Forum On Outbreak of Novel Coronavirus

February 10, 2020

Information

February 6, 2020 - Winslow Auditorium, New Haven, CT

Saad Omer, director, Yale Institute of Global Health - Moderator

David Vlahov, professor, Yale School of Nursing

Gregg Gonsalves, assistant professor, Department of Epidemiology of Microbial Diseases, Yale School of Public Health

Sten Vermund, dean, Yale School of Public Health

Nathan Grubaugh, assistant professor, Department of Epidemiology of Microbial Diseases, Yale School of Public Health

Ellen Foxman, assistant professor, Laboratory Medicine and Immunobiology, Yale School of Medicine

Lisa Sanders, associate professor, General Medicine, Yale School of Medicine

ID4844

To CiteDCA Citation Guide

00:00(ambient chatter)
00:08- [Sten] Good evening.
00:09My name is Sten Vermund.
00:10I'm the dean of the School of Public Health
00:12here at Yale university.
00:13I wanna welcome all of you
00:15in the Winslow Auditorium this evening,
00:17as well as those of you joining via live streaming.
00:21Thanking in advance our speakers who
00:24have joined us this evening on short notice.
00:27My only duty this evening other than
00:29to quiet the crowd is to welcome
00:33this evening's moderator and introduce him.
00:36Dr. Saad Omer is director of
00:37the Yale Institute for Global Health.
00:40He is an infectious disease epidemiologist,
00:44a vaccinologist, and a physician.
00:47He's also a professor of medicine
00:50in infectious diseases at the Yale School of Medicine.
00:53He holds a Susan Dwight Bliss
00:54Professor of Epidemiology of Microbial Diseases
00:57at the Yale School of Public Health
00:58and also has a secondary appointment
01:01in the Yale School of Nursing.
01:03We are lucky to have Dr. Omer here.
01:06He is the inaugural director of our
01:07Yale Institute for Global Health.
01:09And without further ado...
01:11(audience applauding)
01:19- [Saad] Thanks Sten, and besides being
01:23the dean of the School of Public Health,
01:25we at the Institute for Global Health
01:28are privileged to have a true pioneer
01:30in global health, Sten, as one of the deans here
01:35as the dean of the School of Public Health.
01:39And he's one of the founding fathers
01:40of the Institute for Global Health.
01:41So it's a privilege to be here
01:44and talk about this important emerging public health issue.
01:49And, just to outline what we'll be discussing,
01:52we'll be discussing the academic response
01:56of the various parts of the university, not university,
01:59the University and the hospital as an institution
02:02which is located in New Haven, et cetera,
02:06and interacts with its communities.
02:08It is a part of it, but our focus here is
02:10as an expert panel covering various issues
02:14from an academic and research perspective.
02:17And there have been other panels in the past few days
02:23and in the last week or so in the university,
02:26but this one has a focus.
02:28We want to do a comprehensive focus
02:29on a few issues ranging from epidemiology,
02:32to communications, to virology, to some aspects
02:35of preventive measures
02:38and the public health response, et cetera.
02:41I wanna, before I start, I will start with
02:45a few overview slides.
02:48And then, I'll welcome our distinguished panelists.
02:52And most of the session will be based
02:55on questions and answers.
02:57I'll go through a couple of rounds of questions
02:59from the panelists then we'll open
03:01this forum for discussion.
03:04We have a really good and solid, rich base of faculty
03:08and students who have a lot to contribute.
03:12So please, feel free to contribute.
03:14I wanna thank, in terms of organizing this, specifically,
03:19YSPH's Department of Epidemiology of Microbial Diseases,
03:22especially, Albert Ko, who was very instrumental,
03:25I don't know where he is, I don't see him right now,
03:27but I'm sure he'll come.
03:29And he was instrumental in choosing the panelists,
03:33et cetera, and was very helpful in organizing this.
03:37I also want to thank Global Health Justice Partnership.
03:41Gregg Gonsalves, who's one of the panelists,
03:43and Amy Kapczynski, and a few others
03:51who have been really helpful.
03:53Yale is very privileged to have long-standing collaborations
03:57with our colleagues in China.
03:59And there are a lot of efforts going on,
04:02especially, for example, there's a coronavirus
04:06working group focusing on a few research questions,
04:09which is very driven by our Starlight Fellows.
04:13And I would encourage colleagues with connections to China
04:18and of Chinese heritage,
04:19to contribute in today's discussion.
04:23So without further ado,
04:24I will start with my introductory slides.
04:33So we know that the initial cases were identified
04:38and reported from Wuhan City in China.
04:43And it is an unfortunate aspect
04:44that some people call it a Wuhan coronavirus.
04:47I'm very uncomfortable,
04:49and a lot of us are very uncomfortable,
04:50labeling this virus with a place
04:54and adding to a little bit of culture of stigma
04:58that sometimes evolves.
04:59But it was identified, it's appropriate to say,
05:01it was identified, initially, in that place.
05:04It has now, as of this morning, it's spread to 28 countries.
05:13And this is a map, but there's also,
05:16there's some sobering reflection
05:17on the status of the outbreak in the sense
05:19that the major chunk remains in China,
05:23and the major chunk remains in mainland China.
05:27There have been over 28,000 cases reported.
05:33There are model-based estimates that go
05:36much higher than that.
05:37But, in terms of reported cases are 28,353,
05:43including, unfortunately, 565 deaths.
05:47And that's a very sobering reflection
05:52on the status of the outbreak.
05:54But when it comes to emerging diseases,
05:56it's not just that we are concerned
05:58about what has happened so far.
06:00And can you imagine that, during the holidays,
06:03most of us had, in fact, yes, I was looking
06:06at the reports,
06:07there were emails circulating in early January,
06:11starting in late December there was something percolating.
06:13But we didn't know about this major outbreak.
06:16Certainly, it wasn't common knowledge.
06:19It wasn't a major concern and how quickly this disease
06:23has become a major concern.
06:26We think the family of viruses it comes from,
06:31it sort of tells us that it is likely
06:33to have the more prominent host as a bat virus.
06:38You know, when you use icons sometimes,
06:41they look closer to Batman symbol.
06:44(audience laughing)
06:44But, you know, take my word, it's a bat.
06:46But there is a possibility of an intermediate host.
06:52Having said that, there was a lot of rumors~
06:54and sort of preprints that were shared.
06:57Someone looked at the receptors and had some speculation
07:03that we have a snake intermediate host.
07:06And, no matter what you guys do,
07:08don't call it a snake virus.
07:10There was a headline, not in the Baltimore Sun,
07:15in the Scottish Sun-- Baltimore Sun is a much better paper
07:18that the Scottish Sun --that had this snake flu headline.
07:24But, obviously, it got transmitted to humans.
07:26And what really concerned us,
07:28was the well-established human to human transmission.
07:32Because when things come from zoonosis,
07:36when there's a jumping of a virus or a pathogen
07:39from an animal host to a human,
07:43that happens with some frequency.
07:45But what really concerns us is when
07:47there's human to human transmission established.
07:51Just to give you a little bit of a big picture estimate,
07:54so one measure of transmit-ability
07:57is the so-called basic reproduction number.
08:00Some people call it basic reproductive number.
08:02That's not a preferable term.
08:03Basic reproduction number, meaning,
08:07one way of conceptualizing it is that in a naive population,
08:12where everyone is susceptible to this infection,
08:17if there is one case introduced of this disease,
08:21on average, how many cases they would infect?
08:25So that's one simple way of understanding this.
08:27And this is a measure of transmit-ability.
08:29This is not the sole predictor of how big,
08:32how dangerous the outbreak will be.
08:34But it is an important measure.
08:36There's some uncertainty about the magnitude of it.
08:41But we do know that it is not as transmittable as,
08:44let's say, measles, which is one
08:46of the most transmittable common diseases
08:50which has this R0 Number of 12 to 15.
08:53In certain outbreaks, it has gone up to 17.
08:56Ebola had this number of two.
08:58And this is, the novel coronavirus is comparable to SARS.
09:03It's more than the flu.
09:05And so, this is some perspective to keep in mind,
09:08with a caveat that our information is evolving.
09:11We certainly know a lot more about this virus
09:14than we knew a couple of weeks ago.
09:16But our understanding is evolving and so keep that in mind.
09:20Now, this is a natural phenomenon in all outbreaks
09:25that are emerging.
09:27So what can we do?
09:29So I have thought about it a little bit
09:30in terms of the big picture policy response,
09:33and we will be, so the implicit focus will be,
09:36the response, from an academic and research perspective
09:40for the rest of the panel.
09:42But one of the things, those of you who don't know,
09:44that the writers have
09:45very little control over the headlines.
09:50So there's separate editors who do the headlines.
09:52So my op-ed was a little bit more nuanced
09:55than the headline would suggest.
09:57But we certainly have, I certainly didn't go,
10:02for a call and response kind of a framework.
10:04"Are we ready?"
10:05"No."
10:06(audience laughing)
10:07But we did talk about certain gaps.
10:13First of all, what I postulated was, and this was,
10:18I wrote this a few hours
10:19after the first case were identified.
10:21The government hadn't formulated its response.
10:25So some of us were concerned about the response
10:30being handled by the political leadership.
10:34Look, it's not an unreasonable thing
10:35to say that our elected leaders who we elect in a democracy
10:39could be at the helm of a major emergency.
10:43But this is slightly different
10:44and it should vary from pathogen to pathogen
10:47and emergency to emergency, and here's the reason why.
10:51When you have an outbreak with substantial uncertainty,
10:55we should acknowledge that uncertainty,
10:57but the decision-making process should be structured
11:00in a way that the assimilation of ever-changing
11:03and ever-evolving information, and the decision-making
11:07should be very proximal
11:09and ideally led by the same set of people,
11:12who have the detailed, nuanced knowledge,
11:15intuitively of these things.
11:18They should be calling the shots.
11:19And who are those people?
11:20Fortunately, those in this country
11:24who are leading our major public health agencies,
11:27the NIH, the CDC, FDA, even the HHS,
11:32various entities within the HHS,
11:34are mainstream, well-respected scientists
11:37or public health professionals.
