- So the symptoms are gonna be just like
any cold or flu that you get.
They're gonna be cough,
fever, sore throat,
maybe a runny nose, maybe a
little bit of GI symptoms,
meaning nausea and vomiting,
maybe some diarrhea and then
shortness of breath is the one
that we worry about in terms of pneumonia.
Those are the main
symptoms and they overlap
a lot with influenza.
(upbeat music)
- Joining me today is an
infectious disease expert working
on pandemic policy, focusing
on emerging infections
and preventing bioterror,
Dr. Amesh Adalja, welcome
to the Rubin Report.
- And thanks for having me.
- All right, thanks for doing this.
We're gonna try to do this
in about 20 25 minutes
and just pack in as much
information as possible.
So let's just start.
Coronavirus 101, what is this thing?
- So coronaviruses are large viral family.
They cause about 25% of our common colds
and we knew about six of them.
Four of them are common cold viruses,
two were more dangerous, SARS and MERS,
which were emerging infectious diseases
that had a high mortality rate.
The other one's just cause common cold.
But after SARS and MERS,
people got very interested
in understanding
are there more severe coronaviruses.
And what happened was in
China, at the end of December,
they noticed a cluster of individuals
who had an unexplained pneumonia
and they discovered a new coronavirus.
And because of its linkage with SARS,
'cause they're in the same family,
people got very worried
and that's what sparked
this whole initial response.
But they're just a viral family
that causes upper
respiratory tract infections
for the most part but in some individuals
can cause pneumonia.
- Okay, so can you explain
how that's actually different
than the common flu?
- So the flu is a different virus.
It comes from a different viral family,
the influenza virus family.
And they share a lot of
similarities with coronaviruses
in terms of the fact that
they cause similar symptoms,
but they're very distinct viruses.
And influenza is one of our
top infectious disease threats
because it's caused
pandemics through history.
One, just about 100 years
ago in 1918 killed about
50 to 100 million people.
So flu is always on the top of our list.
But we hadn't really
thought about coronaviruses
being able to cause pandemics
until the SARS outbreak in 2003.
And while they are similar in
their clinical presentation,
meaning the symptoms that they cause,
they're a little bit different
in their characteristics
in the sense that there are no vaccines
for coronaviruses, there are no antivirals
for coronaviruses.
And this coronavirus
doesn't seem to be at a,
it doesn't seem to be
acting like the common cold
causing coronaviruses meaning
it's transmitting like them,
but it's killing at a higher rate,
probably about 10 times
the rate of what we see
during seasonal flu, at the upper limit.
So that's why it's a little bit different.
It's more dangerous than the
average flu that you get.
It's not one of those bird flu strains
that kills about 60% of people,
but it's something that is more dangerous
than the regular seasonal flu.
- Okay, so two things there.
Can you talk specifically
about the symptoms,
'cause we're hearing some
conflicting information on that,
and then about the transmission part
because I think that's where people
are most worried at the moment.
- So the symptoms are gonna be just like
any cold or flu that you get.
They're gonna be cough,
fever, sore throat,
maybe a runny nose, or maybe
a little bit of GI symptoms,
meaning nausea and vomiting,
maybe some diarrhea,
and then shortness of breath is the one
that we worry about in terms of pneumonia.
Those are the main symptoms
and they overlap a lot with influenza.
The contagiousness is
that this is a disease
that's pretty contagious
compared to other coronaviruses
like SARS and MERS,
which were scary but not very
contagious between people.
This is behaving more like
the other coronaviruses
that cause the common cold,
meaning that it can be
transmitted through coughs
and sneezes and on some of the surfaces
that people have touched
if they have coughed
or sneezed on their hands.
That's what's making
this more scary than any
of the other coronavirus outbreaks
that we've dealt with in the past.
This is something that
transmits very efficiently
in the community.
And that's why this is spreading
to many, many different
countries and is not really
a containable virus because
of how easy it spreads
and the fact that many
people have mild symptoms
that are indistinguishable from the cold
and they're out there doing things
and spreading this around.
- So is that really the number one problem
that there are probably many
people that have this right now
and they simply don't know.
