Coronavirus (COVID-19): Press Conference with Barry Bloom, 03/19/20

Transcript

You’re listening to a press conference from the Harvard T.H. Chan School of Public Health featuring Barry Bloom, professor of immunology and infectious diseases and former dean of the school. This call was recorded at 2:30 pm Eastern Time on Thursday, March 19.

BARRY BLOOM: Greetings, everyone. My name is Barry Bloom. I’m a professor and the former dean of the Harvard T.H. Chan School of Public Health. My long-term scientific interest has been global health. My field is immunology of infectious diseases. I’m pleased to be on this call.

Perhaps I have a somewhat unusual perspective, in that I had been invited with a colleague after SARS erupted and China failed to address it adequately. In 2003, was invited by the ministry of health to give advice on what they could have done better. And those lessons have carried through to the present time and seeing the current spread of the new coronavirus around the world and things that every country has to do to be prepared.

So I would look forward to trying to answer your questions. I state in advance there still remains an awful lot uncertain in the scientific world. But I’ll do my very best to be helpful.

OPERATOR: And at this time, are we wanting to open the floor for questions? We’ll take our first question in the queue.

Q: Hi, Barry.Quick question on the statistics out of China this morning where they’re showing no new cases in Wuhan or the surrounding province. Do you have any reason to doubt those numbers? I mean, is the decline we’re seeing in China real? And do you have a sense that sort of gives us hope as to a way forward?

BARRY BLOOM: It’s a very important and very good question. I think many of us weeks ago were very skeptical of numbers coming out of China, not that we knew they weren’t correct. But with the interest in keeping the bad news as minimal as possible, one didn’t know to what extent one could trust the numbers.

We had a symposium at the School of Public Health last, I think, Friday. And had videoed in the dean of the medical school at Hong Kong, a former Takemi Fellow and Harvard School of Public Health graduate, who has been the major advisor, both to the government of Hong Kong and a major advisor to the government of China, and also a member of the commission, the WHO commission in China. And having expressed his earlier skepticism was quite confident the numbers we had been getting as of a week ago for at least several weeks prior to that have been quite accurate and were checked and examined carefully by the WHO independent group. So, I’m inclined to believe that if they say there are no cases over a 24-hour period, they’re probably telling it right.

Q: And what are the implications of that? Is that a model that we here in the US can follow?

BARRY BLOOM: Well, the dramatic effect in China was to allow the epidemic to get ahead of the ability to respond in a public health way, which is the problem that occurs in all epidemics– in most epidemics. And since the epidemic doubles every week, if you start with 100 cases, in seven weeks you have 65,000 cases. That’s hard for people to understand.

But the answer is, here it was clear they knew in late November or early December. But only on the 31st did the world know they had an infectious disease problem. So, I would think from there on they’ve had to introduce very stringent suppression measures of keeping people from leaving their homes and dealing with social interactions.

The point here being, it worked. The numbers, ultimately, came down. People were enormously inconvenienced. An awful lot of people got sick and died. But the numbers have come down.

There are two questions that arise from your question. The one is, will it stay down? And no one knows. And China, I think, has been lifting the ability of people to go to work restraint. And if it is done gradually and slowly, it is, I think, most likely it will be– there will be bursts of outbreaks, but they will be controllable.

Q: Thank you.

OPERATOR: We’ll take our next question in queue.

Q: Yes, thank you. I have two questions about the fine points of symptoms. And I know these are not easy to tackle. But there’s a lot of concern out there. So we can shed a little bit of light. If a person feels chest tightness, how can they distinguish that from the COVID-19 symptom of difficulty breathing, versus maybe just being a sign of stress that a lot of us are feeling now? And secondly, if you have a runny nose or some sniffles, should they not worry at all?

BARRY BLOOM: [LAUGHS] Well, let me just establish my credentials. I am not a physician. I’m a researcher and a PhD. So, what I say should be taken with a grain of salt.

But having looked at the case descriptions, both from China and from the first cases written up in the US, a runny nose is not characteristic of this infection. Tightness of the chest, the kind of things that you would expect with stress, is not a characteristic symptom. But really difficulty breathing, heavy breathing, not feeling you’re getting enough air in and oxygen is a sign that really you need to see or consult someone in medicine.

