Transcripts For CSPAN Johns Hopkins University Coronavirus Briefing 20240713

They discussed best practices to protect against spreading and contracting the virus, as well as the database built to track outbreaks in realtime. Experts at the forefront of the response. Expertar from a is recognized in the field of Public Health preparedness, pandemic, and Infectious Disease and prevention of and response to biological threats. We will hear from a researcher who created the outbreak being used worldwide to track the virus. We will talk to an expert in influenza and other emerging infections. A health hear from systems epidemiologist and control expert. Finally, we talked to a nurse epidemiologist Whose Research speaks to streamline care options that optimize navigation, and retention and care for persons with Infectious Diseases. As the outbreak evolves, we hear from a distinguished panel of experts from across Johns Hopkins university who shed light on the understanding of the virus, its progression, and our response effort. Our goal today is to bring their knowledge directly to you. After short presentations from each panelist, the audience will have an opportunity to ask questions directly to our experts. There will be more opportunity to learn about the virus. Johns hopkins asked her experts have been at the forefront of the response. We recently launched the Coronavirus Resource Center. This is a resource to help advance the understanding of the public, andm the brief policy makers to provide a response, improve care, and save lives. You will find links to subscribe to a daily update from the Johns Hopkins center for health security, webinars, and a new daily podcast from the Bloomberg School of Public Health. We encourage you to check it out. Before going further, i would like to take the opportunity to thank congress for its precise 6074, thepassing hr Coronavirus Preparedness and response supplemental appropriations act. Robustckage will fund a response, including Vaccine Development, support for state and local governments, and assistance for affected small businesses. With that, i will introduce our panel. Of the johnsrector Hopkins Center for health security, the Bloomberg School of Public Health. Then dr. Lauren gardner, codirector of the center for system science and engineering. The codirector of the Johns Hopkins center of excellence and Influenza Research surveillance. And the senior director of Infection Prevention. The Johns Hopkins Health System and epidemiologist at the Johns Hopkins hospital. Finally, dr. Jason farley, professor of nursing, a nurse epidemiologist and practitioner. I also wanted to let you know take ans here and to efficient approach to our question and answer and have as many questions as possible, we will be passing out cards. If you have a question, write it on a card and we will get it back to our panelists. We will start with brief words from each panelist. Thank you. Aboutasked to say a bit covid19 spreading and the disease, and a few points about u. S. Priorities at this point. It was first recognized in wuhan, china at the start of december. The following two months, it had grown from one case to more than 70,000 cases. It spread to all 31 provinces across china. Disease has5, the been diagnosed in more than 100,000 people. Than 3300. Ed more outside of china, leading countries include south korea, iran, italy, france, germany, and the u. S. The u. S. Is about seven, in terms of total cases in the world. As of this morning, there have been approximately 215 cases in the u. S. With 14 deaths. Most important, 78 of those cases have no known link to known coronavirus cases. We would consider Community Transition for those cases, transmission occurring without an obvious link to some other case. Sick haveho become cough and fever. The more severe cases can develop pneumonia. The worst cases, they develop a syndrome that is a severe pulmonary syndrome that mirrors the disease caused by sars back in 2002 and 2003. Some patients initial systems can be nausea, vomiting, or diarrhea. In china, approximately 80 of those with illness developed minor symptoms, not requiring hospitalization. People recovering without any medical intervention. 15 of cases required hospitalization of some kind. 5 required Critical Care. Would require ventilation in the u. S. It is not clear how many of them in china did receive mechanical ventilation. Mortality of this disease is difficult to calculate, because of the ways we are diagnosing it around the world. Is an overthere diagnosis, or over representation of people who are the most severely ill. We find a severe cases first, because they are the most obvious and in the hospital. That is going to skew case rates out fatality rates with mortality rates. The more we do the diagnosis, the more we diagnose mild cases, the more it drives down the overall case mortality rate. It is too soon to say how far that will go. In hubei province, where wuhan city is, about 4. 3 of recognized cases have died. That is not a case of fatality rates, it is a crude calculation of the number of cases identified, the number of deaths. In italy, that number is about 3. 2 of cases. In the republic of korea, only about. 6 . I dont mean to minimize it, but. 6 of those cases have died. We think it represents a much more ambitious testing strategy in republic of korea. More than 143,000 people have been tested in a short time. We think it increases the number of mild cases identified and decreases the mortality rate. The mortality rate of those identified over age 70 and over 80 is especially worrisome. It is substantially higher than those who are younger adults. We have not seen serious mortality in children, although we have seen cases as opposed to what we thought. There are a subject substantial numbers of cases. The viruses are one to 14 day incubation period with an average of five days. Spreading primarily via a respiratory droplet. It means close contact, usually within six feet. We have seen some studies with as many as 20 of cases with no symptoms, which makes containing the disease and slowing it down particularly challenging. Major interventions have been put in place in countries experiencing serious outbreaks of covid19. Im sure you have seen in china, they took maximum measures to contain it, including lockdown of cities, closure of travel routes, schools, business. As many as 760 Million People were at one point confined to homes. Havealy and iran, they taken fairly substantial containment efforts, including cancellation of mass gatherings, closures of schools, and as of last night, more than 300 million kids around the world out of school because of the virus. Priorities i believe are important for the u. S. , i think we need to continue to substantially expand diagnostic testing that has changed over the course of this week. Now 45 states out of 50 are reported to have the ability to do testing. Many hospitals will be coming online. They will develop their own tests and get them validated. News that quest is moving to develop its own tests, which is a promising sign, because they have such large volumes of critical testing around the world, around the u. S. , rather. So i think the goal is to get to a point where any patient who has symptoms consistent with coronavirus can be tested quickly. We are not that point now. We dont have the bandwidth. That is the goal. The goal of the administration. State health labs are moving in that direction. We need to do substantial work to get our Health Care System prepared. There are many hospitals that have done that work. I think others have much more to do. In italy, south korea, japan, china. We have seen Major Pressure on the Health Care Systems. We know that in the u. S. , if we see similar numbers of cases, which we will understand better in the coming weeks, there could be substantial pressure on intensive care units to take care of larger numbers than usual of critically ill patients. We also need to make sure our Outpatient Clinics remain available to patients in china. We saw cancer clinics and dialysis clinics have closed in an attempt to manage the virus. That would be a really unfortunate secondary comfort consequence to this disease. We also need to take special care of our longterm care facilities. We have already seen in Washington State how terrible the virus can be within a longterm care facility for people who are most vulnerable. We need to support Public Health agencies. 