So then they're going to the
supermarket, put their hand on,
you know, right by the
cash register or something
or payment processor and then next thing
you know they're transmitting it.
- That's part of the issue.
We know that this virus emerged
in China at least around mid November,
which meant that it had
been spreading probably
for some time in the community and we,
there was no restrictions
or anything like that,
people were traveling all over.
So we know that this sit in many countries
probably before we even knew it.
And we had a pretty severe flu season
and because the symptoms
are indistinguishable
and most people have mild cases,
they were probably mixed
in and not even diagnosed.
And there likely are
many undiagnosed chains
of transmission in the United States
that are starting to pop up now.
Like we saw in Washington
state for example.
And that's the issue
is that we didn't know
who had this disease, so
we couldn't tell them,
you need to isolate yourself
and protect yourself
from infecting others,
nobody did any of that in the early stages
of this outbreak and that's
what we're left with now.
- So on an international level,
it seems that various countries
are having various success
and failures with this.
Can you talk a little
bit about why Italy seems
to be struggling so much with
dealing with the outbreak?
- Sure, so Italy had an
outbreak that started out
and basically their
approach was really to focus
on the severe cases.
They started to test for mild cases
and they actually got criticized
by their central government
for finding mild cases
because it was driving
their case numbers up
and it was making people stigmatize Italy.
Because during an outbreak,
there's lots of stigmatization that occurs
for irrational reasons usually.
And that's what happened.
And Italy didn't really act
quick enough on those mild cases
and allowed those mild cases to spread.
And then you basically
have the oldest population
in the world in Italy.
And we know this disease is
much more severe in those
that are older and have
other medical conditions.
And that really has created a crisis mode
in that area of Italy
where the cases are located
in the Lombardy region.
And from what I understand,
they're not allowed to move
those patients out of Lombardy.
So we've got a basically a
fixed capacity of ICU beds
and hospital beds there and
a disease that's spreading
very quickly in the population
and that population is older,
so you've got these hospitals inundated
and basically running out of capacity
and really in crisis mode.
And in response the government of Italy
has basically locked
down that entire country.
- Yeah, what about the rest of Europe?
It seems like the UK may be
not doing enough at the moment,
but it's a little hard to figure out
who to trust at the moment.
- So the UK has done something
completely different.
They've actually tried to do
something called herd immunity.
So they're trying to
get many people exposed
to this virus so that
it builds up immunity
and they can use that
to cocoon their elderly
and vulnerable populations.
But it's a very risky
gamble because we don't know
how you're gonna keep the
younger people compartment
away from the older people compartment.
They're not, there people
have got they cross over.
You can't really seal the
elderly away from younger people.
So there's a lot of
criticism going on right now
of the UK's policy to do that
and it's gonna result in more cases.
It's designed to do that,
but we don't really think
that it's going to be able
to save that elderly population
by exposing the younger population.
- Right and what about
the American response?
- That's been kind of hit or miss.
There were some early good
steps and then really bad steps.
I would single out the one thing that's,
the worst thing about
this is the fact that
this was a disease that
we were kind of told
is a Chinese disease and
not going to be something
that we have to think about
other than with travelers.
When we knew that it was
not that from the beginning,
because like I said earlier,
this had been spreading since November
and we know that any of this,
any of US notice of this
basically came in January,
so it likely was already here.
And our testing was so restrictive
that we could only test
people if they'd been to China
in the last 14 days and had
severe respiratory symptoms
that were considered
lower respiratory tract.
They couldn't do somebody
that just had a sore throat,
for example.
The mild cases were not able to be tested.
And we had this major
bottleneck in testing
because it was all initially
being done by the CDC
and then the state health labs
but there was a problem
sending that kit out
and there was a little
bit of regulatory issues
that had to be worked out before hospitals
can make their own tests
and big lab companies
can make their own tests.
All of that put us really
behind and all of that lead time
we might've had from the
time it disappeared in China
and became recognized
as a problem in China,
to when we got to where we
are today was basically wasted
because we had no idea
of who had the disease,
how to target our interventions
or anything like that.
- So I think most people assume,
or at the very least hope
that their governments
are doing the right thing.