This is concurrent with a flu epidemic which we are taking for granted every year that kills an awful lot of people and makes an awful lot sick. So, the challenge is, can one simply by clinical symptoms distinguish the new coronavirus infection from influenza? And my colleagues say that’s very different clinically. And that’s why we need testing, testing, testing.

Q: Thank you.

OPERATOR: We’ll take our next question in queue.

Q: Thank you very much for doing this call. I had a couple of questions. One is that we’ve seen different estimates of mortality rates around the world for this disease. And the most recent one, I think, was a preprint and then a paper in Nature, I think, today saying that the mortality rate in China was 1.4%, which is lower than previous estimates.

So, I wanted to ask you, first of all, what you think of that– how 1.4% sounds to you as a possible mortality rate for China and for the world overall. And generally, how long do you think it’s going to be until we really understand what the death rate is?

BARRY BLOOM: So, I may sound like a broken record that you’ve heard before. But the case fatality rate depends on two things, one of which is pretty easy to figure out, which is how many people die. In some places, it’s not always clear whether they die of this infection, or influenza, or something else. So, there’s a certain amount of uncertainty about just counting people who die in a given region in the middle of an epidemic.

The second, and much more difficult, is the rate depends on how many people of those infected actually die. And we have figures from China. And I think everyone would agree that not everybody was tested. So, we actually don’t know what the denominator is. And the more people who get tested, usually, the lower the case fatality rate is.

So, if you remember H1N1 in Mexico, the initial reports– case fatality rate were 5% to 10%. And that was mostly because they were looking at people who were sick, very sick, and in hospitals. But as the epidemiology played out retrospectively and one tackled how many people had any medical problem that could be related to an infection with flu, it went down to 0.07%.

So, the case fatality rate really depends on knowing the denominator. And without testing a very wide range of people, both symptomatic and asymptomatic, we tend always to get a higher number, which is the most frightening number. For the modeling studies, people that I’ve looked at– I’m modeling at about 1%. And it may drop down quite dramatically if we actually knew how many people were infected and not sick at all.

Q: Thank you very much. I wonder if I could ask you another question sort of following up on something you said a little bit earlier about, there would be bursts of outbreaks. I sort of wonder how you see things playing out globally. I mean, we’ve got many areas of this country and the world kind of locked down or semi-locked down. And until we have either an adequate treatment or a vaccine we’re going to risk– assuming that the virus is not going to be eliminated at this point, what do you think will have to be done until that point?

I mean, if you take your foot off the gas and let people go back to work and run around and mill around, and you have possible outbreaks, you may start more spread, even around the world. So, what do you see happening or having to be done until we’ve reached the point where we really can stop it and prevent it?

BARRY BLOOM: I think you’ve asked a key question. And this is different from many other epidemics, not least because this is a really virulent strain of coronavirus. And it is one that we have had no prior experience to. So as bad as flu is, flu comes around every year. More or less everybody has had a flu at some time and has some immunological imprints that may help us make a response, that may not keep us totally from being sick, but at least protects us to some degree every year against flu. We are totally naive to this infectious disease.

And the only way to become protected is either to be vaccinated– and we have no vaccine– or to have become infected and hope that even a low-level infection will generate a protective immune response. And we will be protected for some period of time. So, we’re in the first round, since nobody has been protected against this in the past, of being a globally highly susceptible population. And the question really is– and for this, China has been the laboratory for understanding this disease– what happens as they gradually reduce the restraints on people working, going back to the factories, moving around within cities, and moving out of Hubei and around other parts of China?

So, we know there are– while there were 60,000 cases in Wuhan, places like Guangzhou and Shanghai that had people that had, previous to that, come into their towns with infections, were able to keep the numbers down to the hundreds. So, knowing what’s coming and moving quickly– speed is of the essence. Getting the tools which we, regrettably, don’t still have in the states– to identify everybody and test their contacts. We have the potential– perhaps not as draconian as shutting down the entire province in China of 60 million people. But we have the potential as was done in Korea, for example, of having huge amounts of testing, finding who’s positive, even if they’re not sick, and isolating them. Because even if you’re not sick, if you’re infected and transmit, everybody’s going to transmit between 2 and 2.5 new people. And that number continues exponentially to double.