11:38And so, rather than sort of having this outbreak,
11:42irrespective of the political perspective,
11:44in this kind of a situation,
11:46being handled at the White House level, for example,
11:49it would be best for the agency heads to tackle this.
11:54So similarly, let the scientists
11:56and public health professionals lead.
11:58But, look, it is hard, it's highly unsatisfying.
12:03I was on an AMA Reddit half an hour before I came here,
12:10where a lot of questions, it's easy to speculate.
12:13It's very tempting to say, provide certainty.
12:18We certainly know a lot about this outbreak than before.
12:22But we owe it to the general public
12:24to convey what we don't know.
12:26But also, what is knowable and what will never be known.
12:31And so, therefore, yes, saying that what
12:34is happening right now, you shouldn't be walking around
12:39in a spacesuit on College Street,
12:42it is reasonable to say that.
12:44But on the other hand,
12:45we don't know the future risk of this outbreak.
12:49We have some things to go by,
12:50and we'll flesh that out a little bit in more nuance.
12:53So don't provide false assurances, don't alarm, certainly.
12:57And the other thing that has happened,
12:59as look universities have a unique space in our society.
13:04Which is we are the guardians of evidence.
13:08Lux et Veritas is not an accident.
13:11And when we are guardians of evidence,
13:16we should think about not just what knowledge
13:19is being generated and how it's being implemented,
13:22but the quality of that evidence.
13:24And so, the preprint server movement,
13:26where open science requires
13:28and nudges us to share our data and our academic output
13:33very quickly on these preprint servers without peer review.
13:37Overall, is a really positive development
13:39when it comes to speed of sharing knowledge
13:42and can serve us really well.
13:44The genomes were posted very quickly and very robustly,
13:48in the sense that, in terms of the number,
13:50obviously there was a proportion there was a lag.
13:52But we should also be careful about
13:56how valid that information is.
14:00So one way to thread that needle,
14:01and there have been incidents that things
14:03have been retracted, even in the New England Journal.
14:05So it's not just the new preprint servers
14:08that have been vulnerable.
14:09There have been other things on preprint servers
14:10that have been revised, et cetera,
14:12and people have changed their perceptions
14:14around the outbreak based on that.
14:16So one of the proposals I discussed there
14:20is to have a preplanned rapid peer review system
14:23that is already set up to evaluate information
14:28on a quick turnaround basis.
14:30I'm not going to go into the details right now.
14:33But just to remind you of the response,
14:35this is a public health emergency of international concern
14:39declared by the WHO.
14:40There have been travel restrictions, et cetera,
14:43and there have been quarantine,
14:46various measures akin to quarantine
14:47that have been implemented.
14:49We will discuss the matter to the value
14:51and sort of nuances of these responses in a little while.
14:55These are a couple of things WHO recommends
14:57in terms of preventive measures:
15:00covering mouth and nose when you're coughing and sneezing,
15:02if you're using tissues
15:04into closed bin immediately after use,
15:06cleans hands, hand-washing is a very important
15:09preventive measure, it's not a panacea,
15:12that's gonna take care of all our wolves
15:14when it comes to respiratory disease,
15:16but it is something that you can do now.
15:19It is evidence-based and this is something we can do now
15:23without any further technological development.
15:25And then, there are certain recommendations,
15:27without going into details, on the WHO side
15:28in terms of staying healthy while traveling.
15:31So I'll pause here and I will then introduce
15:35our panelists one by one.
15:37But before I do that, I wanna thank one of my postdocs
15:40who helped with some of those slides,
15:42Amyn Malik, and I already thanked Albert and others
15:45for helping organize this session.
15:49I'm gonna call the panelists in alphabetical order.
15:53The first one is Ellen Foxman.
15:56She's an assistant professor of lab medicine and immunology
15:59at the Yale School of Medicine.
16:01Her research focuses on understanding the natural mechanisms
16:05that protect the airway from respiratory viruses.
16:08And you can see how that is relevant
16:10to what we are talking about right now.
16:12And one of the interesting things that she's working on
16:15is rapid diagnostics for these kinds of emerging diseases
16:19for mass screening.
16:20So that straddles individual and public health response.
16:23And that's one of my favorite kinds of responses.
16:27The second panelist is Gregg Gonzalez.
16:33He's an assistant professor of epidemiology
16:36and associate adjunct professor of law
16:38of Yale Law School, and he's the co-director
16:41of the Yale Global Health Justice Partnership.
16:43So he has two homes, Yale School of Public Health
16:46and the Law School.
16:50And he's a perfect example of an activist scientist.
16:57He's a solid activist, a very passionate activist,
17:00he has the fire in the belly that we all felt
17:02on our first day of grad school.
17:03(audience laughing)
17:05Some of us get jaded,
17:07others stay enthusiastic and passionate.
17:10And he's also a top-notch scientist
17:13and models impact of decisions and operation
17:18instead of using quantitative techniques,
17:22which are really fascinating.
17:24The third panelist is Nathan Grubaugh.
17:28He's also an assistant professor of epidemiology
17:30of microbial diseases at the Yale School of Public Health,
17:33and he has done some very interesting work
17:36on genetic epidemiology and has be co-curating
17:39with his colleagues these viral genomes
17:42that have been posted or have been shared,
17:46and sort of creating this, if you will,
17:50the map of this genome as it evolves.
17:52And this is realtime public health
17:55that takes advantage of important immediate
18:00information sharing and brings it together for, hopefully,
18:06decision-making and response to an emerging threat.
18:09Then, we have Lisa Sanders.
18:10Dr. Sanders is a clinical educator
18:13in Internal Medicine and she's a primary care provider
18:16and an Emmy Award-winning producer of CBS News,
18:21as well as an author.
18:22And the other thing that I like, as a House fan,
18:27she was one of the inspirations for House.
18:30Is that correct?
18:31- [Lisa] My column, nothing personal, I'm way nicer.
18:34(audience laughing)
18:35- [Saad] Because I was trying to look for the resemblance
18:36with Hugh Laurie.
18:37- [Lisa] Sometimes, I win.
18:39(audience laughing)
18:42- [Saad] And then, our last panelist is David Vlahov.
18:47He's the PhD program director and professor
18:49at the Yale School of Nursing,
18:50and then he also has a joint appointment
18:54with Epi here in the School of Public Health.
18:58He was involved and he did some very fascinating work
19:01in early 2000 when SARS broke and anthrax happened
19:05on the response of healthcare providers
19:08or the public health workforce,
19:09including school nurses, et cetera,
19:11who can be the tip of the spear of a mass response,
19:15and was involved from that perspective.
19:18But also, as a professor of nursing,
19:20has thought about and would provide his expertise
19:23on some of the healthcare
19:25and workforce decisions, et cetera.
19:28There are a couple of people who are in the audience
19:30who are not official panelists,
19:33but I may sort of put them on the spot.
19:37One is Dr. Paul Genecin.
19:39He's the director of Yale Health.
19:41So if there are any questions that come
19:43from that perspective, I will point to you.
19:46And Albert Ko, who's an overall smart person,
19:50(audience laughing)
19:51but also, in all of it,
19:53has long-standing links with Chinese colleagues.
19:56But, equally importantly, he's involved
19:59with a WHO working group developing interventions
20:04and evaluating interventions, more importantly,
20:07developing a common protocol so that we are not
20:11have a different playbook for developing counter-measures
20:17against this outbreak.
20:19So with that, I'll switch to the question and answer phase
20:23of this forum.
20:30So my first question will be from Nate,
20:37"So where did this virus come from?"
20:39And I think our best bet to figure this out
20:42is not to send Hugh Laurie and investigate,
20:46but to look at the genetic data and look at other viruses,
20:50et cetera, that could tell something about that.
20:53Could you elaborate a little bit on that.
20:54- [Nate] Yeah, sure, thank you.
20:56First I would just like to say that it's really great
20:57to see so many students in the audience,
21:00so many people that are interested
21:01from a lot of different backgrounds.
21:03So the question really gets at something
21:06that I'm very interested in with outbreaks
21:08and that is misinformation.
21:11So, if any of you are on Twitter
21:14or are reading some columns,
21:15maybe you see a lot of misinformation about the origins
21:18of this outbreak.
21:19For a second telling you this is not a deliberate release
21:23from a laboratory.
21:24Some of the evidence that people present for that
21:28is a paper that did some, I'm gonna say, "shoddy" analysis,
21:32to say that there is elements within the coronavirus genome
21:36that had an, "uncanny resemblance to HIV."
21:39And therefore it was man-made and released from a lab
21:42that they say there's a high-containment virology lab
21:47in Wuhan which is actually perfect
21:49for being able to respond to these events
21:51but then people are suggesting that the virus was manmade
21:54and came from this lab.
21:55That is absolutely not true,
21:56there is no evidence to actually say that,
21:58and the analysis was faulty.
22:00Where this actually came from is like with Saad's slide,
22:03is the group of viruses
22:05that this virus belongs to are beta-corona viruses.
22:07And they're ancient origins are in bats,
22:09there's some 200 different known species
22:13of beta-corona viruses in bats,
22:14and from what we know there are seven of these viruses
22:20that have spilled over into human populations
22:22that caused outbreaks.
22:23Four of 'em cause common cold,
22:25they're right here in New Haven.
22:27One of 'em is SARS, one of 'em is MERS,
22:29and one of 'em is now this novel coronavirus.
22:32So the question really is then,
22:34looking at these genomes and looking at this data
22:36of when and where did this happen?
22:40So the when part of it, if we look at all the genetic data
22:42that we have, we can estimate that the origins
22:45of the outbreak was about early December,
22:49maybe late November.
22:50And there are some questions about whether
22:53this came directly from a live market that was in Wuhan,
22:57it's sort of uncertain if that is actually the case,
23:00the most epidemiological evidence would suggest that.
23:03But it certainly came from a mammal of sort,
23:06so beta-corona viruses infect mammals
23:09and this gets into another point of misinformation out there
23:11that maybe this was a snake virus,
23:13or maybe this actually spilled over from fish.