24 7 to already working isolate cases, diagnose them to quarantine people who need to be quarantined. Itcases significantly rise, may no longer be possible to pursue the strategy of identification with every case and orienting of all contacts. In scalecome too large for Health Agencies to do that. At that point, we would need to shift on focusing the understanding of the burden in the population, recommendations to the public regarding isolation and testing, and possibly measures that we would call collectively social distancing measures, which may include closure of businesses or telecommuting, may be of large gatherings, and in some places, could include closures of schools. Those decisions will probably need to be taken by local Health Officials with local political leaders and business and school leaders. Last word about medicines and vaccines, Vaccine Development is likely to be 12 to 18 months away if all goes well. We have heard that from the countries and internationally from vaccine scientists. Developing plans for mass manufacturing vaccines, when it is developed. Similarly, antibodies are being developed by a number of companies. Those can be developed far sooner, in terms of the process of developing and approving the medications. We will also need plans for mass manufacture of those medicines and hopefully in multiple places in the world if the u. S. Gets a new product, there will be enormous pressure to access the product. Even though it is not usually done this way, we need to take medicines and vaccines in multiple multiple places at the same time. Its great to see this attendance in this kind of meeting on the hill. Has beenhe response very swift, in terms of the emergency appropriations bill. We are excited that is being aimed at hospital preparedness, public agencies, the agencies of government working with industry to make these important products. My name is lauren gardner, im an associate professor at the civil and Systems Engineering department at Johns Hopkins university. Im leading the efforts behind the coded dashboard that most of you are probably aware of. About how thisk works, the features, and a bit about the Data Collection process behind it. Some of these are stats, as well. I can do it from here. This worked earlier. So i can Start Talking about it. There we go. I have the Technical Capability to build this, but not open a powerpoint presentation. Comforting. Is trackingdoing total cumulative cases all around the world. Here in this now global view, the red circles represent the total number of reported confirmed cases to date by region. And the Spatial Resolution of the regions we are recording on depends on where we are in the world. In china, we are reporting at the province level, the county level, australia, canada, and the rest of the world of the country level. On the left is a list of all of the countries. On the right is the recovery, which we are also reporting. You can see the actual number by region. You can click on a location, and it zooms into it on the map, and you also can highlight the specific stats for that region. Then you can switch here and see the finer Spatial Resolution. Another thing we are highlighting is in addition to the total confirmed cases is the number of active cases at any point in time. This is the total number of confirmed cases, minus the recovered, minus the death. Better represents reflects the risk at any point in time. What we will see is a shift of these active cases from east to west. On the bottom right, we have a timeline of the temp oral nature of this outbreak. We are tracking the total cases over time, the recovered time, and they are broken down within Mainland China and outside of china. It can switch tabs and see so we can capture the exponential nature of the outbreak we see in early stages. We can track it at a daily scale. In terms of the number of newly recovered cases reported on a daily basis. You can turn these off and on to see just one series. What we are looking to do soon chart between new daily cases in Mainland China and outside of Mainland China. We now have more cases outside of china than inside of china. I think it is a pretty critical shift in this situation. Box withttom is a text a bunch of really important stuff i think nobody reads. To infectiouslink disease articles, a letter that we wrote that details the Data Collection protocol behind it and what they are. There is a link to the mobile blog, which to the details background about the outbreak, the mapping efforts, and also some modeling efforts behind the scenes. More about the data sources. That is it for this. I should be able to get back to my slides. Can you make these fullscreen . I can do it from there. As i said, this is all hosted out of the school of engineering at Johns Hopkins. One thing about where the data is coming from, and in two minutes, i cant explain the details of the process, but what i can say is it spans the entire scope of pure manual data input to purely automated data input, depending on the source, and also some combination of both. For example, china data is automated, and has been since february 1. It is pulled from a particular website and updated every 15 minutes. At the moment, the u. S. Data entry is completely manual. The rest of the world is some combination between the two. Where the data is coming from is a variety of sources. In general, it is based it starts with the daily reports from who and the National Health commission of the peoples republic of china. They only come out every 24 hours. We use them as a baseline. Through the day, we supplement them with local level, city level reporting and reputable news and media outlets, and local Health Departments as new cases become available. They are coming out at the city level first, so they cant be incorporated into the national outl reports that only come on a daily basis or less frequent. To instill confidence and validate the data, what we are doing behind the scenes is consistently comparing our data on the dashboard with the data provided by the reports. That is shown on the maps on the left. At any given point, we are always presenting more cases. We have the cases that have been reported previously, plus whatever the new cases are at the time. They follow the same trend. Consistently reporting the reliable and accurate data. There are discrepancies, for instance, on the bottom when the province changed the recording reporting criteria and started reporting cases, there was a huge jump. We captured it at the time. Who captured it a few days later. On the right is something i think is really important and critical. It shows the ability to let the public know when a new region becomes affected. It does it in a really timely manner. The countriesis reported in the who situation report and the day they are reported on. Then we include the countries in our dashboard. Blue means we did it before the report came out. You can see we almost always report countries before they are formally reported in the reports , with a couple of exceptions. Week happened in the first when everything was done manually. One of them was early saturday morning. We are doing a really good newof keeping tabs of when important events are happening, and we can see the data we are presenting is accurate and aligned with the official reports, even though we are providing and collecting it in an independent manner. This is provided in the Infectious Disease letter. A little about the user statistics, this has been a bit of a shock. This is a curve of the daily requests. It is not necessarily eyeballs, its interactions on a daily basis. It has been pretty popular. At the moment, we are getting well over one billion requests per day, interactions on a daily basis. Happened,f peaks around late january, when italy first reported the first case. Then there was another one around the time there was a lot of spread in the eu and around the middle east. Is is it is showing where the usage is coming from geographically. It lists the top 10 countries with the u. S. Being the one with the highest usage. The green is the rest of the countries aggregated together. In terms of who is using the dashboard, as far as i can tell, it is pretty much everybody. Everyone in terms of the general public has really been the predominant users. It has gone viral on almost every social media channel that ourts all the way up to local, state, and federal government, Public Health entities, and pretty much everything in between. I think this really speaks to this huge demand for reliable, trustworthy objective information, especially around situations like these. I think it is important to acknowledge the gap and support ande data procurement visualization tools