So, the answer is we would know better what to expect if we actually knew how many people in this country and in each region was infected. And the question is, how long can we sustain being tightly constrained as we are in the States, with the proviso that is really hard for people, and certainly me, to understand– every state sets its own rules, not the federal government. So, if Boston is closed down in Massachusetts, someone in Wheeling, West Virginia doesn’t have to be. And we’re going to have a great difficulty in predicting for the country what happens.

And that leads to the final long-winded answer to your question. China’s biggest problem right now is importing cases that are flying in from other countries. They’ve really done a job at bringing their own epidemic to low level. They’re, I believe, expecting there will be bursts of outbreaks. But they’re going to be getting new imports from people who are healthy when they get on the plane, and two or three days later turn out to have this virus. I think they’re tooled up to deal with that.

But within the United States, if there are outbreaks we are not currently unable to move by car or truck or plane to any other part of the country. We will have to put out many fires– hopefully small– once we have enough of the diagnostic tools to be able to know who has this infection and whom not.

OPERATOR: We’ll take our next question in queue.

Q: Hi, thanks for doing this call. Can you speak a little bit about seasonality. What are the chances– I know this is brand new. But what are the chances that this coronavirus will act like other ones and transmission might dissipate a bit in the summer months? And what does that mean for the health system in terms of potentially buying time for doctors and hospitals to catch up? Thanks.

BARRY BLOOM: It, too, is a wonderful question. And the answer is nobody knows for sure. I think that’s a clear cut and certain answer. Nobody knows how this particular viral strain will respond.

There are some studies in comparisons of the infection in northern China versus Hong Kong, although it’s wintertime there as well. And there doesn’t seem to be a huge temperature and humidity change between those two parts. But that’s probably not fair, because it’s all wintertime. We know from massive studies of influenza, it doesn’t do well in high humidity and high heat. We also know people tend to be walking around outdoors more in the summertime than in the wintertime, and how to factor all of those into what could be predicted.

And then, finally, I think our epidemiologists tend to believe that we overrate the effect of summertime and warm weather on SARS in 2003. We forget the massive public health efforts that were used to test people in Canada and in many countries around the world that really put major public health pressures against spread of the virus. It wasn’t just temperature.

So, if I had to guess, it is, from what I read from the pre-publications, likely to go down a bit, because it doesn’t like high humidity and temperature, likely not to go away, and likely to come back at some level as we spread this out, possibly as the weather cools in the fall. But nobody really knows.

OPERATOR: We’ll take our next question in queue.

Q: Hi. Thank you for doing the call. And thank you for taking my question. There’s been a lot of discussion about how younger people are sort of being dismissive of the social distancing requirements or requests that have been put in place in many places. Yesterday, the CDC released some numbers suggesting that as many as one in five younger adults end up being sick enough to be hospitalized as a result of the coronavirus. And also, obviously, they could transmit it to older adults as well. So, I’m wondering if you could just comment on the general risk to younger adults and also why it’s important for them to comply with social distancing and other public health steps in order to prevent transmission. Thank you.

BARRY BLOOM: Again, a wonderful question. I saw the CDC report this morning. And it’s troubling at a couple levels in terms of formulating an intelligible answer. Under-20s were a very low percentage in China of people that had severe infection. And appears to be the same in Italy. And the question, then, is why it would be so high in the United States when it wasn’t seen in countries that had, at the moment, a probably greater level of infection.

I don’t know the answer. I don’t know of anyone yet who does. I’m sure CDC is looking at it. But it may also have to do with the criteria for admission to a hospital. We are much more likely to have people taken to a hospital for symptoms that are not overwhelmingly serious than in the middle of an epidemic where screening in so-called– let’s say in Shanghai, or Korea, or China, where they have special hospitals with people with fevers or possible symptoms that prevented them from getting into a hospital that had to provide acute respiratory care.

So, it may be partially deciding on who has to go to a hospital in the US that would go to a fever clinic or some other facility elsewhere, such that the numbers are not suggestive that one in five of all adolescents are likely to get serious respiratory infections. One doesn’t know. I can’t think of a biological or medical reason.

Having said that, the answer to your question is if 20-year-olds believe– in China, Italy, Korea, or here– they’re invulnerable to this infection, we know that there are 20-year-olds who’ve died in every one of those places. And they are not invulnerable any more than anyone else to this infection.

OPERATOR: We’ll take our next question in queue.