But can you take this now
down to the personal level
and the community level, you know,
from as simple as washing hands
to just other techniques
people should be doing
in their daily lives right now?
- First message is wash your hands a lot,
touch your face less.
That's the thing everybody can do.
Now because we're in a pandemic state,
we have to think about social distancing
and that's gonna be a little bit different
for every person depending
on what's essential to them
and what's not essential.
Starting with people who are older
or who have medical problems,
they need to start thinking
about their interactions
with other people trying
to limit their risk
because that's what we're
really worried about here.
That's what this is all
designed to help them.
Because if they end up
getting sick in large numbers,
we will crash our whole
US healthcare system
because we don't have the capacity to deal
with that many sick people such
as what's going on in Italy.
Other individuals who are lower risk,
you've got to think
about what you're doing,
how you can minimize your contacts
without completely destroying
your quality of life.
You might, there's, you know,
there's some variation on
what people can and can't do.
Right now we're seeing
governor's close bars
and restaurants, and I
think that's something
that you're gonna see more of
because there's too much
social interaction going on
in those types of places and
they end up being a nexus
for the spread of the virus.
But I do think that just
being common sense, you know,
if you're going to the gym,
go at times where there's not peak hours,
maybe order out instead of,
or take-on instead of sitting
in a restaurant maybe,
and mass gatherings are
basically being banned
everywhere because of their risks.
So that's not an issue
to think about anymore.
But it's that type of thing
that you're gonna have to do
at least for a period of two weeks,
maybe longer to see if
we can actually blunt
the curve basically, or flatten it out
because we don't want to
exceed hospital capacity.
So the idea is let's slow the number of,
the rate of infection
so that they're coming
at a slower clip to the hospital
so that they don't get overwhelmed
because we're really nervous about that.
That's the biggest dot, you
know, linchpin in our response.
- So I know that you talked
about the differences
that Italy has just in
terms of the demographics
and population, but I hear
a lot of people saying,
oh, we're just two weeks behind Italy.
Do you think that that's
a fair estimation?
- If you look at the numbers,
we have a case count around
what Italy had two weeks before.
So I think it is something
that people are saying
with some evidence behind it.
I think we're gonna start to
know if we're gonna follow
this Italian type of model
or we're gonna have more
of a South Korean outbreak.
But it's increasingly looking
like it might be a little bit
of a hybrid between
them because we were not
as quick with the testing mild cases
and isolating them as South Korea was.
- Yeah, can you talk about
flattening the curve?
That seems to be the phrase
that everybody's talking about.
We're seeing a lot of images on Twitter.
- Sure, sure.
So what we're talking about
here is the epidemic curve.
So think of it like a bell curve.
You have a peak in cases and then they go,
they peak and they come down.
What we're trying,
and then we have a line here
where hospital capacity is.
You wanna keep your curve
below hospital capacity.
Even if it means you have
the same amount of cases
but you flattened out
so you never exceed hospital capacity.
So that's what we're trying to do.
We know that we can't contain this virus,
but can we slow the
accumulation of cases to a rate
that's manageable by hospitals?
That's what flattening the curve is.
So you don't have this big peak,
you kind of have a rolling peak
that's not as a huge of a spike.
And that's kind of the
strategy being pursued
by many different countries now
in order to preserve our hospitals.
- Where are guys like you
turning for sensible information?
I see online that seems
to be the number one thing
just for the average person is
we live in a strange time
where people don't trust
our institutions the way they used to.
You know, there's always a
lot of noise on social media,
I mean where are you
getting actual information?
Where should we point
people to besides, you know,
interviews like this and things like that?
- So obviously there are, you know,
if you're an infectious
disease person you kind of
have your own sources
that might not be suitable
for people in the general public.
But there are good sources.
The CDC is actually a very good site.
There's a lot of stuff
on there that you can use
that's actually vetted
and there's guidance
and lots of different types of,
had all types of different
scenarios that you could imagine.
I think I would also make sure that people
are looking at their local
on state health department websites
because if something happens
to them, it's gonna be local,
you need to know what's going on locally
and what the plans are there as well.