moving forward that are to be made publicly available. This is clearly something that was missing and needs to exist moving forward. Lastly, this is not something that i have done or could do, or whatever do on my own, and all of the other people part of the team really deserve all of the credit for the work being done, especially the guys on the right. They are two of my phd students. Frank has really been the pioneer behind this and led the efforts behind building out of the dashboard. They have worked to keep this running. We also have other really great support in science and engineering, and where the whole effort is being let out of. Then we have wonderful support from Johns Hopkins university of life physics lab, and the technology we are actually using to build the dashboard. This whole thing has been internally supported through Johns Hopkins university. Next we will go to dr. Annie packers. The cards being passed around are for you to write questions on. Give it a quick wave and somebody will come and grab it so it is ready to go during the session. Hello. Im here to focus my discussion on issues related to the virus and immune response to infection. Dr. Anthony fauci from the National Institutes of allergies and Infectious Diseases has provided important leadership covid19 to contain the outbreak and provide research. As well as driving forward Vaccine Development efforts. In january, he also pulled together laboratories researching influenza and other respiratory viruses, and are just ring resources and expertise to bear on the covid19 outbreak. I would like to summarize some of the work that has been initiated and continues to go on through these efforts and other efforts. The coronavirus family includes viruses responsible for a wide spectrum of disease in humans, ranging from the common cold to severe disease caused by sars, mers, and now covid19. , understanding the differences between the original sars virus and covid19 viruses, viruses that are similar genetically, yet have very different disease penetration and perhaps transmission patterns, is critical in understanding how the covid19 virus has been able to spread to some parts of the globe, while the sars virus was eventually contained and then eliminated from the human population. We need to understand virus shedding in much greater depth. That involves looking for infectious virus levels in respiratory secretions, not only virus levels quantified by the current tests. This will give us a better understanding of the true window of time in which a person can be infectious and will better inform our Public Health responses to the epidemic. The area virus sequencing and has provided us us with a powerful tool to follow chains of transmission by tracking unique mutations that have occurred in the virus genome during replication. However, they may help the virus to adapt to its new human host. That might be associated with better virus transmission or altered disease potential. Understanding and monitoring changes in disease to varying how they track changes in the virus genome is a high priority Going Forward. Planning work to understand the immune responses to infection. Some basic questions, such as what kind of immune response is induced by infection . How long do they last . , and does infection protect you from a second exposure to covid19 question mark those are critical questions that have informed responses and will guide the vaccine projects currently Going Forward at a rapid pace into clinical trials. The factors that drive disease severity need to be identified. Shows age,ical data gender, and preexisting medical conditions are associated with severe disease, but we need to understand why thats occurring. Understanding how disease in these populations compares to milder disease seen in other age groups to help inform better treatment regimens for highrisk populations. Covid19 is sometimes compared to seasonal influenza. It is important to remind everyone that influenza is responsible for over 18,000 deaths in the United States this year alone. That is with vaccines, antivirals, and having a portion of the population that is immune from severe disease because of previous exposures to influenza. We have none of those things to battle covid19. A deeper understanding about what the virus is doing in humans will drive more informed and effective interventions and treatments essential to controlling the outbreak and minimizing the impact on human health. Thank you for the opportunity to speak. I will turn it over to lisa. Dr. Merigakis. My name is lisa merigakis, an associate professor of Infectious Diseases at Johns Hopkins University School of medicine, and im the senior director of Infection Prevention for our hospital and Health System. What i wanted to talk with you our Health Care Infrastructure and the preparedness activities nation inacross the facilities and Health Care Systems like Johns Hopkins medicine to prepare and make sure we are as ready as we can se to safely care for patient who become infected with this novel coronavirus. At the beginning, i would like to remind us remind you that we have faced a number of Infectious Disease threats over the past several years. The good news about that is we learn more every time. We become more and more prepared. And i would like to point to the importance of the periods in between Infectious Disease threats, and how Building Infrastructure and preparedness is critical for our ability as a Health Care System across the nation to respond to this kind of a novel pathogen, particularly pandemic respiratory virus. In particular, there has been a in particular, there has been an investment in preparedness infrastructure in this country that began with the ebola crisis in 2014 and 2015 in west africa and the assistant secretary for preparedness and response regional approach to making sure we have Treatment Centers for patients with highly Infectious Diseases and a whole network of regional Treatment Centers and assessment hospitals and frontline care facilities, so the emphasis is that all parts of our Health Care System maintain readiness and an all hazards approach. Att funding was directed viral hemorrhagic fever. The great news it allowed infrastructure to grow, partnerships to develop between the Health Care Infrastructure on the front lines and Public Health authorities. And all aspects of Emergency Management and preparedness. That level of preparedness has really allowed us to pivot more rapidly to be prepared to meet this threat. That does not mean, however, that we do not have a lot of work remaining to be done. Because we do. I will say that every institution has some manner of pandemic respiratory virus planning. We need to take those out, and hopefully everyone has already done that. Certain at Johns Hopkins medicine we have. Dust off those plans and think about really the nittygritty of what it will take to operationalize and implement those plans. Inevitably, one finds that there are novel aspects of the pathogen that must be addressed in applying those preparedness plans to the specific situation. And also moving forward, and making sure that all of the myriad details are in place that might not be contained in such a plan. So we have heard from some of the other speakers about mode of transmission, a major piece that plays into preparedness. I would say that most of the pandemic respiratory virus planning in this country and probably around the world has centered on the assumption that such a virus would be spread by the droplet route. By really larger droplets that are expelled when a patient infected with a virus coughs and sneezes. Those particles tend to go six feet in front of that person and then fall because they are relatively heavy and they land on surfaces and the floor. Thats what it is so important to use environmental touchection as high surfaces is one of our strategies. However, there is another strategy called airborne transmission whereby smaller viral particles or droplet nuclei remain aloft for a longer period of time, so they can float around in the air and be inhaled by someone who comes along bit later, maybe even after the patient has left the room. That is a different kind of threat that we are used to handling in health care environments, with tuberculosis and other kinds of pathogens. So there is a notion that this virus, although most of the data suggests it is spread by the droplet route, that it is possible the airborne route may also play a role, especially in certain circumstances, where procedures are being performed in the health care settings, like