Q: Thank you. I’d like to ask a sort of provincial Massachusetts question. So, we heard from Governor Charlie Baker today that they think they can do 3,500 tests a day starting early next week. And it feels like there is this kind of race going on between– can we ramp up our testing, and get enough protective equipment out there, and get people distanced enough so that the virus will go blooey here. Or will we not– as Governor Baker said, he’s trying to get ahead enough so that he can be proactive enough to head off the virus.

How are you seeing this picture, this race now, at this point? And what are the prospects?

BARRY BLOOM: I think we’re behind the curve. And if the major hospitals in Boston who’ve been begging for tests for the last three weeks or longer haven’t been able to test, we have no idea what’s going on in this state. The tests will begin. They will be hopefully aggregated, so we’ll know on a daily basis how big that curve goes. It will not be particularly epidemiologically meaningful, because we’ll be measuring what we can test for, not what’s really out there.

So, it’ll take a while before we can get systematic testing, which should be– if you want to draw the curve how bad things are, you want to know, how many people are today getting their first infection? How many people today are getting their first admission to a hospital? Those are figures that will let us think about how things are going.

So again, I take Korea as the best case, but also Singapore and Hong Kong. When they had a few dozen cases, they were testing everybody they found– all but eight contacts in the whole place of Singapore. That’s extraordinary it could be done. But they were testing vast numbers of people, not just those in acute respiratory distress, but anybody that they thought would be a contact.

And we’re in a position of hoping to have enough tests to know whether someone with acute respiratory symptoms has flu or has the new coronavirus. And we won’t get a sense of how many people are walking around able to transmit it until we have more drive-through test facilities and more people who can identify cases and contacts and have them self-quarantined.

So, we’re behind the curve. And the numbers may go up quickly. They may be scary. But in fact, we’re measuring what’s already been there for several weeks, not what we need to know, which is whether the curve is bending or not.

OPERATOR: We’ll take our next question in queue. Please go ahead.

Q: Hi, Dr. Bloom. Thank you so much for doing this talk. You mentioned earlier that your area of expertise is more research and not medical. And one of my questions mainly medical, but I’ll ask it anyway to see if you have a take on it. But a lot of our readers are asking us about ibuprofen and anti-inflammatory medications, and that it increases the risk of complications in those infected with the virus. Do you have a take on that? And particularly, what is it about these medications that is of any concern in the medical community?

BARRY BLOOM: I really can’t answer that. I’ve seen the reports on both sides of the ibuprofen. You know, they’re not cures of anything. So, in terms of affecting the course of the infection in general, they’re not going to make much of a difference. I think the common drug that people are now interested in doing a systematic testing of is the hydroxychloroquine, which has shown in SARS and MERS some beneficial effects. And any beneficial effect without severe side effects is better than doing nothing.

My big hope, to answer an earlier question that is related to yours, is it’s going to take a year to a year and a half at the earliest before we know whether the vaccines that are being tested are likely to be safe. And that’s a non-trivial question, because vaccines go into healthy people. Drugs go into sick people. So, you have a little bit more of a cost-benefit difference. We can’t make healthy people sick with a vaccine that hasn’t been shown to be safe. And that’s the reason vaccines will take so long.

There are some new drugs. There are lots of people working on this, repurposed drugs that have been approved for other purposes– remdesivir that seemed to work on one case of MERS. I would think that’s the quickest thing that could prevent people from the severest outcomes of the disease. But we know that transmission, or the number of viral particles, is greater at the earliest stage of disease. And the later stages of disease probably occur when the immune response is fighting the virus and lessening the number of particles, but also ravaging the body with an overreaction to the virus and the antigens that they release.

So, the immune system is complicated. And something that prevents people from being severely ill or dying is wonderful– unlikely to affect the outcome of the epidemic, unless it could be used very early on.

OPERATOR: Our next question. Please go ahead.

Q: Barry, thanks for doing this. It’s really helpful. I want to go fact screen. You mentioned at the very beginning that you, in fact, had met with the minister of health in China after SARS to discuss what they could have done better. At that point in time, they had temporarily shut down their wildlife markets. They did that temporarily in February 2020. And then they banned it.

My specific question is, when you talked to them back in 2003, did they talk about the policy of shutting down any of the wildlife markets?