And then I would say for science stuff,
I recommend STAT news the most
STAT news is owned by the Boston Globe.
It's probably the best scientific
reporting, in the world.
That's where I look at that every day.
And there's another group
called CIDRAP, C-I-D-R-A-P,
which is at the University of Minnesota.
That's the Center for Infectious Disease
Research and Policy.
They also put out very good news articles
that are easily digestible by the public
and have a lot of really great
factual information there.
- Yeah, I know this is gonna
be a sort of a vague question,
but if you're just the average
person and you're at home
and you're doing these things
and you're social distancing
and you're trying not to
be out there too much,
I mean, what level of concern
should we all really be
feeling about this right now?
- So this is a hard question
because there's a nuanced answer to it.
If I'm talking to a patient
that I've just diagnosed
with this, I'm gonna tell them,
"Don't worry, you're gonna be
okay, you're not going to die.
This is something that has
a very low mortality rate
in most individuals and it's
gonna be like a severe cold."
But it's a very different
thing when you're talking
to a hospital CEO or
you're talking to a mayor
or a governor because the
sheer number of people
that are gonna get infected
because there's no immunity to this,
is going to be so high that
even that small percentage
that needs hospital care could overwhelm
our hospital system.
So it's a totally different
conversation you're having.
And I think that's why
people are understandably
mixed up because they're
hearing both of those things
and they're both true.
They're just different contexts.
And you have to really have
that kind of nuanced communication
because people then say that
you're exaggerating the risk,
but we're not exaggerating the risks.
The risk is to the
individual is not very low,
but the risk to a hospital or to a city
or to a town is really high
because of the sheer number of
people that will be infected.
- So I think when some people hear,
oh, there's no immunity
or there's no cure,
they sort of don't see an end,
like how does this actually burn out?
So can you explain a little
bit about how something
that can't be cured at the
moment can actually end?
- But what may happen is that we will see
a pretty strong first wave.
We might get a little bit of
a respite in the summertime.
It's unclear if we will or not.
Some coronavirus viruses do
decrease their transmission.
We don't know for sure about this one,
but there is some suggestion
that we might see a little bit
of decrease in transmission
over the summer,
but it will likely be back in the fall.
I think this first wave will be bad
and then we'll have
enough people immunized
by getting infected,
that this won't be that much of a problem.
It will be something that we have with us
and it might cause severe disease,
but until we have a vaccine,
this is going to be with
us in the population.
- Yeah, all right.
Well, I'm trying not to overload people
with too much at once.
Is there anything else
that we should get out
in this initial call?
I hope as long as this
continues that you'll be able
to find a little time for us.
But is there anything else
that you really wanna get
across to people at the moment?
- Sure, sure.
One thing is, you know,
this is an emerging
infectious disease outbreak.
So information is evolving.
So when you see something
change or some guidance change,
you should expect that 'cause
we're learning on the fly.
This is real time.
So, everybody in the
infectious disease field
is trying their hardest
to try and deal with this.
It's become the top priority of almost
every infectious disease
doctor in this country
to try and keep everybody safe
and understand this outbreak.
So, I just think that
sometimes people get a little,
they get very fixated on certain numbers
and when the numbers change,
they think somebody has,
you know, somebody's pulling
something over their eyes.
It's not that, it's just
that this is so fluid
that we don't know what's going
on even between this call,
when I started this call with
you and now I'm sure something
has happened that's
changed one of my answers.
So it's important to know
that we're doing this
all on the fly trying to
use the best, you know,
the best of our mindset to
come to a solution here.
- All right, well listen,
I really appreciate you taking the time.
I know you have another
hit on CNN in just a moment
and we'll link also to your
interview with Sam Harris,
which was really extended.
I wanted to give people
sort of as much as we could
in a short amount of
time 'cause, you know,
what I can do is hopefully
give a little information
to people and not have
everybody feel kind of crazy.
So I appreciate it.
And as things develop,
we'll reach out to you and
I'll keep trying to amplify
your voice on Twitter and the rest of it.
So thanks for taking the
time, I really appreciate it.
- Yeah, thank you for having me.
- Hey everyone.
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with coronavirus and our
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