intubation of a patient that needs mechanical ventilation, for instance, that may cause those aerosols to be present. So, out of an abundance of caution, the current guidance from the centers for Disease Control and prevention is to use airborne precautions for this virus. So part of what is being done is dashing health care sick facilities around the nation and the world is to try to figure out how best to take that pandemic respiratory virus planning and adapt it for airborne pathogens. That means several things. It means we need to look and we all are looking at our facilities and the air handling in those facilities. To determine critical planning for patient placement and then staffing to go with the patient placement so we can provide the safest care possible in our facilities. We all have airborne isolation rooms, as theyre called, that have special air handling for treating patients who have tuberculosis, measles, etc. But we do not have a large number of those rooms. Many facilities, and Johns Hopkins medicine is leading this effort, to look at air handling modifications that can be made to turn entire medical units in acute Care Hospitals into a respiratory isolation unit. We are also working around the clock about how to ready ourselves to handle an influx of patients, and a surge. We call that Surge Capacity planning. Many of our hospitals operate in a lean sort of way, meaning much of our Health Care Delivery has been moved into the outpatient or ambulatory setting. So, looking at the remaining inpatient acute care facilities, that have really been streamlined for cost control, which is entirely appropriate, now, we need to ask ourselves, how we can ensure we have the staffing and readiness in case a large number of patients do need inpatient care. All at the same time. Particularly if they need Critical Care services and mechanical ventilation etc. So that is a lot of the work going on. Even when we find the places for patients to be housed and the right air handling conditions, then staffing is another major concern. We are working with our Human Resources colleagues, and with so, looking at the remaining inpatient acute care facilities, that have really been streamlined for cost control, which is entirely appropriate, now, we need to ask ourselves, how we can ensure we have the staffing and readiness in case a large number of patients do need inpatient care. All at the same time. Particularly if they need Critical Care services and mechanical ventilation etc. So that is a lot of the work going on. Even when we find the places for patients to be housed and the right air handling conditions, then staffing is another major concern. We are working with our Human Resources colleagues, and with our planners, to make sure that we have the providers, the nurses, the respiratory therapists, and every member of the Health Care Delivery team ready, so that we can ensure we can provide care to all who need it. I want to walk through a couple aspects of how a patient might move through the health care setting. It has implications across the health care spectrum. As dr. Ingleby alluded to, patients have a wide spectrum of symptoms. They may be a asymptomatic. They may have mild disease they may have symptoms that look like a common cold or shortness of breath. We need to get the right care to the right patient at the right time. That means keeping the worried well and the mildly ill out of our emergency departs and clinics where they might not need to be and they might cause exposures to other people who are there for other medical reasons. And also kind of clog the system. We have services that provide inhome care, home care colleagues. We also have opportunities to use strategies like telemedicine and phone triage to support patients who are recovering at home, and really encourage patients who are worried they may have the virus but have very mild or no symptoms. To recover at home. Turning then to those who present for care, testing is an enormous concern on our mind right now. As has been mentioned already, we need the ability to test rapidly. We need that to be at scale, so we can do widespread testing. I think you have heard today some reasons why we need that, to understand the epidemiology of what is happening in this country. Also for any given patient to decide on appropriate therapies, and to get them into appropriate isolation precautions. So that is a major amount of work going on. A word about supply chain. This is of concern across the Health Care System. Something our supply chain colleagues are helping us tackle to make sure we have all kinds of options on the table about personal protective equipment, which is top of mind to keep our Health Care Workers safe. In addition to personal protective equipment, having a large amount of manufacturing in china that has in many cases been disrupted, has led to allocation or suggested caps, or enforced caps, on over 400 items across all kinds of categories we use in health care. So i think we have some strategies to deal with this. But this is one of the challenges we are tackling. I will mention a couple more things. Partnership with federal and state Health Authorities is critical. The more we can all work together, the stronger we will be able to respond to the needs that may come our way. What would this look like . It might look like Regional Strategies for patient placement at staffing. A lot of things i have described so it is not Health Systems like ours planning on our own, but really partnering with other Health Systems and federal, and state, and local Public Health authorities. I think we need to be mindful of accessibility issues and affordability issues. That will be very important for patients. Especially those who live far and have affordability challenges. We are preparing to participate in clinical trials. Do not have a vaccine. We do not have therapies. But we do have candidate therapies. It will be important to learn more about that, and make sure we are offering the very best care at any given time and me collecting data so we can learn how better to handle this disease. Thank you. Dr. Maragakis. I will hand it over to dr. Jason farley. Im dr. Jason farley, professor at Johns Hopkins University School of nursing. I would like to thank our colleagues are on the forefront of covid19 response. I thank you for what you are doing and the work you continue for keeping us informed and uptodate to date as this outbreak occurs. I would also lead to thank each of you here today, supporting the members and the tireless effort you have for the work you do for our nation. As my colleagues have detailed, this is a quickly changing outbreak. One that is causing alarm across the nation and the globe. The situation of covid19 as much an outbreak as it is an outbreak of this information. An infodemic is the word they used. As the only nurse on the panel is my duty to speak to about Health Care Workers at the front the forefront of the response. They are following their duty in stepping to the forefront to care for patients with covid19. As many of you have seen, they there are growing concerns across the Health Care Workforce related to their personal safety, as well as access to personal protective equipment as well as timely testing that has been mentioned. It is important we arm everyone with Accurate Information as well as personal protective equipment throughout the Health Care Workforce. In a survey conducted recently by the National Nurses united, a Union Representing approximately 150,000 nurses, which is granted a small sample compared to the 4 million registered nurses in the United States, 6500 respondents to the survey. They participated with about 29 reporting their hospitals new about a plan that was in place at their facility. For coronavirus patients. 