Coronavirus (COVID-19): Press Conference with Howard K. Koh, 03/30/20

Transcript

You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Dr. Howard K. Koh, the Harvey V. Fineberg Professor of Public Health Leadership. This call was recorded at 11:30 a.m. Eastern Time on Monday, March 30.

Previous press conferences are linked at the bottom of this transcript.

HOWARD KOH: Welcome, everybody.

I am a physician who is trained in multiple areas. I was the state health commissioner here in Massachusetts through 9/11 and anthrax. And that began my professional commitment to emergency preparedness. And so those themes came into play when I was assistant secretary for health in the Obama administration H1N1. And so, this COVID challenge has been yet another chapter in our public health history that I am very, very familiar with.

To summarize where we are right now I would say that, right now, our country is running a public health marathon. And today is a very important day, because the CDC guidelines, which were initially proposed for 15 days, have been extended for yet another month. This is the right decision. And from a scientific point of view, it’s the only decision that could have been made. If you look at the data, you know the US now has more cases than any other country in the world. Death rates are doubling every three days. Today’s figures show that we have about 150,000 cases of COVID, and some 2,500 deaths.

The case fatality rate, which is a very important indicator it’s being examined worldwide is staying about 1.5%. And we can talk more about that if you want to later on.

Testing had been a challenge initially. But testing is now ramping up. Some 900,000 tests performed to date in the United States. So, the good news is the number is rising, but it’s still not nearly at the level we need it to be. For example, if you look at countries like South Korea that have done very aggressive testing from the beginning, our rate of testing here in this country is about one fourth of that of South Korea.

Now, some progress in this area just in last few days is that new point-of-care tests have just been approved that can give results in five or 10 minutes. So that will improve things in a very substantial fashion going forward.

So, in the midst of all this, there have been many potential strategies developed to take the pressure off of overwhelmed hospitals. It’s been fascinating to track how innovative states and cities have been to set up testing sites off of campuses that are medical centers, to again take the pressure off of overwhelmed hospitals. For example, here in Boston, a new testing site was just set up at a race track, actually, to try to prioritize health care workers and make sure that their status has been accurately assessed.

We are seeing also more attention to telehealth capacity from health care providers. And that hopefully also can give people the care they need and deserve, but do it in a way that doesn’t overwhelm hospitals.

There’s lots of attention now to ramping up surge capacity. I hope that’s a theme that you’ve all heard about a lot. And we who are involved in the emergency preparedness world talk about surge capacity in terms of staff, supplies, and space. Staff, of course, has to do with health care workers, and protecting their health, and supporting them in any way possible. It is a growing theme.

Supplies – you’ve heard about the challenges with respect to masks, and ventilators, and ICU beds. There are some growing strategies about consolidating what we have, tapping into stockpiles local and national, donation of masks from other sites like construction sites or outside labs. And also, the importance of increasing production for companies that traditionally make masks as part of their business, like 3M, but also repurposing other businesses to help out.

With respect to space, lots of attention to coordinating space in the most useful way, inside and outside of hospitals. The efforts to decrease elective surgery have opened up outpatient sites for repurposing. And then we’re hearing, in the community, more efforts to use convention centers, like in New York, dormitories, to house homeless populations, setting up field hospitals in various places. Those are all efforts to maximize space.

And through all this work, there’s been attention to special populations I mentioned health care workers first and foremost. They are frontline heroes for us. Their challenges need to be front and center for us, because they are working to save lives every day, as we all know. We need heightened attention to the elderly, because they are at high risk for death. How do we best support them in this time of need? Everyone should know about their own risk profile. And we need to support the best way possible people with medical conditions. I’ve mentioned the homeless already. I want to say, again, when you have a situation like this, where the advice is, stay home, and you don’t have a home, that is an overwhelming challenge for homeless people, but also for society at large.

So there have been some efforts here in Boston and elsewhere to set up special testing sites for people who are homeless, and even isolation sites as cases inevitably rise in that population. We haven’t heard much about that yet, but that’s going to be in our future, I am sad to say. Through all this, and throughout my career, there’s always been debates about what is the proper role of government when it comes to public health. And I think we can all agree, at a time like this, that in the face of an epidemic or pandemic, we all need government to work as effectively as possible to get people the protection they need and deserve.

What’s also been fascinating is to see the rising role of private business. It used to be said that the worlds of private business and public health really didn’t overlap, but that is absolutely no longer true. In fact, one of the lessons of coronavirus the virus, in my view, is that the worlds of private business and public health are inextricably intertwined. And we’re seeing many examples of that, day in and day out.