23:15We don't know of any of these viruses that have ever
23:17infected anything other than mammals.
23:20So what exactly that intermediate host was,
23:23if there was an intermediate host,
23:24before we had a human outbreak is sort of unknown.
23:29- [Saad] So that brings me to the question about
23:32the viral pathogenesis, so Ellen, do you mind elaborating
23:37a little bit on that part of how the virus effects our cells
23:42and us as humans?
23:44- [Ellen] Yeah, sure.
23:46Hello everyone, it's great to be here.
23:47So my life study's respiratory viruses
23:52and there's a lot of those as we were all familiar with
23:56the common cold, the flu, and these viruses that we get,
23:59year after year.
24:00And so I thought I'd talk about this virus
24:02in the context of that, what are similarities
24:05and what are some differences?
24:06So as many of you probably know,
24:09the way a virus causes illness is it is able to enter a cell
24:13or several cells of your body and hijack those cells
24:16and basically turn those cells into factories
24:18for making more virus, which can be damaging to the cells.
24:22But then your immune system realizes that's happening
24:26and comes to that area of the body to fight it,
24:29fight the virus and get rid of it.
24:31And wherever that battle is going on
24:32is where you get the symptoms.
24:33So if you get the common cold virus in your nose,
24:36the immune system's fighting it in your nose,
24:37you get the symptoms of the runny nose and so forth.
24:41If that battle's going on in the lungs,
24:42then you're going to get lung symptoms,
24:44breathing problems and whatnot,
24:46the things we associate with pneumonia.
24:49So this virus can do both of those things.
24:52It can effect the nose or it can effect the lungs or both.
24:56So you might ask, "Well, why are we more concerned
24:59"about this, we get these viruses every year,
25:02"they're going on in New Haven right now.
25:05"We've got lots of other respiratory viruses."
25:07And the main thing is, is the fact that it's new
25:11to the human population.
25:13So as I'm sure many of you are also familiar with,
25:16is the idea that when our body fights a virus
25:19there's a memory immune response that's formed,
25:21that makes it so if we see a virus,
25:23that virus or a similar virus again,
25:26our body is much better at blocking it
25:28before it even gets into cells.
25:29So that's always the concern about a new virus
25:33is that none of us have
25:35that pre-existing immune defense up and going.
25:39And that makes it potentially easier for the virus to spread
25:41from person-to-person and also if it gets into your body,
25:45you don't have that first line of defense
25:47that could maybe prevent disease
25:49as well as if you had seen the virus before.
25:51And that's why, like a new virus,
25:53is always a cause to be alert, it's a cause to be vigilant.
25:58Just because it's new,
25:59doesn't mean it's worse than other viruses that we know,
26:03that we're familiar with but it means there's a potential
26:06and that's why there's a reason
26:08for the heightened vigilance about it.
26:11- [Saad] That's a very important point to remember,
26:14that just because it's new, doesn't necessarily mean
26:20it's worse, unless it's a disaster movie.
26:22(audience laughs)
26:24You get that, it's not-
26:25- [Ellen] Yeah, we just don't know
26:25a lot of those things yet.
26:28- [Saad] Yeah, exactly.
26:29And so Lisa, you're practically a doc
26:32and tell us a little bit about what preventive measures
26:36we can take now and perhaps if the outbreak expands
26:41in the community.
26:44- [Lisa] Well, it seems now, we all know what to do,
26:47hand-washing and coughing into your elbow
26:52and things like that.
26:54Not probably getting too close to people
26:59who have obvious infections, giving them their space,
27:03there's probably pass-through fomites
27:06or other kinds of respiratory-borne particles.
27:12So I don't think there's anything particularly wild
27:15that we can do, I'm not sure that,
27:17certainly if you had a cold
27:19perhaps it might help if you wore a mask.
27:21But certainly there's no evidence that wearing a mask
27:24is going to keep you from getting it.
27:26Nor does there seem like there're very many people who
27:29have it now to get it from.
27:31So I think having ordinary levels of precaution makes sense.
27:36I mean, I assure you,
27:38most people don't wash their hands nearly enough.
27:41So if people just washed their hands just a little bit more,
27:44it would probably go a long way.
27:47- [Saad] Yeah, that's certainly aligned with
27:48CDC recommendations and specifically,
27:52at least at this point,
27:52CDC doesn't recommend wearing face masks.
27:56It's probably perhaps one of the reasons people wear them
28:00is for self-efficacy, they want to feel in charge.
28:04It's a situation of helplessness,
28:07when there is a lot of uncertainty.
28:09So perhaps those of us who, there's a few who work
28:12on health behavior and communications,
28:14perhaps we should have a message of self-efficacy
28:16in the form of saying, "You can wash hands."
28:17Which is not going to take care of everything,
28:21you can practice some level of social distancing
28:25without being paranoid about this,
28:28especially when you have someone infected,
28:30social distancing doesn't mean that start discriminating
28:32against people willy-nilly, it means if you have someone,
28:37if you are specifically in that kind of a situation,
28:39you take some of these precautions.
28:42And also, the original prevention to public health response
28:46David, do you have any thoughts in terms of the response
28:50at the mass level and some of the things
28:53that you were involved with earlier on,
28:57in previous similar outbreaks?
28:59And the second part of that question
29:01of some of the things that have been employed
29:03by various countries, including China, including the US,
29:06and some of the others.
29:08- [Assistant] Here you go, sir.
29:09- [David] Oh, okay (laughs).
29:12Thank you for the question.
29:16In terms of what's going on in China,
29:20there's quite a bit of discussion about whether quarantine
29:27makes things better or makes things worse.
29:30And the idea of having people
29:33that are separated and protected,
29:36seems like it would be a good idea,
29:39but it also has a stigmatizing effect
29:43where people can under report, go underground, if you will.
29:49And if we take the example of Ebola,
29:52which again's a very different,
29:54it's an analogy that doesn't work at a lot of levels,
29:58but again just that stigma of being confined
30:04and not trusting in a particular environment,
30:09there's a lot of discomfort and anger and acting out
30:18that can happen with that.
30:21So what's the process that can be a middle ground.
30:27And the approach that I think seems better,
30:32although you have to look at what is the local situation,
30:35what are cultural considerations that go with that,
30:41are to be able to have a conversation with people,
30:45in terms of what is your likelihood of having been exposed
30:50given what we know
30:52and taking that person to have the individual responsibility
30:57for staying at home, for example, right?
31:01Secluding oneself for a period of time,
31:05that's a social contract that happens,
31:09and for many people that seems very reasonable
31:13and there're going to be others
31:15that may need a little bit more assistance in that area.
31:21So I think that's one of the larger issues that comes up
31:25and has certainly been in the news,
31:28is quarantine or cordon sanitaire, right?
31:33What are the different levels of protection one can have?
31:38Now another part of the question is
31:42what is a public health response?
31:46And Robin Gershon and Chris Korechi were doing a study
31:51of nurse preparedness in New York City
31:56and found that if there was some sort of disaster
32:00that was about to happen, what barrier,
32:03how many of you would have at least one barrier,
32:06that would stop you from showing up to work, whatever?
32:09So turns out it was 90%, like a childcare,
32:14all those different issues and then, it was not by design,
32:20but the Anthrax, hit New York City and they followed up
32:23and they found out that every single person,
32:26every single one of the nurses, showed up to work,
32:28and did what their job was, right?
32:32So part of it is recognizing that people will rise up
32:38to what that challenge is,
32:40what their professional responsibilities are,
32:43and part of that also is having the education and support
32:50to be able to do that.
32:51So I'll pause, 'cause I could keep going, I'll pause.
32:55(audience laughs)
32:56- [Saad] Yeah. No, so very insightful.
32:58So you mentioned quarantine
33:00and Gregg I want to sort of switch to you,
33:02there was some really interesting work,
33:04I wasn't here in New Haven in the area at that time,
33:08but there was Ebola-related quarantine, as I understand,
33:12in the area and even as an outsider,
33:15as someone who looks at these issues,
33:18I found Yale Law School's and some of the people who were
33:23involved in the Global Health Justice Partnership,
33:24collaborated with the ACLU,
33:26on a report that came out of that experience.
33:29Which is a very, very helpful, very pragmatic tool,
33:33that a lot of public health practitioners
33:36should pay attention to.
33:37Could you elaborate, in terms of, if we quarantine
33:40or whatever the parameters of quarantine should be?
33:43And if we do that, how should that look like?
33:46- [Gregg] So if you were here in 2014, 2015,
33:52in wake of the Ebola epidemic in West Africa,
33:55several governors across the country,
33:58decided to quarantine individuals returning from,
34:01West Africa healthcare workers, in absence of symptoms,
34:07confine them under quarantine.
34:08Including two Yale students,
34:10who were not infected with Ebola,
34:12and including a West African family from Westhaven,
34:15who were not infected with Ebola,
34:17this was done by former Governor Dan Malloy.
34:20We're still in a lawsuit,
34:23the law school's immigration clinic is partnering with us
34:27in a suit against the State of Connecticut
34:28against these quarantines,
34:29but we wrote a paper with the ACLU
34:33and Doctors Without Borders that talked about
34:35what would happen, the epidemiological and the legal
34:39implications of the Ebola quarantine on healthcare workers
34:42in the wake of the Ebola epidemic.
34:44And Dan Bausch who was one of our evening speakers
34:48two weeks ago was one of the scientific advisors on that
34:50(murmurs) illness and helped out.
34:51You can see the report on the GHJP website
34:54at the Yale Law School, but the back of the report
34:57has recommendations about what happens next time?
35:00Guess what, it's next time.
35:02A couple of things to remember,
35:04one is to use the least restrictive measures possible,
35:07so not to overreact.
35:08So in the case of the Ebola epidemic the quarantines
35:11were absolutely unnecessary, unjustified.
35:14As David is saying, there may be self-isolation
35:17and staying at home if you feel sick
35:21or quarantined if necessary, but really to use
35:24the least restrictive measures for a start,
35:28rather than sort of going full-steam ahead for quarantines.
35:31The other thing is to ensure robust procedural protections.
35:34You have rights, under the US constitution,
35:37to bodily autonomy and due process.