BARRY BLOOM: They knew that they were a possible source of transmission. They knew that they had to shut them down for a period of time. And my understanding is both with changes of health personnel in the ministry and many revisions to the political system since then– the live markets are seen as something part of a cultural tradition and politically difficult to make go away. Everybody that I know of for many years has been saying they’re enormously dangerous for transmission of zoonoses from one animal to another animal species, and also into transmission into humans.

I don’t know why they haven’t shut them down permanently. It’s the same issue with people proposing to reduce the coal industry in the United States. It’s part of a cultural tradition that’s very hard to deal with by orders from on high.

OPERATOR: We’ll take our next question. Please go ahead.

Q: Hi, thank you so much for this. Looking at this week’s Imperial College London report, it suggests that the best strategy is interventions aimed at suppression. That includes social distancing and K quarantine, household quarantine. But the model predicts that even if you have effective suppression, it’s going to be followed by a big spike in cases in the fall.

I know we’ve touched on this a little bit. It offers the suggestion that intermittent social distancing is one way to deal with that. So, I want to sort of come back to this possibility of cases rising again in the fall. Can you talk about the danger of a spike happening, even if we do have successful suppression of the spread? And do you think that they’re suggestion that intermittent social distancing is something that could work to help flatten, I guess, the secondary curve at this point.

BARRY BLOOM: It’s a profoundly important question. And let me just emphasize that no one really knows that this virus will survive the summer and come back in the fall. In the beginning, the analogy was made with influenza that goes away in the fall. SARS went away in the fall. Maybe this will go away in the fall.

There is no evidential basis for that. So, everybody, including the model makers, are speculating. But they are awfully thoughtful in how they have thought about their models.

The problem is that no one other than those who’ve recovered from infection are likely to be immune. Which means that if it does persist in the fall, if it’s reintroduced, even if we could get rid of it by the summer, and new cases are occurring elsewhere in the world in travelers who come back to the States or visit the States, there is always going to be a possibility of continued bursts and outbreaks in the fall.

And the question then, do you have to deal with them– how do you deal with them? And I think the sense, as the New York Times editorial by Zeke Emanuel and his colleagues said today, it’s like going downhill on a snowy, icy road. If you put your foot on the brakes, you will crash. If you don’t put your foot on the brakes, you will crash. So, what one does is pump the brake in a kind of responsive way to see where you are at the current time.

I think that’s the model that the Imperial Group is saying. If it comes back, it will come back at a lower level than it started, because not everybody will be susceptible. And if you have to clamp it down for a bit and you have testing to see how extensive the number of sensitive people are to become infected, you’ll have a guideline and something to measure whether things are getting from the 100 level to the 1,000 level, from the 1,000 level to the 5,000 level. And you have to introduce different constraints or suppression measures, depending on how easy it is to find a few contacts in one town in Minnesota. Or you have to shut down a whole state that seems to be problematic, or reduce contacts in other ways.

So, I think the key to every decision making in policy depends on testing and having really smart people model the course of the epidemic in real time, not just by analogy to China.

OPERATOR: Next question.

Q: Hi. Thanks for taking my question. I guess it’s kind of two parts. One, how long do you think the sorts of social distancing measures that are in place now in the US will have to be in place to prevent a surge in cases that overwhelm our health care capacity? And if we’re sort of successful in the interim, do you think that it’s possible that we could go back to a time where all we really needed to keep outbreaks from spreading is sort of widespread testing, and then isolating cases as they pop up, and tracing their contacts and isolating those? Sort of until we get a vaccine.

BARRY BLOOM: So, I believe that maintaining every level of social or personal distancing that was outlined in the Imperial College model has to be done. It starts with voluntary quarantine for anybody who thinks they may have symptoms, whether they have this or not. It means social distancing of those people who are over 70. But because of this fragmented health system in the US, every state is going to do something differently. So, making generalizations about the United States in this context becomes really very difficult.

Assuming we could have a systematic imposition of all of the above and that the leakage rate is something like 25%– that is, it’s 75% effective– the sense is that they could really turn the curve down by two or three months. It won’t go away. China didn’t go away once they turned the curve down. But that might be the time that we could release some of the constraints on people, so they could resume more normal lives.

In Korea, people still went to work. They had to get certain permissions. They had to get tested at certain checkpoints. People were removed from their households to be in fever hospitals. There are lots of ways to try to contain the people who might be ill and allow others the opportunity to go to work. And of course, everybody in China and Korea wears a mask, even before this.

