who is working on everything else at the same time, right? So people are very overstretched. And coordination and communication is not straightforward either. So I just—it could be done better, I feel. It certainly could be done better.

FASKIANOS: We have lots—go ahead.

OSTERHOLM: I was just going to say I think Jennifer (sic; Jessica) nailed that very well. I think the issue with serology, of course, is not being able to pick up that early stage of infection. And so I think that’s exactly right.

FASKIANOS: We have a lot of outstanding questions, but I’m just going to try to squeeze in one last question. So please keep it brief.

OPERATOR: Thank you. The final question will come from Ken Kelley, Special (sic; National) Institute of Allergy and Infectious Disease. Please go ahead.

Q: Hi, Mike. Ken Kelley here.

There’s been an unprecedented response by industry developing drug candidates, antibodies, and vaccine candidates. And if I follow the logic from your comment earlier that there’ll be very limited supply chains, what does this mean for the use of an animal model, which the FDA typically requires to get into testing? My understanding is there are only three—(inaudible)—these two mice that are—(inaudible)—stage two are non-human primates. So how are the how are the animal models going to be prioritized or rationalized by industry to get the most important candidates brought forward?

OSTERHOLM: Yeah, I think, Ken, this is a very important point you’re raising. And it’s one for the entire issue of what we use testing for. And I have maintained that one of the priorities right now should be, in fact, what testing we have is to know if you have patients in your hospital, are they infected or not? What is it? If you have health-care workers, make sure even if they have a mild illness you know whether they’re infected or not, so that they’re not transmitting the virus, and the whole issue in long-term care.

But where I put a group closely thereafter is reserving enough testing for human studies, so that we know that if we have to enroll someone in a drug trial that they really have this or not, because that could hold us back immensely. And animal model studies, et cetera. So I think that the supply chain I was talking about was manufacturing. But I think the supply chain piece you’re talking about is really another part of the whole entire investigative process, which is very important—the R&D side of it.

And so I don’t know where the animal issues are going to go yet. But I think they can play a very, very important role. I do feel like the response right now relative to vaccines and therapeutics is actually exceptional, I mean, in terms of what’s been coming forward, how it’s coming forward. I worry we want to judge some of these products, the capability, before they’re really adequately evaluated, and people are taking actions based on that. And so I think you raise a very good point that I don’t have an answer for, other than to say that we agree that this is an area that needs clear and compelling definition right now.

FASKIANOS: Jessica?

METCALF: So actually, I think it’s a very—there’s many exciting technological innovations in, for example, vaccine design. But I can’t really comment on—I think we’re still figuring out how we do it best.

OSTERHOLM: Yeah.

FASKIANOS: Well, we are at the end of our hour. And so we pride ourselves on ending on time. So I will do that now. I want to thank you both very much for being with us today and sharing your insights and your analysis. We apologize to all those who were queued up and we could not get to you. We will have to have you back. So to Michael Osterholm and Jessica Metcalf, thank you. We will circulate tomorrow the reports that Mike referenced. And I believe that Jessica is also working on something that might be issued today. So we will include that if it’s available.

As a reminder, the audio and transcript of this call will be posted online at CFR.org. Of course, this is fast-moving, so information may be updated on an hourly basis. We are standing up a lot of conference calls. The next one will be on Friday at 1:00 p.m. Eastern time on the Middle East response to COVID-19, with CFR Fellows Steven Cook and Ray Takeyh, and Leonard Rubenstein of the Johns Hopkins Bloomberg School of Public Health. So thank you all for being with us. Stay well. And we look forward to continuing this conversation with all of you.

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