35:40So when our students were put into quarantine,
35:43we could appeal their cases immediately to the courts,
35:49but it was a 14 day quarantine and we ended up saying,
35:52afterwards because the time-period was too short.
35:56But you do have robust- you do have rights
35:58under the constitution to due process.
36:01Kaci Hickox was a nurse, with MSF, who came back to the US
36:05and was quarantined by Governor Christie,
36:07a republican in New Jersey,
36:10her quarantine was overturned by a judge in Maine,
36:12who said it was epidemiologically unjustified.
36:14So in one case the law worked out.
36:17The other thing is ensure humane conditions of confinement.
36:22Now I saw on the news today that China is thinking about
36:25quarantining or taking all the infected people,
36:29in Wuhan and other places,
36:30and putting them into quarantine camps.
36:35What are the conditions going to be like for them?
36:37Are they gonna get adequate health care?
36:38Is there gonna be adequate infection control?
36:42We're thinking about the risks
36:43to us here in the United States,
36:44but think of the thousands of Chinese patients
36:47with coronavirus now whose health status
36:52is going to be put into precarious position
36:55if they are isolated in these facilities
36:56that we have no idea of who's overseeing their quality
37:00and their ability to prevent onward transmission
37:05from these sites.
37:06So there's lots of things we can do,
37:07I'm not gonna go through all the recommendations,
37:08but follow the science, as Saad said.
37:12Follow the evidence.
37:15If you hear the words, "abundance of caution," beware,
37:19because it means, "Damn the evidence and we're gonna do
37:23"what we want to do."
37:24And that's what Governor Daniel Malloy,
37:25Governor Chris Christie, and Governor Andrew Cuomo did
37:28in 2014, 2015, which was bi-partisan stupidity.
37:31(audience laughs)
37:33- [Saad] On that note of bi-partisan Kumbaya, I guess
37:38(audience laughs)
37:40So I want to switch to a lot of those decisions were made
37:43in a communications environment, in a public,
37:45in the view of an interesting, to say the least,
37:50public discourse.
37:52So, Lisa, as someone who has been involved, as an author,
37:55as a producer, obviously as a physician,
37:59on top of all of this, what do you think,
38:02what is your initial impression of what is happening now?
38:07What are some of the nuances,
38:08what are some of the adequacies,
38:09what are the things that we should have learned
38:12from previously that we could do better?
38:16- [Lisa] Well, if you, I don't know how accurate
38:18a representation of the country Twitter is,
38:22but you don't have to look very deep in Twitter
38:24to start seeing real crazy about this proliferate.
38:31And to some degree I think that's completely natural
38:37because of the disconnect between the messaging that we have
38:41"You're much more at risk of the flu, just wash your hands,
38:45"don't worry about it, it's going to be okay."
38:48Versus closing the country off
38:50to people from different countries, who've been to China,
38:55imposing quarantine, sending people to concentration camps
39:03when they're diseased.
39:04I mean, that suggests a level of concern,
39:08that doesn't really match what we're told to do, right?
39:12So we're told to calm down and yet everybody
39:16in the government seems to be extremely excited.
39:19And nobody's really trying to make that connection
39:22and when you have big gaps like that,
39:25it's inevitable that crazy creeps in
39:29because people are worried and that's how people express it.
39:33I think that we need to acknowledge that we have to
39:37try to make sure that nothing bad happens,
39:41while saying the risk right now seems limited,
39:46and acknowledge that we don't know what the future holds.
39:48I mean, I think that those are the reasonable steps.
39:51But this kind of "pooh-poohing" concern, of course,
39:55makes everybody crazy and really worried
39:59and I think it's completely natural.
40:03As journalists, of course, we need the snappy headline,
40:08it's essential, I mean, maybe the New York Times
40:11doesn't need a snappy headline,
40:13although I think they have been tempted
40:15by that once or twice, but certainly other publications
40:19need that, television needs that.
40:22I mean, people are, this is a competitive environment.
40:25So some of that is understandable,
40:27I don't know that it's forgivable.
40:30But as public health people, we have to step in
40:33and try to make it make sense to the people around us.
40:39We can't depend on the media necessarily to do it.
40:42- [Saad] So the frontline of this response, in this country,
40:47because of the way certain powers are given to the state
40:51and local health departments, a lot of people don't realize
40:55that yes, CDC provides technical guidance,
40:58but actual action, in terms of outbreak prevention
41:02and control, on the ground happens
41:04at the state and local health departments.
41:06Over the past 20 years, there has been a lot of investment.
41:10The investment in terms of resources have stalled.
41:16Should we be reassured, in one way, by the headstart
41:22we have had, since SARS and Anthrax and the 2009 epidemic
41:27and/or should we be concerned because of the cuts
41:32that the public health system has seen over the last,
41:37at least, six, seven years?
41:39So any thoughts on that, David?
41:43- [David] I'm not sure except, how best to start on that.
41:50You know it's a crisis like this that can be a stimulus
41:55to get the public health funding.
41:57I mean, we certainly saw that in earlier crises,
42:00it may be delayed, but I think there's a opportunity here
42:06to say we've gotta take the public health preparedness
42:10very seriously and to generate the resources
42:15to be able to respond to this.
42:17- [Saad] But isn't that, usually vanished after,
42:19sort of we get this bolus, this sugar rush of investment
42:23in global health and then we have
42:26this seven years of crankiness
42:28after that sugar rush dies down.
42:30In terms of where we, the public health system,
42:32after building up, having this surge,
42:37then suffers from these consequences.
42:41Any thoughts on a sustainable way
42:45of investing in public health this way?
42:47I know Sten, Development had a very good op-ed,
42:51in terms of the global health investment
42:53and not having these boom, bust cycles
42:55and sustaining the infrastructure.
42:57But domestically speaking, sort of any thoughts
43:01on how to maintain that infrastructure that doesn't
43:02go through these cycles?
43:07Sten, do you want to contribute?
43:09- [Sten] Sure.
43:13The reality is that public health is faced
43:19with an inherent challenge.
43:22It's hard to convince policy-makers to pay you
43:26to do something to prevent something from happening.
43:28It's much more intuitive to invest in hospitals,
43:34to care for the ill,
43:35than it is in public health infrastructure
43:37to prevent the illness to begin with.
43:39So that is part of the theme I think this evening
43:42of all the panelists,
43:43that we're up against tremendous communications challenges.
43:48How do we advocate for infrastructures
43:52for disease prevention, for rapid response?
43:57To be prepared for something that might or might not happen?
44:00And there's so many compelling demands,
44:04in a developing country you advocate for public health
44:08and you're up against the minister of defense,
44:11you're up against the minister of tourism,
44:13you're up against the minister of education.
44:16Where we have more resources and high-income settings,
44:20it's almost equally challenging.
44:23The NIH budget is in the neighborhood of
44:29$33 billion dollars a year
44:31and the CDC budget is a fifth of that.
44:33So people understand disease, research to treat disease,
44:35tremendous investments in clinical trials,
44:40the prevention budget is far more modest.
44:44So I think it's part of our duty,
44:46here in the school of public health,
44:47to work more diligently on how to communicate
44:51with lay audiences about public health and prevention.
44:55How to communicate with policy makers
44:58so that they appreciate that an ounce of prevention
45:02is worth a pound of cure,
45:04which I suspect our grandmothers told us.
45:07And at the end of the day, integrating acute care settings,
45:13with chronic care maintenance,
45:18as with the HIV investments in Africa,
45:21where a tunnel vision approach,
45:23that these are for HIV, HIV and nothing but HIV,
45:27when people may be dying of untreated hypertension,
45:30where there may be an Ebola virus epidemic around the corner
45:33in which those infrastructures could be helpful,
45:36a coronavirus epidemic.
45:38I think we need to be broader in our thinking,
45:41less siloed and more attentive to how infrastructures
45:46can be very potent, they can serve a function today,
45:51for an investment today,
45:52but keeping in mind that there may be
45:55an investment in near future,
45:57for which these infrastructures can be highly valued.
46:03Ultimately, that's a challenge we're facing.
46:06I know that the Bloomberg philanthropies are investing
46:08in precisely that with Tom Friedman's initiative
46:14in New York City and the whole philosophy of that initiative
46:17is chronic disease care, upgrading that care globally,
46:21but having each chronic disease investment, be prepared
46:26for acute responses to outbreaks
46:28and I think that's a very wise philosophy.
46:31- [Saad] That's a really good point.
46:33In terms of, coming back to a little bit more science,
46:37and one of the misconceptions
46:39and one of the more frequent questions
46:40some of us get asked by the press is,
46:42"Is this virus mutating?"
46:44And that's such a general question,
46:45I'm not gonna go into the details of
46:47why is that a non-specific question because we have someone
46:52who knows a lot more about it than I do, so Nate,
46:54would you like to elaborate on the various layers
46:58of that question?
46:59- [Nate] So this is one of my favorite topics
47:01of misinformation during outbreaks
47:04and the answer is, "Of course, it's mutating."
47:06But go back a second.
47:08So mutations sort of conjure up these inherent fears
47:14of something unexpected and some major change,
47:18think of American pop culture - X-Men, right?
47:22These mutant humans have these extraordinary abilities.
47:25You think about, have your ever read "Andromeda Strain"
47:28or watched the movie "Outbreak"?
47:30As soon as a mutation is introduced into the picture,
47:33something new is happening.
47:34So of course, the people that grew up on this,
47:39when you hear the word mutation, right,
47:41this is what you're thinking about.
47:42You're thinking about these crazy changes that can happen,
47:45not about the fundamental evolutionary processes.
47:49So every time a virus replicates, when it copies its genome
47:55on average about one mutation is introduced.
47:57And most of these mutations don't do anything to the virus,
48:01some of 'em make the virus worse than their loss,
48:03and some of them provide a benefit.
48:05But what we're actually thinking about, I think,
48:07when people ask about mutations
48:09are actually natural selection.
48:11So are these viruses becoming better adapted at something.
48:16So I think it's a perfectly reasonable question to ask,
48:19"Is this novel coronavirus, adapting to humans?"