Last week, the president and Congress put through a major stimulus package – actually there have been three sets of stimulus packages – in response to the coronavirus challenge. And so, funds will now be coming to states and cities. And it will be very important to have a coordinated approach to those funds to build public health and prevention and preparedness back up to where it could be and should be. And so, there’s tremendous activity going on right now. And we are running a public health marathon.

As I conclude my opening remarks, I want to stress that we will get to the other side of this epidemic. It’s not easy. It’s very disruptive for millions of people. And getting to the other side of this epidemic will require a sense of shared sacrifice and shared purpose. Fortunately, we’re seeing, through some early polls, that the public are supportive of these actions, and want to do their part. Social distancing is a way for people to stay home and therefore save lives. And we must continue to support one another, to stay connected while we’re staying apart.

But that ends my opening comments. And happy to take any questions you might have.

MODERATOR: All right, and I’d be happy to open up the floor for any questions.

Q: Hi there. One of my questions– I have a couple here. But one is just on transparency. We’re seeing a lot of just control of data. And I’m wondering if you think the public needs to know more to help fight this. Like does it mean more to people if they know that there are positive cases in their hometown, versus just their county? Can that help with social distancing and with the potential spread of the virus?

HOWARD KOH: Thank you for that question. I think that’s a very important question to start us off. So, I think back to my time when I was a state health commissioner. And that was a different challenge, but it was a major challenge and crisis nevertheless. And one of my jobs as the Massachusetts commissioner at the time was to report what the public health system was doing, and show that the system was working for people.

So, for example, we had thousands of white powders coming into our state laboratory at the time. And through the press conferences I ran with the governor and others, it was my job to keep track of those numbers and report how many cases we were processing, and what the results were.

So, in my view, at a time like this, sharing the data, good and bad, on not just cases and deaths, but also tests, and hospitalizations, other indicators, is very important to show that the system is working to try to protect people.

I’ve noticed that Governor Cuomo, in his briefings, now starts with presentations of such data. And even though the numbers can be very unsettling and disruptive, it does show that government is working to collect that information and put it out before people. So, thank you so much for your question. I think that’s a very important theme to demonstrate trust and transparency in a time like this.

Q: I guess my next question too would be – again, I have two questions here. But one is about, do we know, just from modeling and projections, where – the federal government right now is saying we’re hoping to get out of this with 100,000 deaths nationally. Do we know where a projection might be for Massachusetts specifically, or New England? We’re now into 48 deaths as of yesterday afternoon.

My next question would be just about ventilators. We’re seeing some Boston hospitals are, right now, using about 30% of their available ventilators. Do we know what the number is that they might need in a city like Boston?

HOWARD KOH: So, let me take your second question first. For any assessment of supplies, it’s critically important to understand exactly what we have, and then try to coordinate those supplies to meet the need. Hospital A could be overwhelmed, but hospital B, nearby, may not have that level of volume. So, if those hospitals can work together, and communicate, and coordinate, that’s hugely important for a statewide response. So, I’m sure the mayors, and the governor, and their health leaders are doing that on a day-to-day basis.

Getting that information can be harder than one might think. So that’s really where addressing the challenges of assessing what we have, and then correcting any maldistribution of resources will be very, very important. And then your other broader question about projections and modeling– there have been many models put forward that you’ve heard about, day in and day out. Most of them have been global or national. The projection of 2.2 million deaths is absolutely the worst-case scenario for the United States. We need better data for regions and states. And so much of the outcome will depend on what we all do now as a society. So, I’m hoping that with the extension of these guidelines for social distancing, we can drive those numbers down.

Q: Hi. Thanks so much for doing this. I’m a freelancer, by the way. I was hoping you would talk a little bit about testing. And I’m hearing that there are shortages of reagents. Are we going to be able to do the kind of testing that I think we’re going to need to be able to get out of our houses? And how soon do you think we’ll be ramped up to an adequate level of testing?

HOWARD KOH: A very important question. So, I think, going forward, the ability of the United States system to ramp up is going to accelerate dramatically. Again, these new point-of-care tests that were just approved will help. One company, Abbott, has pledged that they will have 50,000 tests a day available within a week. So that will be very, very important. Again, we can look to global comparisons to see how other countries are doing this. And South Korea is testing at a rate four times what we are right now. So, we still have a ways to go.

It’s really important to get testing that really reaches a better part of the population. Because until we do, we won’t have really good numbers about how many people are infected. But part of the rise in the numbers is because the testing is rising. But we still have a ways to go.

Q: Hi. Thank you for taking my question, and thanks for doing this. Locally, we’ve seen a response that’s been maybe not as stringent as public health officials or epidemiologists might want. The governor has thus far refused to issue anything beyond voluntary orders, and has refused to issue state health orders. In a pandemic like this, what does leadership actually look like? Because this doesn’t really feel like maybe what you’d want to see.