44 of these registered nurses said they perceived they had received guidance from their Health Care System. Another 30 in the sample did didnt really know what was happening on the ground at their site. This is the most alarming factor. That means the communication in the individual Health Care System has fallen short in some way, but this is a mere glimpse of what is happening at the front line of the epidemic. This is a mere snapshot. It has led to activities such as the New York Times and others reporting significant anxiety among the Health Care Workforce. I think that is contributing to Community Level anxiety. The cdc put out interim new guidelines, which they are doing frequently and quite rapidly, approximately two days ago. They recommended Health Care Workers who have potentially been exposed or in settings where there is Ongoing Community transmission report every day to work and report whether they have symptoms or fever. They also noted implementation of contact and airborne precautions in the Health Care Facility would be implanted and implemented and recommended. Despite the fact we do believe the virus is most likely transmitted via droplet. That sixfoot, high sneeze cough and spray we see in those pictures youve probably seen across the internet. With that droplet transmission, close contact is generally required. The cdc has a clear definition of what we believe close contact is. Lost contact is defined by cdc as that six foot parameter, or contact for a prolonged period of time with someone was known coronavirus symptoms or known to have coronavirus. Importantly, that can be with personal protective equipment depending on the circumstances and without. The cdc has given a clear roadmap for the type of exposure a Health Care Worker might face. Lets consider what is considered high, moderate, and low risk has been clearly outlined in the cdc guidance. I invite you to take a look at that. It will provide a clear picture. Also, you will see across media i think what is somewhat of a misrepresentation often of an ebolalike personal protective equipment response. Posted on multiple media outlets. I want us to call our attention to what cdc actually recommends for protection. Right . For airborne precautions, we are talking about n95 masks and their face has been shaped perfectly for that map, they have been evaluated to determine if it works for them or not. We are not recommending the general public go out and seek that type of respiratory support and protection. Also, there are personal air purifying respirators which look like a spacesuit that comes down and covers your entire face. That adds another layer of protection because it covers all mucous membranes. It is another layer of protection many healthcare workers have access to. At Johns Hopkins we are trained on the use of them. That must be used in conjunction with contact precautions. Barrier precautions as appropriate, as well as standard precautions as the case may be, in addition to appropriate Health Care Worker and Health Environmental cleaning. Our frontline staff are cleaning staff, our housekeeping staff are equally important in stopping the spread of this outbreak both within facilities as well as in ambulatory care settings as our clinicians are providing the care. Hand hygiene works. Absolutely. You dont need a nurse to tell you to wash her hands, but purel, whether it is alcoholbased or waterbased Hand Sanitizers, water and soap are equally effective. Use what you have at home. It is equally effective. I think that is important. High touch and hightraffic areas, so you are thinking about the metro you all rode in on. Those are hightraffic hand environments. In yourottle of purel pocket, keeping frequent hand hygiene is really critical. It is your most important protection. When we think about how long coronavirus will live on those hard surfaces, the answer is it depends on environmental conditions. Also the type of media that was coughed or sprayed out. Estimates range from a couple of hours to up to several days. I have seen estimates as high as nine days after exposure to an environment. We must also keep in mind, the cdc interim guidelines provides that clear exposure table for Health Care Workers and has given clear guidance which i will go into now for the community. One final thing before i leave the Health Care Workforce recommendations, we are still in the middle of influenza season. So we must think about other respiratory viruses. That could be causing i was in clinic last week and diagnosed a patient with influenza b. We are seeing a Record Number of influenza cases that are common in our environment. As we move to the general and public infectious control precautions and things you can do. I think first and foremost we heard a lot about staying at home if you feel ill or sick. All of us who took the metro, have heard that coughing, sneezing, sniffling, stuffy had head nyquil symptoms on that metro. It is critical that we heed if you are not feeling well, stayathome. From a patient and humancentered response, there are millions of Health Care Workers throughout this country who do not have the option of staying at home. Because if they do not report to work, they do not get paid. There is a balance we need to achieve with the recommendation. Finally, we know about cough hygiene, cough into your elbow. Lots of elbow bumps as opposed to handshaking. There are principles and practices one can employ, there. As i mentioned, n95, the special types of masks Health Care Workers use are in short supply. I was in a Conference Call in some of the work i do in tuberculosis in south africa, and the cost of an individual n95 mask for workers in tuberculosis wards in south africa have more than quadrupled in the last month. We are seeing a global shortage of n95 in the u. S. For our Health Care Workers, and in some sites reporting challenges 5s, achieving enough n9 and in the worlds leading Infectious Disease killer, global settings as well. And in the worlds leading Infectious Disease killer, tuberculosis, we are having challenges for Health Care Workers. To close attention to the options. If you are sick, a simple paper mask, the slight blue paper mask, 10 help not prevent you can help not prevent you from getting ill but prevent you from infecting others, by stopping the droplet transmission. That cough and sneeze. If you are concerned and living in the community, and there is community transmission, we talked about social distancing, meaning staying at home, telecommuting, possibly watching your sunday services or saturday services or whichever day you worship, those Services Online or through other means as opposed to congregating in those settings. Also limiting travel. We have seen lots of limitations that have occurred and recommendations on limiting travel. And thinking about, as dr. Maragakis pointed out, we do not have the capacity for a large influx of worried well. Meaning if you have a cold and youre feeling fine, talk to your primary care clinician. Seek advice. But overwhelming the Health Care System at this point is the opposite of what needs to happen. Finally, on Public Health messaging and communication, clear, consistent, trusted messaging is extremely important. We need a people centered approach, meaning we must raise awareness without raising panic and fear. That is a delicate balance. That needs to be struck. We really have to avoid, and the data being presented, is important, because it helps to realize the overgeneralization of any region of the world and any population within the world, clearly we have gone beyond that. There are initial reports of stigma and discrimination that were occurring for people from certain parts of the world. That is not something any of us would like to see happen. I think we should use an evidencebased approach and look at the data to know that stigma and determination of any kind, particularly as it comes to covid19, is not something that should be supported by any evidence we have available. Thank you. Thank you so much. Im going to go ahead and start the q a session. I would say about one third of these are focused around Testing Capacity. Maybe i will start with one for dr. Maragakis and dr. Ingleby. Do you think the Testing Capacity is adequate in the u. S. And to hospitals with labs have access to everything they need to either package up and send a perform the test . Thank you for that question. I think the short answer is no. Testing capacity is not currently adequate. We need more. We need this as soon as we can have it. And i think there are a variety of efforts underway to provide access to that testing. One of them is that test kits have been distributed from the cdc to the state health labs and many state labs are now coming online to provide testing for their areas. In addition, microbiology labs like the one at the Johns Hopkins hospital have taken a number of steps to develop their own testing and we hope that ours will come online in a matter of days if the validation step goes well. So i think all of those individual efforts are to be commended because we desperately need the testing. And then finally, we also know that commercial laboratories and companies who develop diagnostic tests are also working on this issue so that hopefully we will have, and i think this is probably a matter of weeks, hopefully not months, but weeks that we would have access