I think there’s much that we could be doing during these three months that would help bend the curve to the point where, as everybody says, we protect the hospital system. I’m hopeful we could actually do more than that, to the extent that a lot of what needs to be constrained can be loosened by the fall– expecting there will be outbreaks in various places, but being prepared with testing, large numbers of people able to do contact tracing, which we don’t now have with cuts at CDC over the past many years– we can tool up to find cases if the numbers are low.

But to be absolutely honest, as I said at the beginning, models are not predictions. And nobody really knows for sure how long it would take to really lower the curve that we could live in a tolerable way, and how much can be released of all of those constraints– schools, social distancing whole populations, protecting people of 70 years of age, isolating anybody with a fever from their contacts. How long we can do that is unclear. And I think that’s a political question and a kind of solidarity question that we haven’t been tested in since the Second World War.

OPERATOR: Next question.

Q: Thank you so much for taking the question. It actually goes along with what you were just saying. We hear a lot about contact tracing here in Florida and what they’re doing with those efforts. But as we’ve reported in the Herald, testing is still really a challenge. We’re only testing the most severe cases, the most symptomatic people, or those with known ties to travel. So, my question is, how effective can contact tracing be without that kind of widespread testing?

BARRY BLOOM: I think you’ve answered the question. Contact tracing can only work if you find, essentially, every contact. So, I would contrast, for example, at the same time, what was happening in 60,000 people being infected. And in another part of China, 200 people were infected. Guangzhou or Hong Kong or Singapore.

And the difference is once they knew what was coming, and once they had developed a diagnostic test, it works really well when you have a limited number of contacts and you can identify all of them. Once the numbers exceed the number of public health people that can find them or the number of tests you can do, it’s very difficult to work by containment of known contacts or infected. You’re working at social population level mitigation, which is locking everybody down to avoid social distancing at every level possible. So, testing really can be done best when you know what the problem is and you have enough tests for everybody.

Let me just say that we’re using a challenging molecular test that has to be done by qualified people in high tech machines to get the answer at the present time. There are tests being developed– in China, they are developed– where with a stick drive, anybody in their house could look to see whether they have been infected with the coronavirus. It will not be 100% sensitive. It will not be 100% accurate. But boy, I would really like to have a test that I could look at tomorrow and ask whether I am likely to have been infected and then could report that somewhere. And we could get everybody’s answer in without having to wait in lines and drive-through things.

So, the science is moving to the point where we can do that, not necessarily testing for the virus, but for example, testing the immune response to the virus, which starts as soon as you are infected. And a week later, whether you’re sick or not sick, you will probably have an antibody that– we know how to do very quick antibody tests for HIV and many other diseases. And they could be made household tests as we do with pregnancy and other things.

It is how to move what we know how to do in a laboratory to a commercial area where people can get– on their own, be empowered to do their own testing. That would be the ideal for me. And that’s not going to be tomorrow in the United States.

OPERATOR: Next question.

Q: Thanks for taking my call. I’m seeing a few things having to do with transmission and whether the virus moves more through the air or is spreading more on surfaces. I wonder what you can tell us about what scientists have figured out on that and what it means for public health recommendations.

BARRY BLOOM: A wonderful question.

To answer your question, that was published– we can go in the New England Journal paper where scientists actually did experiments to measure, if you put so many viral particles down on cardboard, or copper, or plastic, or steel, how long can you find viable viruses there? And the answer is– how much stays in the air? And the answer is a matter of minutes to hours. About 35 or 40 minutes you lose half of the viability. So, this is an exponential decay. It’s not a straight line. It’s a half-life.

And so, in that context, it’s hours in the air if you’re in the same room with somebody. If it’s on a surface, it can be up to 27 hours as a common number of how far they carried out the test and find some level of virus, but much lower that was put down. Cardboard did better in terms of reducing the time the virus remained viable, for reasons that, at least, those authors had no idea, nor do I. We know that viruses in general like flu don’t survive well on fabric, clothes, as they would in surfaces that are hard.

But we’re talking about the persistence in some places for a matter of days on surfaces, which means disinfection is something that should be done at a minimum, in places like factories where there is lots of surface contact of goods and things, as often as possible.

OPERATOR: Next question.