48:22So during the Ebola epidemic, in West Africa, we found
48:26that early on in the outbreak,
48:30there was a mutation that appeared
48:31and through a lot of experiments and everything,
48:34we found that it eventually dominated the outbreak.
48:36And it looked to be a human adaptation.
48:38But when we look at the epidemiological evidence,
48:40so that people who are infected with this mutation,
48:43or with not, there wasn't a difference in the death rates,
48:46there wasn't a difference in how much virus you had.
48:49It was a human adaptation that didn't really have a major
48:51epidemiological impact, the same with SARS.
48:55SARS, after it was introduced,
48:57we found these changes that happened
48:58that looked like they were human adaptations,
49:01but when you look back at the data
49:02you can't actually determine if this had any major impact
49:06on the overall epidemic.
49:09So could this novel coronavirus
49:12adapt better to infect humans?
49:13Sure, possibly could.
49:15Will it have a major impact on the epidemic?
49:17Will it cause more deaths?
49:19There's not really any evidence to suggest that.
49:22- [Saad] So my last question of this phase,
49:24before I open up, is from Ellen,
49:27and I want you to talk about a little bit about diagnostics.
49:32So our ability to detect this,
49:33especially from the perspective of being Global Health,
49:36you always think about inequities.
49:40For example, in Africa, one of the questions is,
49:43the fact that we haven't detected a lot of cases,
49:47is because is it the absence of the virus
49:53or the absence of detection, et cetera?
49:54So could you talk a little bit about our ability
49:56to have these diagnostics and it's implications
49:58for an equitable response through knowing the burden
50:03and the ability from a scientific perspective,
50:06to detect these viruses in populations.
50:09- [Ellen] Okay, sure.
50:11(alarm rings)
50:12So one thing that was really quite amazing
50:14about this outbreak compared to other ones
50:17is how quickly the actual genome sequence
50:20of the virus was online.
50:22It took about a week, I mean, it was amazing
50:25and so advance in technology,
50:29we all know that it's much easier to sequence genes
50:35than it used to be,
50:36but this is really a great example of that,
50:38where as soon as that outbreak was recognized,
50:42that scientists were able to actually,
50:46right from the patient sample,
50:48get the whole sequence of the virus.
50:50In the past you had to try to grow it
50:52and there was a many steps.
50:53And that was really an example of the application
50:55of a pretty expensive technology actually,
50:58but in a way that's gonna benefit
51:00a lot of people very quickly.
51:01As far as diagnostic tests, that's discovery,
51:06that's virus discovery and this has really been quite
51:09like a poster-child for amazing infrastructure
51:13for virus discovery.
51:16As far as diagnostics, having that genome sequence
51:20online immediately, the way that we detect viruses,
51:24here in our hospital right here in Yale,
51:26is often by doing a detection of the snippet of the genome.
51:29And having that genome sequenced that quickly means
51:32you can quickly make a diagnostic test.
51:34Which the CDC has done.
51:37But then the other issue comes of
51:41if you do a diagnostic test enough times,
51:44on a population that doesn't have the disease,
51:47you're gonna get some false positives.
51:49Any positive would be a false positive.
51:50So right now what's happening is, there's a lot of criteria,
51:55before people will be tested by the CDC,
51:59that they actually have a chance of having the virus,
52:02before they will be tested in the US.
52:05As far as around the world, I mean, these kinds of tests
52:10are not super cheap.
52:11These PCR based tests, it's a little bit complicated,
52:14you need a special machine,
52:17you need people who are trained to perform the test.
52:24So for all those reasons, it's not something that you can
52:27quickly and cheaply get out to tons of people.
52:30So there are a lot of efforts now to say,
52:32how can we use our new technologies that we have now,
52:35that we're developing on a research scale,
52:38to make cheap, quick tests that could be distributed
52:42and could allow people to be diagnosed more widely.
52:46- [Saad] Before I open up for questions,
52:49I just want to remind everyone that outbreaks,
52:51as the plague in Europe or the 1918 flu pandemic
52:56or more recent Ebola outbreak, et cetera,
52:59can bring the best and the worst out of people.
53:01It's extremely important for us to treat each other
53:04with dignity and respect and compassion.
53:07Dignity and respect and tolerance is somewhat passive
53:12ways of looking at the world
53:16and in my short time at Yale, I think I can fairly say
53:22with some confidence, this is not a passive community.
53:25So it also demands that we are active in our compassion,
53:30for our peers, for our students, not just when the outbreak
53:34is in China, but when we have a scenario,
53:38that your mom or uncle or cousin from Colorado calls
53:42and says, "I've heard this thing on Twitter"
53:47and there is that tone of concern and fear,
53:51that is part of that conversation.
53:55So as part of the Yale community,
53:57it our responsibility to in these kinds of situations,
54:02I'm not saying this is gonna happen,
54:04with this and uncertainty doesn't mean
54:06that it's gonna explode,
54:08it means that it could go on the other side as well.
54:14But if it does happen, my hope is that all of us,
54:18would look back on this year,
54:20as part of the Yale community, most of us who are here,
54:24and we'll be proud of our response as a group of people.
54:27So let's just remember that before I open this
54:30and have no doubt that it's not gonna happen,
54:33absolutely gonna happen.
54:34But my hope is that we go one step beyond that,
54:37we bring the same passion and compassion
54:42and lack of passivity to this as we bring to the other
54:46parts of our endeavors at this campus.
54:48So the way, there is a microphone somewhere,
54:51yes, there're a couple of microphones on either side.
54:55So please ask your questions, state your name, et cetera
55:00and if you have an affiliation one way or another,
55:05if you're comfortable please state that as well.
55:09Please raise your hands.
55:13Yes, this one here.
55:19- [Mark] Hi, Mark Russi, Yale School of Medicine and also
55:22Yale health system.
55:24In 2003, there was a lot of discussion about the phenomenon
55:29of a super-spreader (mumbles) of Hong Kong,
55:33the index patient at the Metropole Hotel.
55:37Are you seeing, perhaps this is question
55:39for Nathan and Ellen, are you seeing anything, either
55:43potentially ascribable to host factors or to some
55:46combination of low levels of humidity, directional airflow,
55:51et cetera, that leads you to believe that there are cases
55:55where there is a substantial excursion from the R0 that
55:59we're seeing of about two and a half for this disease?
56:08- [Ellen] I will start by saying I don't really know
56:11the answer to your question.
56:13The only thing that comes to mind is this.
56:16There was a report in several Chinese media outlets,
56:21that they tested environmental samples,
56:24at that Wuhan market,
56:25and there was a good number of them
56:29tested positive for the virus.
56:32So that suggests that at least at that market,
56:36there was a spot where there was a lot of this virus.
56:40Why that was is not clear, but there was a spot
56:43where there was a lot of this virus.
56:45Was it from an individual who was shedding it?
56:48Was it from an animal?
56:50I don't know the answer to that, but that's the only thing
56:54that I can think of that I've read about
56:56or heard about that would suggest what you're talking about.
57:00I don't really know the answer to that with regards to any,
57:04I have not heard of any reports of super-spreaders
57:06or anything like that at this point.
57:07I don't know if anyone else might know.
57:13- [Saad] Do you want to say something?
57:17So there's a question at the back, right hand side.
57:20- [Wu] Hello, Wu from School Of (murmurs).
57:22Okay so I have some questions, first one is,
57:24is there any scientific way to learn the quality
57:27of the data published by Chinese officials?
57:30And the second question is emphatically, if the initial
57:32outbreak is happening in New York,
57:35which has the closest resemblance to high-insurance filled
57:38population and mobility and if the public health official
57:41was notified two weeks after the initial outbreak
57:44how can things handle different?
57:47- [Saad] So I will, so Nate, you have thought
57:50a little bit about sort of information quality
57:53around this Rpeg, do you have nay thoughts to contribute
57:57to on this?
58:00- [Nate] You can start it, I'll join in.
58:01- [Saad] I'm sorry?
58:02- [Nate] I said you can go ahead and start me.
58:02- [Saad] So I can start.
58:03So that's a really good question, so we don't have a direct
58:08sophisticated way of saying that what a given paper
58:14is saying is valid, other than we do have tools,
58:17they are tools that have been with us and have served us
58:20overall well, but not perfectly, for decades,
58:23if not centuries and that, the most effective tool,
58:26is called peer review.
58:27And that's where someone else, who's not involved
58:31with this whole process, says,
58:34"But there's something odd about this."
58:37And then they sort of, they question, they push back,
58:40and if the responses are not satisfactory,
58:44then sometimes the paper doesn't get published, et cetera.
58:48So that has changed, we are in a very different
58:51communications environment now.
58:53Scientific communications environment,
58:55in this kind of situation, the results of these products,
59:05intellectual products, are being shared on Twitter
59:08before they are even submitted
59:09they are on preprint servers, et cetera.
59:12Which is okay, which is overall sharing
59:14the viral genome quickly and publishing that
59:17has a lot of value.
59:19I think we'll have to compliment that with a rapid,
59:24standing peer review system.
59:27That looks at that and says,
59:30"We are gonna perform peer review.
59:32"You have posted it on a preprint server."
59:34The preprint server flags it,
59:35sends it out to this group that has signed contracts,
59:38maybe pay them to have this commitment.
59:41Say, I'm gonna turn around because there's a finite
59:44types of people that you would need
59:47in an emerging pathogen kind of a situation.
59:52You would need epidemiologist, you would need virologists,
59:54you would need a few clinicians who would pay attention
59:58to these kinds of things.
59:59So you can have them on a retainer in future situations
01:00:02where you say that this paper is submitted
01:00:06to this preprint server.
01:00:07We evaluate quickly and we say does that make sense or not
01:00:12before you know while the information is still out there
01:00:15we give it a stamp of approval or otherwise.
01:00:17So that would be a way to do that?
01:00:19Any other thoughts, Nate?
01:00:21- [Nate] Yeah, I'll just say something
01:00:22on the quality of the data that's coming out.
01:00:25So one thing that's really important to keep in mind here,
01:00:29is the sheer number of cases that are being reported a day
01:00:32now into like the 3 thousands.