to more rapid forms of diagnostic testing that are not so laborintensive as now. The only thing i would add to that is to say that this is the process that occurs when a new emerging Infectious Disease is discovered and a country need to test for it. In that cdc is the developer of the initial test. Then they move that out to state Health Laboratories around the country. Neither cdc or health labs are intended or designed to handle very high clinical volumes around the country. For that to occur we need to have diagnostic companies fully involved and it seems they are at this point. The only question is when will they be able to get their tests online and i think theyre working quickly to do that and hopefully in the next week or few we will be able to see more scale at clinical sites around the country. Great thank you. , the next question for dr. Farley. As we start to see or people infected and cases rise, as the Testing Capacity increases and we see cases that may or may not be already there, what is the best way to keep people calm and informed, and what those message what those increased numbers mean . This is a setting in which having more appropriate testing will lead to Greater Public comp. I think the data reported to us from south korea and the actual case fatality rate data, in a setting in which we know that testing was rolled out quickly and adequately and to a large number of people, we saw numbers of total cases that were having severe disease and or subsequent death decline significant. I think that really will help us to message correctly. Right now, because of the focus on testing for those most ill, have a really large case for fatality rate, larger than we hope to expect it will ultimately be. I think that is the first thing. The second thing is, messaging around that needs to be one of the Public Health experts providing that knowledge and expertise. I think we have seen great data coming out with dr. Fauci, and ambassador birx, as well as dr. Redfield with that message. Lauren another question, what should be doing to protect vulnerable populations such as those with disabilities, seniors, and the populations that are going to be most affected by this disease . Dr. Maragakis it is an important point. We are all susceptible as far as we know to this virus. Because no one has immunity because it is a novel virus. But we are not equally susceptible to that severe consequences of this infection. Our data suggests so far that 80 to 85 of people who become infected will have mild to know no symptoms and it will be a selflimited disease. Really what i think you are alluding to is the very vulnerable populations, which at this time, seem to be older individuals, individuals with suppressed immune systems or underlying medical conditions. This is familiar to us. This happens every year with influenza as well. Some of the same populations that, when infected with respiratory virus, can exacerbate the underlying medical conditions and lead to severe consequences. So, measures we can take, first of all is knowing that. And taking we have heard a variety of strategies here today so i will not list them again. Taking extreme caution with those who are more vulnerable. One spot of bright news for this virus is that the youngest children do not seem to be as vulnerable. That is a blessing in this case. We are not sure exactly why that seems to be the case. But a difference for this virus. Lauren grade, thank you. And a followup question, how long can covid19 survive on surfaces and how are scientists starting to look into this question of analyzing that . A very important question. As has been mentioned here before, how long a virus survives on a surface is dependent upon a lot of different parameters. How large the droplet was deposited, what was in that droplet . There are studies that suggest that sometimes your mucus present can stabilize the viruses and maybe extend the amount of time they are there. Some of these things are ongoing now. We cannot give you a firm answer. I think it is also very clear that all the disinfectants we can use against standard viruses work very well against this covid19 virus. So, almost irrespective of how long the virus can survive on a surface is the fact that if you do a good job of cleaning the common areas, areas people are touching on a regular basis, you will be reducing your risk to getting infected. Good cleaning technique, good disinfection techniques, being aware of your environment. And the weak links people have. Like the door we will be pressing when we leave here, is a common area where a hundred of us will be touching. Understanding those surfaces and intervening there, is probably the best strategy to min mice try to minimize transmission. Lauren and perhaps washing your hand as soon as you leave the room. [laughter] dr. Inglesby, we have a question about the emergency authorities available to the president and governors and other political leaders. When we have a public emergency like this. What circumstances would you think that activating these authorities may be necessary . Are we there yet . Do we have more to go . Dr. Inglesby in the u. S. , Public Health authorities are mostly devolved to the states. In most states, there is a law that allows owners to do what governors to do what they think is right in the interest of Public Health, and protecting Public Health. So, if necessary, governors around the country will likely have the power to cancel gatherings, to quarantine individuals they believe need quarantining, perhaps to use facilities that would be used for isolating cases or quarantining cases. I think local decisionmakers will make those choices. Hopefully in ways that are the most wise for their communities. At i think we have seen that governors who have cases have already invoked emergency authorities to allow them to do these kinds of things. They are in place and it is not a large barrier for them to use them. I think they will use them in ways they think are most important for their communities. Lauren thanks. A question for the whole panel, particularly dr. Maragakis. Hand sanitizers hard to get in many stores are sold out. What is the alternative . Dr. Maragakis great question. I took a picture last weekend of my local stores empty shelves. There was no purel, no handbrand, no kind of any sanitizers whatsoever. It was surrounded by shelves of soap. Good oldfashioned handwashing, soap and water will work. So far, i do not think there is a shortage of soap. So we should not panic. If there are empty shelves, just wash our hands and get back to the sinks and soap. The other good news is that alcoholbased Hand Sanitizer and perhaps the companies will be unhappy with me for saying so, we can make it. There is a key ingredient there, the alcohol. So im not too worried about this. Lauren great. Thank you. Dr. Farley, could you talk about First Responders and how they can prepare for the outbreak and things they can do to protect themselves and how we can support them . Dr. Farley sure. Obviously, when we think about the sharp end of the spear, our First Responders are the sharp end of the spear, and our critical component in the chain of survival for so many of our patients. Our First Responders, ems and others, are very well equipped with personal protective equipment in ambulance vehicles and others. Where it is probably less clear at this moment is what one needs to do as the spread occurs more generally in the community in terms of how they would respond to each individual call. Remember, our First Responders walk into scenarios where they really have no Background Information other than 911 has been called. Right . So each jurisdiction, and each area will need to make its own ems related decisions as to what level of ppe, depending on the spread within a given community, the First Responders would use. It may get to a point, if there is an ongoing Committee Community transmission, that it would make sense for a slightly elevated level of personal protective equipment for First Responders. But that would be on a community by community, emf, by ems basis. Lauren thank you. Dr. Gardner and dr. Farley . You touched on this but there is misinformation and false data out there. How do you combat misinformation and analyze whether the data you are seeing are real and accurate and trustworthy . Dr. Gardner i will start with this because it is relevant to the dashboard. It is tricky. There is a lot of misinformation. We are not focused much on that, as on spending all of our efforts really finding the sources that are reliable. Like i said, the