HOWARD KOH: So, it’s been really critical to watch the trends and try to assess where we’re going to be in the immediate future. And I know there have been efforts to rank parts of the country by risk – high risk, medium risk, and low risk. But I can assure you that in this dynamic environment, what is low risk today can easily be high risk tomorrow. And the social distancing guidelines are our major weapon to try to make a difference here.

So, if there are parts of the country that have not been aggressive, this is the time to double down and not lighten up. And I’m hoping that the extension of the national guidelines will prompt many more state and local leaders to do that. We have over 220 million Americans following these guidelines already in a very strict fashion. And we also need to be aware that cases and deaths continue to rise. So, in a time like this, we need to be as aggressive as possible.

Q: Thank you.

Q: Hi there. Just another one about testing – right now, we’re hearing a number of things. One, one of the first responder testing sites, there are some people who are going on between six and eight days waiting for a result. And these are first responders who are quarantined at the moment awaiting those results.

Along with that, from Saturday to Sunday, the state lab only tested two samples according to their data that they released yesterday. And we’re seeing other lab sites who talked about they have the capacity to test 1,000 or 2,000 samples a day. But we’re only seeing between 10% and 30% of that volume. Do we know what the issue is at the moment? Is it a lack of reagent or a lack of testing kits? Or is it that these guidelines may still be a little too narrow to get testing expanded?

HOWARD KOH: Well, initially, there are challenges with reagents and the CDC kits. And I think that’s pretty well known. And initially, there wasn’t enough collaboration with private labs and hospitals who could make their own testing kits. But I would hope that those issues are behind us now. We have a system that involves not just state labs, public labs, but also the private sector.

And then, as I mentioned, the introduction of the new point-of-care tests that can give you results within five or 10 minutes should really improve the turnaround time. So, it’s very frustrating for people to wait many days to get their results. That’s not an efficient system. I’m really hoping that in the upcoming numbers of days and certainly weeks, we can ramp up to levels that we’ve seen in other countries around the world.

Q: Thanks for speaking to us. It’s really important. And I understand that the focus here is the US, but I wanted to ask you a question about Brazil, once we’re talking about leadership and government attitudes. You’ve mentioned that we need government to work as effective as possible. And here in Brazil, the president Jair Bolsonaro keeps saying coronavirus is like a small flu. And besides that, he’s trying to convince Brazilian society not to isolate. He’s been calling for a protest against isolation. And in fact, yesterday, he went to the streets to shake hands with support.

And I want to just to highlight that we don’t even know if Bolsonaro had COVID-19 or not, because he never showed his test results as other presidents did. And during a recent visit to US, most of the people who were with President Jair Bolsonaro got infected by coronavirus.

So, could you comment a bit on the Brazilian situation. What is the risk of not having a strong leadership in this crisis? And what would you recommend to Brazil?

HOWARD KOH: Well, I think every country leader has seen that in a crisis like this, the best recourse and the only recourse is to rely on the science and the public health leaders who are reading that science and updating it. We know that coronavirus is not like the flu. It’s at least 10 times more deadly in terms of the case fatality rate. The seasonal flu kills about 0.1% of those infected. For coronavirus in our country, that number is at least 10, maybe 15 times higher. And in China, the numbers appear to be higher still.

And then also we know that coronavirus is much more infectious than the flu. Data shows that if a person is infected, he or she is likely, without any other interventions, to infect another two to three people. For the flu, it’s one to two people. So, it’s already doubled the infectivity of the seasonal flu.

So that’s what the science shows us. And in a time where this pandemic is engulfing just about every nation in the world, I hope the societal leaders can learn from other countries, and try to stay ahead of the curve as much as possible. We’ve learned from China, we’ve learned from Italy, we’ve learned from South Korea. And so, I think if leaders can learn from one another, and be as transparent as possible, and rely on the science, that’s what’s going to make global health improve going forward.

Q: Hello again. Thanks for taking my question. So, we’ve been hearing a lot about social distancing, shelter in place, case tracking, quarantine, and testing. But what beyond that should we be doing? There are a lot of folks who are just laid off, and who cannot find work because the places they would ordinarily work are just not in business. There’s a social cost to a lot of this stuff. I’d just like to hear about leadership on that front, because poverty is also a public health issue.

HOWARD KOH: Absolutely. Again, the huge lesson from COVID going forward is that business impacts health and health impacts business. We saw, in our country, that over 3 million people have already applied for unemployment benefits. And that’s a very challenging situation for our country. We hope the stimulus package or recovery package will help individuals like that get back on their feet.