01:00:35Those are at least then, 3000 tests
01:00:37that are being performed a day
01:00:39and probably not all of them are positive.
01:00:41So you gotta think about some of it may,
01:00:44the quality it may not really reflect what is happening,
01:00:47I don't think it has anything to do with the quality
01:00:49of the reporting per se.
01:00:51It's just like, how many tests can you actually do
01:00:53in some of these places everyday,
01:00:55to get that information out.
01:00:56So there's going to be under-reporting that's happening,
01:01:00that isn't necessarily deliberate by any means,
01:01:03but it's just sort of a function of overloading systems.
01:01:09- [Sten] I mean, the only thing we can say is
01:01:12that data-sharing is important at this moment.
01:01:13It's like, whoever has data needs to share it
01:01:15at a global scale among the scientific communities.
01:01:18'Cause it's not just what you see in the publication
01:01:20that's important, it's the raw data
01:01:22that people can run re-analysis on
01:01:24and there's some question about whether all the data's
01:01:26being shared in sort of a transparent way
01:01:29at the current moment.
01:01:31- [Saad] That's a very important point.
01:01:33- [Ellen] One more comment about
01:01:34the preprint servers though, it is quite amazing
01:01:37that Nate talked about that sort of wrong analysis
01:01:41misconcluding about the HIV present
01:01:44in the coronavirus genome, but I have to say
01:01:46that went up on a preprint server, many scientists read it,
01:01:50many scientists commented about it, and said,
01:01:53"This is a problem."
01:01:54And the authors took it down and apologized.
01:01:57And that all happened like within a few days.
01:01:59So actually in a way, the system is, there is sort of this
01:02:02informal peer review going on.
01:02:04Likewise, with the New England Journal article
01:02:08that was retracted.
01:02:09So there is sort of an informal process that's kind of
01:02:13coming out of our global connectivity,
01:02:15which is sort of encouraging.
01:02:17- [Saad] So I'm generally a glass 10% full kind of person,
01:02:20It's always something to be hopeful about.
01:02:23With this exception, after having worked in vaccines,
01:02:26I've interacted with a few swamps of 4chan,
01:02:29where these conspiracies live and thrive and multiply
01:02:35and my concern is, even after all the retractions,
01:02:39some of that stuff will find a life of its own.
01:02:43But it is, there is always these kinds of things
01:02:46have trade-offs.
01:02:47I think having access to especially raw data,
01:02:51but also some of the analysis quickly,
01:02:54my tendered objective is, it's a net positive.
01:02:58A net positive not by sort of close margin,
01:03:02but substantially, but it has had, to quote Batman,
01:03:09or actually, Spider-man,
01:03:10"With great power, comes great responsibility."
01:03:13Voltaire said it,
01:03:14but he probably didn't say it wearing tights.
01:03:16(audience laughs)
01:03:19But so with the power of sharing that information,
01:03:24it is our responsibility to guard the veracity
01:03:28and the quality of that information,
01:03:29through the full scientific process.
01:03:34- [Ley] I can talk without the mic, I'm Ley Chen-
01:03:36- [Saad] So we have broadcasting, so
01:03:38- [Ley] So I will wait.
01:03:41- [David] Who was the person in the back
01:03:42that was there first.
01:03:46- [Lay] Should I wait, Lay Chen, School of Medicine,
01:03:48Department of Pediatrics.
01:03:50I have a question about the,
01:03:53seemingly the difference in mortality
01:03:55between Wuhan patients and those outside.
01:03:58Do you think that's simply a question of not knowing
01:04:00the denominator of how many people are really sick
01:04:03outside of Wuhan or it's something specific
01:04:08about the environment?
01:04:12- [Saad] So, Albert, do you have any thoughts on that?
01:04:13- No, go ahead, I don't know.
01:04:14- The mic right there.
01:04:16- [Albert] So I think that of course the numbers
01:04:18coming out of Wuhan are very concerning,
01:04:20especially because of the number of deaths
01:04:22and the proportion of deaths.
01:04:23But this is kind of very much like many epidemics that occur
01:04:28at the epicenter, the cases that were identified were
01:04:33primarily severe cases.
01:04:35You can tell by the age, the average age is around 60,
01:04:38in cases that were reported.
01:04:40If you compare that to what we're seeing among travelers
01:04:45or evacuees that are being identified,
01:04:47we're seeing that all ages
01:04:48and many of them are having mild symptoms.
01:04:52So this is probably as you're suspecting, we call it
01:04:56case ascertainment bias, in that many of the cases
01:04:58in the initial part of the epidemic were more severe.
01:05:03- [Saad] So I'm gonna come back to the question
01:05:04that was asked, it was a two part question.
01:05:06And one of them was what would happen if something like this
01:05:08was reported in New York City?
01:05:10And I think that's an important question,
01:05:12and we should keep it in mind before we criticize other
01:05:15entities, countries, in Africa or in Asia or in wherever,
01:05:19in terms of what would happen.
01:05:20Both in terms of, it's a good counter-factual,
01:05:22both positive and negative as well.
01:05:24So any thoughts on that?
01:05:27- [David] Well, in New York City,
01:05:28you have quite a bit of history,
01:05:31and it's also a major, in New York City I think there's
01:05:36greater preparedness based on a history
01:05:41and certainly a recent history of events that have happened.
01:05:45So there's memory, if you will, and preparedness
01:05:48that goes along.
01:05:51The second part is that the information and decision-making,
01:05:56is much more de-centralized
01:05:59and so that decisions can be made much faster
01:06:03than what's being reported overseas.
01:06:08So again, how much preparedness is there?
01:06:12The experience with it, what's the level of decision-making,
01:06:15I think those would be three of the bigger buckets
01:06:18and we could probably flesh that out more.
01:06:21- [Saad] So we were fortunate to have folks from
01:06:22the health department or experience with health department
01:06:25so as the mic goes there,
01:06:28I want to talk to Paul a little bit.
01:06:30Dr. Jensen, any thoughts about hospital preparedness
01:06:35in this kind of a situation?
01:06:37- [Paul] For Yale?
01:06:37- [Saad] For Yale.
01:06:39- [Paul] Yeah. Well, first just to say
01:06:41that the Wuhan hospital is full,
01:06:44the capacity for surge is a real question.
01:06:50We have a fairly elaborate preparedness plan,
01:06:55including the capacity to setup a field hospital
01:06:59at the Lanman Center at the gym in a case of need,
01:07:03but the concern about how we would be able to respond
01:07:08to a large number of pupils with serious illnesses,
01:07:10is a real one.
01:07:15I just can't say, but there's a balance on one hand between
01:07:20trying to balance anxiety and concern,
01:07:22which is predominately what we're dealing with now
01:07:25over against the issues of what would really happen
01:07:27in the event of an outbreak.
01:07:32And then just speaking to one point that she made,
01:07:33a little bit tangential about self-efficacy
01:07:36and the need that people have
01:07:39to feel like they're doing something,
01:07:41anyone hasn't had their flu shots, please get one.
01:07:44(audience laughs)
01:07:48- [Drew] Sir, I'm Drew Hadler, I was a former Connecticut
01:07:51state epidemiologist.
01:07:53For the last 11 years I've been working in emerging
01:07:55infections program here, but also as a consultant
01:07:56to New York City Health Department.
01:07:59So I think I came from a control perspective, I can't say
01:08:02what the reaction would have been, but I think
01:08:05from the information-gathering perspective,
01:08:07it would have been much, much more focused
01:08:10and the information will be out there
01:08:12a lot of the information that we need.
01:08:14So for example, I was there when pandemic flu hit in 2009
01:08:20and New York City had a huge high school outbreak
01:08:22it was one you could see through the city,
01:08:24where four or five kids came back from vacation from Cancun,
01:08:28turned out they had H1N1 they went to the same high school
01:08:31and within two weeks, there were 900 cases
01:08:34in that high school and at least that many family members.
01:08:37That was a fair amount of resources went into that,
01:08:42it was fully described, transmission issues were described,
01:08:45speculant disease within that context was described,
01:08:49the city also setup surveillance
01:08:50for hospitalized cases of H1N1 right away,
01:08:53'cause they didn't have it going on quaran,
01:08:55and quickly had counts of am I in trouble, is this going on.
01:08:59They also had mortality surveillance and so within a month
01:09:04we had a full spectrum of really good information
01:09:08to say that H1N1 was no more (mumbles) can sense,
01:09:13then any seasonal influenza.
01:09:16We do know it was effecting children more than older adults,
01:09:20which the (mumbles) seem to believe
01:09:21there's good explanations for that,
01:09:24because older adults, people in their 50s,
01:09:2540s, 50s, and older, actually it turned out
01:09:28did have some immunity to H1N1.
01:09:30And weren't quite as severely as effected as younger people.
01:09:37So basically we could put it in perspective
01:09:38and then base control measures on that.
01:09:40Again, I don't know what the immediate control measures
01:09:43were dealing with this but there would have been
01:09:46surveillance setup that would have attempted to find,
01:09:49full measure of the disease, how severe it was, and CDC
01:09:54would be invited in as it was then.
01:09:57Which actually helped the CDC (mumbles) station because
01:09:59we can see the life department anyway
01:10:01and so there would be a lot of communication with CDC,
01:10:04daily conference calls with jurisdictions around the country
01:10:08to explain what would be happening if New York City
01:10:11is the one that was affected and we'd have the information
01:10:17we need to try and have a rational response to it.
01:10:19Not one that's sort of all desperate.
01:10:29- [Saad] There's someone in the back, there.
01:10:35- [Thatcher] Thank you, Thatcher, School of Public Health,
01:10:40New (mumbles) Health.
01:10:41So my question is about the large number of patients
01:10:42so since the outbreak a large number of patients,
01:10:49with mild or severe, no matter mild or severe,
01:10:51they rush to the hospitals so I believe the number
01:10:55is quite more than 10 times,
01:10:5810 times more than the hospital can feed.
01:11:02So my question is, so would you recommend people with mild
01:11:07symptoms not to go to hospital and just to stay at home?
01:11:13- [Saad] So I can start the response,
01:11:17and if anyone has anything to add
01:11:19or you have any thoughts on that.