dashboard is built on Data Collection. That stands for everything from fully automated to fully manual entry. The manual entry is because, especially at the moment, all of u. S. Entry and the canada and australia entry is done manually, because we are checking each case as it is reported, and looking into what is the source reporting it, and making sure it is a valid source coming out of some kind of Public Health department and a real conference case. Confirmed case. The automated data we are including, we include only after we have vetted it and observed it for a period of time. So we are confident. In the data being provided on the sources we are scraping and automatically updating into the website, and the other thing, like i said, is we put a lot of energy into the information we include in the dashboard and as a second double check, we continually compare the data that we are presenting with who data, which is an independent source, and make sure that our data aligns with that data. Again, i mentioned the only discrepancy is based on, at a given point in time we would not expect it to be the exact same. We would expect ours to be higher because it is built in real time, but we can see that over time, the trends align. I think that really, one of the motivations behind this and one reason why it is so popular is because there is such a need for having trustworthy, reliable, objective information. Today, given all of the noise that is out there. We basically do the best we can to provide that as one single source. Dr. Farley i also wanted to mention one thing. There have been a number of rumors started, and a number of perhaps preliminary or perhaps incorrect scientific papers put out there in this for rapid dissemination. There is a small cadre of scientists out there on social media really patrolling for these things. Not just responding in terms of this is not true, but actually using facts and evidence and logic to argue against some of these things. In some cases one can say, if someone says something truly incorrect that his inflammatory, perhaps the genie is out of the bottle. But at the end of the day, having responses that scientists have put together that really point by point discredit or disprove or cast doubt on other peoples conclusions is something that is really important, in terms of for most people having some level of confidence that the right information is getting out there. And that there is a level of policing of the information, so not everything is getting out there and being freely disseminated. Dr. Gardner actually, i will add to that. One of the best things about having a billion eyeballs on our dashboard is that in some ways this is crowd sourced information. There are so many people watching it. As soon as we become behind on cases, people send us that information, which my email inbox is not happy with, and usually the source of the information. We are guided to the correct information if we are missing it. And if we ever over report we will be corrected on that as well. So we are cross checked by the public on this. Because of the way it is designed. I would add that each, particularly those of you in the room who are staffers with members, you have in your possession a digital influencer. Someone who has the social media capacity to influence fact, Accurate Information, and to prevent misinformation from moving forward. We all also have a personal responsibility to vet and validate things we share on social media. So if you are sharing things that he personally dont know the source of that information or dont know that you would trust it for your own health, why share that piece of information on social media . Finally, i want to applaud cdc and who for working with our social media giants and helping to dissuade the propagation of misinformation on various platforms. There has been the buy in of many of the platforms to take unfactual andl inAccurate Information and that is the exact type of response we need from them at this time. Lauren thank you. I will hand this over to dr. Inglesby. As we have heard from dr. Maragakis, Johns Hopkins has impressive presentation of medical capabilities for this and we are preparing to respond to this outbreak. What would you say the state of readiness of hospitals across looksuntry broadbased like, and what can we do to improve it . Dr. Inglesby we do not have a completely systematic way of answering that question. We do not have systems that can pulse every hospital to understand its complete state of readiness. Hospitals have been involved in receiving support through a federal program called the Hospital Preparedness Program and they work with their state Health Agencies on that. In the end, even though it is a substantial grant program, there are many hospitals in the country so the overall support for any one hospital is still relatively modest. I think at a high level, we have to say that the Readiness Level across the country is quite varied. In big institutions that have large teams, we can expect readiness is higher. I think if we think about institutions that are smaller or away from cities, i have more concern they have less search capacity, less training, less control, infection less access to information that some of our best hospitals in our biggest cities have. In our planning at a federal and state level, we need special attention to smaller institutions with less resource and with less access to some of the top leaders or protective equipment or other kinds of strategies we use for the big institutions. Lauren great. Thank you. I am going to combine two questions for the panel. Particularly thinking of our population that cannot telework, or telecommute or work from home, how can the public if they do have to go out during the outbreak protect themselves while taking public transportation, going to schools, working at the cannot work from home, etc. . Dr. Farley sure. Hand hygiene. Hand hygiene. Hand hygiene. Number one. If you are sick, stay at home. Those are your two most important features. The statistic of 80 to 85 of people who are known to be infected with coronavirus are doing very well. Most of us in the workforce, particularly young, healthy, ablebodied people, are at very low risk of clinical complications from this virus. That is an extreme important message. Hand hygiene. If youre concerned about touching surfaces if you would fall over if you do not hold the rail in the metro, take a small package of clorox wipes and wipe it down before you grab it. It is all general personal hygiene techniques and practices. Lauren great. Thank you. So, if viral particles can remain airborne and for a certain amount of time, or if the disease can create droplets, can you talk about the advice out there on not Wearing Masks and why that is important for the general public . Dr. Maragakis sure. This is another area we need a lot of messaging to the general public. We do see a lot of images of people around the world Wearing Masks in public settings. The current guidance is that is not necessary. And it may not really add to protection. The things we just heard about washing our hands, even though it sounds so basic, that is the critical link. We touch surfaces. We touch doorknobs. We touch our face. That is how viruses get access to our mucus membranes. If we wash our hands, that is the best way to prevent infection. Dr. Pekosz and i would also emphasize, a mask may sometimes give you a false sense of security. As was mentioned here, we get trained on how to put these masks on and they are verified in terms of how well they are fitting, before i came here, my biosafety officer walked by and jokingly gave me a razor. Im going to have to shave to be refit tested for n95 because having facial hair precludes me from using an n95 effectively. These are things the general public may not understand. Any time Something Like a facemask that has the potential to help you, if it is not used correctly, is a false sense of security and help facilitate bad may behaviors and exposures. I think the training behind those masks is something that needs to be emphasized to the general public. It is not just having a mask, is knowing how to use it effectively and safely. Dr. Gardner i would add one more thing. I think we have already talked about some of the supply chain challenges. Really trying to get the supplies we do have to the people who need it most and where we know it is effective. Lauren we have a couple of questions on the illness itself. I will combine them. How long after contracting the coronavirus will it take for someone to test positive . Are false negatives possible . If so, what does that mean for spread . If you recover from covid19, can you get it again . If yes, what does that mean for Vaccine Research and development . Anybody who wants to grab one of those, go for it. Dr. Inglesby ill grab a couple of those. We know the incubation period is a wide range. From the time you are exposed to the time you are sick can be from 114 days. The first patient that came back from china had mild symptoms at the start and eventually self identified, brought himself to the hospital, and over a. Period of time developed a cough and fever. And then mild shortness of breath. It can take time for those symptoms to accrue. For people who get really sick it can beat five or six days from the time you start with symptoms to the point where you feel very ill and need hospital care. It is important for people who have initial mild symptoms to be aware your condition might change over time and it might need hospitalization at some point. Most people will not need that. There are the cases that do have some progression of illness over time. I dont remember the rest of those questions. Lauren testing . Dr. Inglesby is it possible to have a false negative . Yes. People are tested multiple times in the course of their illness and we have heard reports of people testing positive and then testing negative and then testing positive again. Most scientists do not believe that as a person being reinfected. It is just the nature of the test. It is not a perfect test. You might test negative and then a better or subsequent test is positive. In most cases, repeated tests negative are required before someone is discharged from care. Dr. Pekosz the question about reinfection is a really important one. We have only now got to the stage where we have had people who have been infected, recovered and recovered long enough for us to start asking those questions. That is going to require the develop meant of new types of tests. Tests that are based on antibodies, that tell you not that you still have the virus, but what your history of exposure to the virus was. Our best guess is antibody levels are going to be predictive of whether you are protected from infection. The antibodybased tests people are now developing and we will soon hear about will give us a lot of information about how strong your immune response is, how long it lasts, and how well that will correlate with protection. The answer is, we will know more over the next couple of weeks, as is the case with a lot of questions about this outbreak. Lauren great. Thank you. Im going to ask dr. Maragakis this one because we had a conversation about it. We have seen a lot of people bumping elbows instead of shaking hands. Can germs be transmitted this way because people are also told to sneeze or cough into their elbows instead of their hands. [laughter] dr. Maragakis what a great question. I go back to the earlier comment about handwashing. I shook hands with someone two days ago and they looked at me astonished and said you are still shaking hands . I do think that any time Something Like this happens, we have to look at our cultural practices. In this country, handshakes are almost second nature. I know our european colleagues are also looking at the kissing each other on the cheek. And other opportunities we have. That falls into the category of social distancing. Yes, bumping elbows is one way. There are other ways. I would say we need to come up with a different kind of accepted cultural greetings. That everyone can utilize. Because this is the threat with us today. We know respiratory viruses sweep through every season. That would be a good habit to get into. As far as sneezing into your elbow, it is a good point. I had not really thought about that. Lauren im going to ask one one last question since we are short on time. Anyone who has thoughts on this one, im sure there are a lot of people in here who would love to hear it. We have spring break coming up and people are making decisions about canceling plans and changing travel arrangements. Maybe we can go down the panel and give us some thoughts on what it means to cancel plans or if you should be thinking about canceling plans . Dr. Inglesby very difficult set of questions because at this point, thinking about Domestic Travel for spring break. We are going to learn a lot about disease in the coming weeks as we have more capacity for testing. I think we will see that we have disease in most places in the country. Whether your risk is higher when there are 20 cases in the state versus 50 cases in the state, i do not think we have that kind of perfect knowledge. It is not clear yet that going to special places in the country is likely to increase your risk. Federal Health Authorities have advised they do not think there is any need yet for any kind of Domestic Travel restrictions. From studies on airplanes with other viruses, we think just using airplanes as one mode of travel, that there is risk if you are sitting very close to someone with coronavirus, or with another respiratory disease where it has been studied before. Or in one row or two rows in either direction. But typically, the whole plane is not considered at risk. It is really do have the bad luck sitting to someone with a disease in a row in front or behind . These are decisions people need to make on their own. There probably isnt going to be guidance that is clear for everyone in every condition. I think a lot is going to depend on what your destination is, whether it is national or national. And just understanding appropriate things we can do in our own control to reduce risk around hand hygiene, or trying to avoid people who are actively sick in your presence. I think these decisions will be changing over time. At this point, there is not any National Guidance around travel restrictions to mastic late. Domestically and there is clear guidance around where the u. S. Government believes people should not go, or should only go for essential work reasons. Lauren any additional thoughts from the rest of the panel . Dr. Pekosz i will tell you what we are dealing with. I do not have an answer for this either. We are dealing with the question of scientific conferences. The past president of the American Society for virology, an association of 2000 virologists who get together and he discuss wideranging issues. Our meeting is in the middle of june in colorado state. We are having seen it get significant discussions as to whether or not that meeting should go forward. People come from all parts of the country, areas that have transmission and areas that do not. Is important importantly, the financial considerations for individuals, where we would like to wait and make a decision, but at some point, airlines may not refund tickets, hotels may not refund hotel costs. There are all those other factors that are coming into our decisionmaking outside of just the question of whether or not this is a thing we should be doing at this point in time regarding epidemic control and covid spread. It is a complicated question that a lot of societies are dealing with as well as individuals. Lauren great. Thank you. We are out of time and this concludes our briefing. I want to thank you all for being here. Judging by the number of people in this room, we can tell this is an issue that is on everyones mind. I will encourage you to visit the Johns Hopkins Coronavirus Resource Center online where you can find the Johns Hopkins resources to help advance the understanding of the virus to inform the public and brief policymakers to improve care and guide a response, improve care, and most importantly, save lives. At Johns Hopkins, we are guided by the principle of creating knowledge for the world. My colleagues stand ready to assist you with any policy or Research Support you may need on covid19 and other issues. Thank you for attending and for tuning in, and ill remind you to wash her hands after you leave the room. Have a good afternoon, everyone. Thank you. [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] to follow the federal response to the coronavirus outbreak, go to cspan. Org coronavirus where you of our coverage, including hearings, briefings, and review events any times at cspan. Org coronavirus. Cspan, your unfiltered view of government. In 1970 nineble and brought to you today by your television provider. Earlier today, President Trump joined tennessee governor bill lee for a tour of the tornado damage in cookeville. Heres a luck. [cameras clicking] thank you very much. This is governor bill lee and he has done a fantastic job