We need the health system to, first of all, help us get to the other side of this curve. And so, the public health approach is first and foremost. We’re not going to have a thriving, recovering economy until we can get to the other side of all this from a health point of view. And then, once we do, I hope we can continue to support a society, people who are particularly vulnerable, help them get back on their feet, not just in terms of a health point of view, but also a business point of view, and then do this together. And so, we need all sectors of society to work together going forward.

It’s interesting– in public health, we have this concept of so-called social determinants of health. And that concept is basically public health is too important to be left to just health professionals alone. And I know part of my work as a professor and former public official is to work closely with the sectors of housing, and education, and business, and faith-based organizations. This is a time to really encourage all those sectors to step up and work together.

Q: Forgive me if someone asked this, because I had to switch from my phone to my computer. But my question is, we’ve been hearing a lot – even the president has mentioned this – about this peak arriving in two to three weeks. Can you be more specific about this? Is it possible to gauge a peak at this point? And if so, do you feel that it is this two to three-week time frame?

HOWARD KOH: So again, we need the best data possible so we can track these trends. And now we’ve talked already in this call a couple of times that, without optimal testing, we still even don’t understand how big the burden is right now. So as the testing continues to ramp up, the number of cases will continue to increase. We want to watch the slope of this curve, which is going up relentlessly, and make sure it starts going the other way. And then, Janet, we also need to be fully aware of what’s happening in other countries like China.

So, the good news is that, in China, they’re on the other end of this crisis, as you’ve all seen. They started to open the country back up. They’ve had, I believe, no domestic cases in the last week or so. They’ve had some new cases that are imported. So, they’re relaxing all their restrictions.

But they went through a very draconian lockdown for 2 to 2 1/2 months. And our country has been at this for, depending how you count, certainly less than a month. So, I think those projections that you are hearing are very reasonable. You will certainly understand that because the models are so varied and so much depends on how much our community can be activated nationally to practice distancing and make sure our transmission goes down, that it’s hard to be much more precise than that.

Q: Hi, Dr. Koh, again. I have two questions. You have mentioned the homeless. Do we know what was the homeless situation in other countries like China, Italy, and Spain? And considering also the vulnerable population, what about the population inside prisons? Do you consider it at a special risk too?

And the second question, I would like you to explain to us if there is an option right now for social isolation. Is there something now that could be done? And the reason why I’m asking you specifically this is also because of Brazil. Because this is the question that it’s been raised by Jair Bolsonaro, the Brazilian president. He thinks that social isolation is not an option for us. So, is there an option for social isolation?

So, there’s two questions, about homeless and population inside prisons, and if there is an option to social isolation.

HOWARD KOH: Boy, those are great questions. So, the broad answer is that any situation where people are congregating close to one another, it increases the risk of transmission for coronavirus. So that includes homeless populations who are crowded in shelters, prisoners who are crowded in incarceration facilities. All those situations need to be examined closely – the elderly that are close to one another in nursing homes. All those organizations are looking for ways to improve distancing there.

So again, the strategies have to be to use the space that’s available in the most creative ways. If you can think of ways to spread out people in those settings and decrease rates of transmission, that’s going to be hugely important. Maybe there are spaces in prisons or nursing homes that can be used.

And again, for the homeless, we need to track this very, very closely, here in our country and around the world. Here in Boston, they set up special facilities to test people who are homeless, and then also isolate them when they start getting sick, which we are getting prepared to take care of going forward. So, I think our city, with the support of the mayor– and also from private business, by the way – has been very proactive on that front. Doing interventions like that is important, not just for the people involved– in the homeless, in this example – but also for the broader population. Because the health of the person and the health of the community is inextricably intertwined.

Q: Actually, about the second one– sorry that I put two questions and then things got a bit confused. So, if there is an option for social isolation, not considering only the homeless and the prisoners, but the society in general. Do we, at this point of the pandemic, have an option for social isolation? Or is it the only thing that we should be doing right now?

HOWARD KOH: So, every society has got to examine the options that are unique to their country and their culture. Here in the United States, compliance has been pretty high and public support has been pretty high in states like Massachusetts, my home state. And again, we need our leaders to be communicating with the public and coordinating services the best way they can at the state and local level, with the federal government.

I mean, this is the time when people demand government to step up and take care of them. That’s what public health is all about. So, I’m hoping those themes can apply to your country, and all the countries around the world.

This concludes the March 30 press conference.

Yonatan Grad, Melvin J. and Geraldine L. Glimcher Assistant Professor of Immunology and Infectious Diseases (March 27, 2020)

Sarah Fortune, the John LaPorte Given Professor and Chair of the Department of Immunology and Infectious Diseases (March 26, 2020)

Press conference with Caroline Buckee, associate professor of epidemiology and associate director of the Center for Communicable Disease Dynamics (March 25, 2020)