01:11:21So this is very important.
01:11:22So at the big public health response level,
01:11:25in an emerging situation,
01:11:26having clear evidence-based communication,
01:11:29is extremely important.
01:11:31So talking to people that at certain stage of the outbreak
01:11:35and response, certain kinds of symptoms, need to stay home
01:11:42for the "abundance of caution" in terms of the individual
01:11:44response may require, if there is a judicious use,
01:11:47to self-isolate without disrupting the more old-fashioned
01:11:54society in that sense.
01:11:57But also, so Dr. Jensen mentioned, Paul mentioned,
01:12:00something very important, getting your flu shot.
01:12:04And the reason why you say it's not biological, is that
01:12:08flu shot doesn't protect against the coronavirus.
01:12:11But it does protect against a major respiratory illness.
01:12:15So it helps in two ways.
01:12:16First of all, it has it's own benefits in terms of
01:12:21reducing morbidity and mortality in several age groups.
01:12:25But also it reduces, if you are reducing symptoms,
01:12:29of respiratory illness in a population,
01:12:32then unnecessary visits
01:12:34that were not caused by Coronavirus go down.
01:12:38So again, we're not helpless, passive, spectators
01:12:43to something that is unfolding.
01:12:46We have inherent self-efficacy in the form of
01:12:51for example, hand-washing, which is evidence-based
01:12:57measure for all respiratory illness, flu shot,
01:12:59and some of the other measures.
01:13:00Do you want to say something more, Paul or Albert,
01:13:03any thoughts on this?
01:13:05- [Paul] Yeah, I think that's very important.
01:13:09Also just to, a less likely influenza is in the community,
01:13:16the more likely it is to be able to
01:13:17assess people with respiratory infection quickly
01:13:20and efficiently in the event
01:13:22that we do have an outbreak of coronavirus.
01:13:28- [Sten] That's an interesting point, I did it in a study
01:13:30awhile back, looking at if you have syndromic surveillance
01:13:34in New York City, looking for outbreaks,
01:13:36can you immunize people enough
01:13:38so that you have greater specificity.
01:13:42And the challenge of getting enough people immunized
01:13:46is there, so from a population perspective as a concept,
01:13:49I think it's great, but that could also add to the case
01:13:55that we want to make, is that's another reason
01:13:58why we should be encouraging immunization.
01:14:02- [Saad] Yes, there's a question there.
01:14:03- [Hadjur] Hadjur from the (mumbles) So as a Chinese,
01:14:08all my family is still in China
01:14:10and my friends share me all these information all day.
01:14:14So my question or wondering is when will this end?
01:14:19I think the correct question is when do you expect
01:14:23the turning point will be?
01:14:25Some experts say we have incubation period of two weeks,
01:14:31and since the quarantine of the whole, has seen
01:14:35a lot of quarantined have been taken,
01:14:38there is roughly 10 days or two weeks already passed,
01:14:44So if you're doing some modeling or forecasting when do you
01:14:48expect this (mumbles) will show?
01:14:54- [Nate] I'll just start with something basic on this.
01:14:56So just based on one model that I've seen,
01:14:58and I don't know necessarily if this is going to be
01:15:00the most accurate prediction, but it was looking like
01:15:03mid to late February would be the peak.
01:15:06But there's a lot of things that can happen,
01:15:08between now and then, that would even change those estimates
01:15:11and then you have to wonder, the data
01:15:13that this is all based on.
01:15:14So I don't know if we have a really great handle
01:15:18on when this is going to be peaking
01:15:21and when it's going to start coming down.
01:15:24- [Saad] An enough providing false assurances,
01:15:26I think it's reasonable to share experience
01:15:28with other corona viruses, especially SARS,
01:15:32but there does seem to be a seasonality associated
01:15:34with those viruses.
01:15:36And they seem to be more transmissible using the term
01:15:41loosely in this kind of a situation,
01:15:44the peaks are higher in winter.
01:15:48So there is, again, tentative hope that some of those months
01:15:55will have a positive impact.
01:15:57But again, it's tentative, we are dealing with,
01:16:01I would be providing false assurances by providing
01:16:04some certainty around that.
01:16:06- [Sten] I think the fairest thing
01:16:07is that we don't know, during the Ebola outbreak
01:16:10there were multiple mathematical models that predicted
01:16:12wide sort of trajectories of the epidemic.
01:16:14So I think that information is trickling out,
01:16:18to parametrize these models, so until we have more data,
01:16:22until we have more sort of examination
01:16:24of how these parameters were put together,
01:16:26I think the safest thing is to say, we don't know.
01:16:34- [David] I taught with Alex Langmuir, who was the founder
01:16:37of the immunologic intelligence service.
01:16:41And the one thing that we used in class was Farr, right?
01:16:46Farr's law, and it's the first law of epidemics which is,
01:16:51"Whatever goes up, must come down."
01:16:54So we don't know where that point is-
01:16:59- [Saad] Sorry, did you say that you sort of
01:17:01talked to Langmuir himself?
01:17:03- [David] We taught together.
01:17:05- [Saad] Oh, you taught together, okay.
01:17:06So you were professor at the age of 12, I guess.
01:17:08(audience laughs)
01:17:10(mumbling)
01:17:12- [Jerry] Hi I'm Jerry Friedlander, School of Medicine,
01:17:17School of Public Health.
01:17:20So one of the real unusual characteristics of this
01:17:23is how rapidly it's spread globally
01:17:27and in a month's period of time this is (mumbles)
01:17:30so many countries. It's very different (mumbles) precipice.
01:17:35Unfortunate time in which this occurred
01:17:38and people traveling.
01:17:41So I wonder what we know about the response in other places?
01:17:45We're most concerned about what happens here
01:17:48in the US, but this is a global epidemic now,
01:17:51of some magnitude that we don't really know.
01:17:53The response will be different in different places
01:17:57and that's gonna have consequences actually
01:17:58for the global nature of this and (mumbles)
01:18:03and the future.
01:18:04So is there any coordination, on an international level
01:18:08at this point?
01:18:10Can we, somehow or other, advocate for this
01:18:14if it's not going on in a way that's actually functional
01:18:18and important and the information coming from other
01:18:22places will be very, very important in terms of what
01:18:25we understand and how we can respond.
01:18:27- Albert might-
01:18:28- [Saad] Albert, you wanna?
01:18:29(mumbling)
01:18:30- [Albert] I think this is being videotaped.
01:18:33(audience laughs)
01:18:36So the politically correct answer is that, of course,
01:18:39there is coordination,
01:18:40and that coordination is being done by WHO,
01:18:44on many different levels in terms of operating response,
01:18:46in terms of training, capacity and so forth.
01:18:50But we all know the situation with WHO
01:18:53has been essentially neutered
01:18:54because of the lack of multi-level funding.
01:18:58Much of the funding is bilateral and which is really
01:19:02incapacitated some effective responses and coordination.
01:19:07So I'm being a little harsh on that, but I think that is
01:19:11a gap and that's why we have this myriad of bi-lateral
01:19:15responses which are potentially not well-coordinated.
01:19:19And I think the concern and I'm just gonna jump on to,
01:19:22I think what Kai said, and others, is that
01:19:25I mean, this is I think we're still in the exponential phase
01:19:30of the epidemic in many of the cities
01:19:33of the 5 million people who left Wuhan before.
01:19:37We don't know the exact proportion of who's effected but
01:19:39I think it's fair to say, with regard to provinces,
01:19:42Shanghai and Guangdong are in the exponential phase.
01:19:46And that delay of models,
01:19:48which has been modeled three days,
01:19:49and maybe much longer,
01:19:51so I think we're in for the long-term.
01:19:53I think the big question is, is that
01:19:54in places that have weaker surveillance systems,
01:19:57I'm thinking about Southeast Asia, South Asia, maybe
01:20:00there's only three cases, but how many kits are available?
01:20:04And so the concern is we can go all the way
01:20:08back to the beginning of what Nate said,
01:20:11this is probably one of seven pandemics or so,
01:20:14of the coronavirus, it would be good to be optimistic
01:20:18it would be good to think that we can push this
01:20:21into a season that has low-transmission.
01:20:23But I think we have to tie it on this being, spreading
01:20:30and not necessarily peaking early.
01:20:33And I think we also have to plan on what's gonna happen
01:20:36in the most vulnerable populations around the world.
01:20:39And what happens when it gets there,
01:20:41and this is a case fatality rate, that may not be as high
01:20:44as MERS or SARS,
01:20:46but it's not going to be negligible either.
01:20:49- [Participant] It's going to be heterogenous
01:20:51in different parts of the world, seasonally.
01:20:55- [Lisa] So, I want to go back to a question that was asked
01:20:56earlier about the people going to, with mild infection,
01:21:00going to the hospital.
01:21:02And I think that a lot of that could be prevented
01:21:05if we had a very good sense of what the natural history
01:21:08of this disease was and what it looked like
01:21:10when it was bad.
01:21:12Like, does it start off mild and become bad?
01:21:16That's one disease pattern.
01:21:18Or does it start off bad and stay bad?
01:21:20If it starts off bad and stays bad,
01:21:23then if you got a mild case, then you shouldn't go
01:21:25to the hospital.
01:21:26But until we know what that is, until we can describe it
01:21:30and make that public, people, of course,
01:21:33are going to go to the hospital
01:21:35with even the mildest symptoms 'cause of course
01:21:37they're worried.
01:21:39And rightfully so perhaps,
01:21:41but I think that's one of the pieces of information,
01:21:44that we really need to get out to people.
01:21:46Is what does it look like when it happens.
01:21:50Like, is it bad all the time?
01:21:52Or does it start off mild and get bad?
01:21:55That's an important distinction.
01:21:57- [Saad] So, in the interest of time,
01:21:58I want to finish on time, I'll take only a couple of more
01:22:00questions and there were a few questions on this side.
01:22:05We spent some time on this side for awhile,
01:22:08so you had a question for awhile
01:22:11and then there was one more in there.
01:22:12So unfortunately we will have to stop here
01:22:15and I'll be happy to stay back and maybe others
01:22:19will also stick around.
01:22:21- Hi I'm (murmurs) from the department of internal medicine
01:22:24and herbology.
01:22:25I was wondering, you mentioned seven of these corona viruses
01:22:28some causing cold and yet some like SARS
01:22:31with a lot of fatality do we know, biologically,
01:22:34what is different about the SARS
01:22:38versus the ones that cause colds
01:22:41and causes this without fatality
01:22:46and can use that information
01:22:46when we're studying mutations in this current coronavirus
01:22:49to predict potentially what might be more of a problem?
01:22:56- [Saad] Start?
01:22:57- [Ellen] I can start, I can start on that one.
01:23:01Well, one interesting thing is there's a coronavirus,
01:23:06the corona viruses that circulate every year in New Haven
01:23:09and throughout the US, sometimes cause colds
01:23:11and they can cause serious illness,
01:23:13particularly in people who have other health conditions
01:23:16kind of like what we've seen a little bit
01:23:18with this virus too.
01:23:20As far as the receptor the virus uses to enter cells,
01:23:23this virus uses the same receptor as SARS
01:23:26and the same receptor as a different Coronavirus
01:23:29that causes colds, so that's not the key thing.
01:23:32With SARS there was some information about it suppressing
01:23:37the anti-viral response pretty well,
01:23:40which you can imagine would allow the virus
01:23:42to get to a higher level in the body.
01:23:46But as far as this virus, I really don't know.
01:23:49So it's interesting that people have studied already
01:23:53where those receptors are found, the receptor the virus
01:23:57uses to get into cells, they're in the upper airway,
01:24:01they're in the lower airway where the gas exchange occurs
01:24:03in the lung and also in other tissues of the body,
01:24:06like in the liver and the blood vessels
01:24:08and things like that.
01:24:10But I think there still needs to be more work
01:24:12on the pathogenesis of this one to figure out exactly.
01:24:18It's not totally clear, kind of getting back to something
01:24:21that was said earlier is
01:24:24at the beginning when a lot of people
01:24:27who are presenting to a hospital are very, very sick,
01:24:31a lot of those initial people were also people
01:24:34with other medical conditions,
01:24:35who you might expect to get ill.
01:24:38More ill than somebody who's perfectly healthy and young.
01:24:42So it's still not totally clear,
01:24:45how that factors into the pathogenesis we're seeing
01:24:47and the mortality rates too.
01:24:52- [Nate] Really quick, so we can go to the next question.
01:24:54So it does seem to be,
01:24:56if the virus can use the ACE2 receptor,
01:24:58it can infect humans, if it cannot use it,
01:24:59then it can't infect humans.
01:25:02That's one of the parts of it,
01:25:03but whether this is gonna be SARS or a common cold?
01:25:07We can't just look at the genome and sort of gaze at it yet.
01:25:10We don't have the tools or enough data to say
01:25:12how bad this is gonna be, that's not quite possible.
01:25:17- [Saad] So there was another question from there
01:25:19or that has been answered by?
01:25:21So I'll come to Evelyn and then I think we have,
01:25:24I said two or one more, sort of
01:25:27time for one more question, et cetera.
01:25:30So Evelyn, do you want to?
01:25:31- [Assistant] Michael can we do this question and then I-
01:25:35- [Saad] Okay.
01:25:36- [Evelyn] So I know China just finished building
01:25:39a thousand person hospital isolation ward.
01:25:43What do y'all think?
01:25:44Is this an efficient way to contain the outbreak
01:25:47or are we gonna end up
01:25:48with more issues than we started with?
01:25:51- [David] I'm curious about the construction and the quality
01:25:57and the resources that go into that,
01:26:00supplies that are available, what's the access?
01:26:04Really don't have enough information about the specifics.
01:26:08But I am gonna turn it over to Gregg, who does.
01:26:12(audience laughs)
01:26:13- [Gregg] No, but that's not the point, the point is that
01:26:15we can't abandon our Chinese brothers and sisters
01:26:19and say like, "Let 'em do what..."
01:26:22The point is that the conditions of confinement
01:26:24have to be clinically suitable
01:26:27and meet human rights norms.
01:26:28And if they're being dumped in a hospital
01:26:30with poor infection control
01:26:31and without sufficient clinical capacity
01:26:34to take care of people, it's not the right thing to do.
01:26:36We all have friends in China
01:26:39and we need information to get out
01:26:41so that people are taken care of both in their communities
01:26:44and in any facilities they might be sent to.
01:26:48- [Evelyn] Hi, Evelyn Shay from the School of Medicine
01:26:50and Public Health.
01:26:52I actually wanted to follow up on Jerry's question
01:26:55and hear from Albert, when you said there are myriad
01:26:58bi-lateral initiatives, is that countries with China?
01:27:03I'm curious to know sort of the degree to which
01:27:06there's a partnership with China,
01:27:09whether it's CDC or government
01:27:11and how effective that has been?
01:27:15How much are they doing this on their own domestically?
01:27:20How much is their engagement, it's a little bit hard to tell
01:27:24from the outside.
01:27:26(presenter chuckles)
01:27:27And I think this goes along with what Gregg was saying,
01:27:31to what degree is there-
01:27:39- [Albert] So I'd very much like Sten or David to answer
01:27:43this question.
01:27:45(presenter laughs) (audience laughs)
01:27:51- [Sten] My authority is my friends in China on WeChat.
01:27:55Who've been lighting up my phone all week.
01:27:59And it does seem like the Chinese
01:28:01are pretty much on their own on this one.
01:28:03There isn't any substantial international help
01:28:06infrastructure in Hubei province in Wuhan city.
01:28:11The US CDC has a presence in Beijing but I'm going to guess
01:28:18that there isn't a coronavirus control expert in the group.
01:28:21But they do have good, solid (murmurs),
01:28:23just that it's not improbable that there's communication
01:28:27with the China CDC.
01:28:29China's CDC's a pretty sophisticated operation.
01:28:31They have a sort of a command center
01:28:36for outbreak investigations some I visited that reminded me
01:28:40of the CDC command center and was modeled after it.
01:28:43And I am thinking that the Chinese
01:28:47are largely tackling this on their own.
01:28:49I have no evidence to the contrary
01:28:51and my friends at WHO are not deeply engaged.
01:28:54I know people high up in the state department
01:28:58that I talk to and they're helping the Chinese,
01:29:00but they're helping them from Geneva and from Atlanta.
01:29:04So I think there's a lot of communication,
01:29:07a lot of consultation, but on the ground,
01:29:10the Chinese are handling this on their own.
01:29:12I think that's fair to say.
01:29:14- [Evelyn] Can I just...
01:29:15- [Sten] Yeah.
01:29:16- [Evelyn] Sorry just to follow-up,
01:29:22if this is helpful at all, but I was speaking,
01:29:23I was in Beijing recently
01:29:24and I was speaking to a documentary filmmaker
01:29:29about a film she made about emerging epidemics
01:29:32and she was focusing on the Ebola virus
01:29:35but when she was in Africa she said that the best
01:29:40makeshift hospital that she had encountered were the ones
01:29:46built from China so I think that if that's reassuring
01:29:51that's great infrastructure-wise
01:29:52but I understand-
01:29:55- [Sten] Just put things in perspective
01:29:57and I think there's a lot of issues coming around
01:30:01freedom of information and dissemination of information.
01:30:05As I said,
01:30:06the Chinese CDC is a very sophisticated organization
01:30:10and once, and I think this is up to debate
01:30:13and this is all speculation,
01:30:15but once the outbreak was shown,
01:30:18I mean it was identified.
01:30:20And there are probably policy reasons why it wasn't
01:30:27the early warning system didn't work
01:30:30as it had worked with H7N9.
01:30:33And they detected other emerging pathogens,
01:30:36in the interim time between SARS and are very efficient,
01:30:39why it didn't work now is unclear.
01:30:41And that's something that
01:30:42I think we really don't have a good answer,
01:30:45but once they had detected it, and once it went into
01:30:47the early warning, through IHR.
01:30:49They followed all IHR regulations very sophisticated
01:30:53responses, they sequenced the genome,
01:30:54they are now doing,
01:30:57many randomized controlled trials for treatments,
01:31:02many of those are probably gonna come out with information
01:31:04in the next one or two weeks about how to cure.
01:31:06So very sophisticated responses on many fronts.
01:31:12I think we have to just put this
01:31:14all kind of into perspective.
01:31:17- [Saad] Yeah, so I'll then wrap up, I wanna wrap up
01:31:20exactly at seven.
01:31:21I know there are other questions
01:31:22and that's an indication of the importance of the issue
01:31:25and the engagement so I'd be happy to stay back.
01:31:27I can't speak for other people, but I'd stay back
01:31:32if you have other questions, et cetera.
01:31:35But I don't want to wrap up as we wrap for seven on time,
01:31:39colleagues who put it together and helped to organize
01:31:42on a quick notice.
01:31:43I'm not going to be able to go through the full list,
01:31:46but specifically Ros and Alyssa and Mike Skonieczny and Jen
01:31:52and many others from different parts, and Colin and others
01:31:59from YSPH and YGH et cetera.
01:32:02Who made this possible at a very short notice.
01:32:04But I will wrap up, as I wrap up, I want you to remember
01:32:08the intensity of response, mounted by health workers,
01:32:13both clinical workers, but also public health workers
01:32:17in China as we speak.
01:32:20They keep all of us safe,
01:32:22they have risen up to the challenge.
01:32:26Set aside all the politics, individual health workers
01:32:30and the health system, folks on the ground,
01:32:33have responded, not just on behalf of their own community
01:32:37but on behalf of us.
01:32:40And if there was any doubt of the sacrifice,
01:32:43we should remember one of the physicians
01:32:45who was initial canary in the coal mine, passed away.
01:32:49There are reports that he passed away.
01:32:50There were mixed reports, but I think it's now confirmed,
01:32:53that he passed away today.
01:32:55On that somber note, we should also remember
01:32:58that we are not helpless observers, we have self-efficacy,
01:33:03both as humans and as compassionate beings
01:33:08and as scientists, public health professionals-