Q: Hi, Barry. I have a general immunology question. We’ve been reading about NBA players who are infected but don’t have any symptoms. And then other people who become very, very ill. Is this an unusual characteristic of COVID-19? Or is this typical of any disease?

BARRY BLOOM: I don’t think it’s typical of any disease. But I think there is a gradation in respiratory diseases. For example, in my favorite disease, tuberculosis, something like 2/3 of the world’s population, perhaps, has been infected with the bug that causes of TB. Either they cure it, or it remains latent, and they’re not sick ever. But at some point, some of them, particularly, with may become immunosuppressed either by chemotherapy, or by HIV, or their immune system wanes in old age, when their immune system shuts down– your ability to control a persisting infection goes down. So, in this context, it isn’t terribly surprising there’s a huge gradation.

In one of the key questions, which is an immunologic question is, is there any way to predict anyone who comes into a fever hospital, or a clinic, or a hospital for testing, can you sort who’s going to get really sick and develop a cytokine storm and be life threatening, and who is just going to have a bad case of this viral infection and recover after 10 days? And the answer is, we have no test for that. There is a hint that there might be certain cytokines that– looking at China data, one unpublished archived paper preprint suggests there might be such a thing. And I learned that there are investigators at Harvard hospitals that are interested in pursuing that.

And that would be very helpful for hospitals to know who’s going to get sick, but isn’t going to need a ventilator, or respirator, or extracorporeal oxygen treatment. That would free up some of the major hospital interventions that we’re worried about running out of. Research to be done.

OPERATOR: Next question.

Q: Thank you, Barry. What would you tell providers in the community– physicians and nurse practitioners– who are not in the acute care setting? What roles are they playing in this pandemic? And what can we tell them to help them help their patients?

BARRY BLOOM: I think the first priority I would have is how they can protect themselves. And this is where testing is so terribly important. It’s one thing to know how to deal with a patient that you know has been infected and might be at a risk. And you would take certain precautionary steps in dealing with them. But if you’re a school nurse and you have no idea whether your kids who are healthy are able to transmit the virus to you, or if you’re a nurse in a hospital worrying whether you’re in a position to transfer the nurse to your kids, those are serious questions that really worry the hell out of me.

And the protective tools that we have available to people at the second line– the high school nurses and practical nurses and home nurses– they’re not there yet. And it would be really helpful if everybody knew who was carrying the virus for 10 days and stayed up and had to go somewhere. Tell someone that you’re in contact with, I might have this virus. Please protect yourself. That would be ideal. But for that, we really need testing, personal protective equipment, and masks.

And I would start with masks. I’m not the biggest fan in masks, but there are a few scientific experiments that I can’t dismiss that suggest that surgical masks are not all that bad. And in fact, in some studies, two studies, in hospitals, in seven medical centers, they were essentially as good as N-95 masks. I wouldn’t count on that. But it’s better than nothing. And in this case, anything that would protect the frontline people strikes me as something they try to utilize.

OPERATOR: Next question. Please go ahead.

Q: Hi, Professor Bloom. Can you talk a little bit about the recent government directives concerning nonessential surgery? How nonessential is being defined, who’s defining it. Is this something that’s being determined on a case by case basis?

BARRY BLOOM: It’s a terribly [LAUGHS] important question to which I don’t have a very good answer. My sense from the infectious disease people who are not surgeons, obviously, is that there is no general guideline that the federal government has put out as deciding what is essential and what is nonessential. Hospitals are being left, as I understand it, at least in most states, to decide on their own. And I have heard there’s a clamoring in the network of scientific communication.

Every hospital, not least for liability purposes, but for real life purposes, would like guidelines on how to tell people who have a pain here and an appointment to look at their annual melanoma reading– to tell them what’s essential and what’s not. And we don’t have those guidelines that I’m aware of.

OPERATOR: Next question.

Q: Hey, doctor. Thanks for having this chat. My question is more to do with public health and panic buying. Here in Ohio and across the country, we’re seeing a surge in sales from everything from food, to hand sanitizer, and even guns and ammunition. From a public health standpoint, what are the concerns with panic buying?

BARRY BLOOM: They make things worse. That’s the best that I can say. Because the most mobile, affluent, healthy people are the ones who are able to do the panic buying. And the most vulnerable, those in the elderly population, those not quite so mobile, those that don’t own cars, are the most vulnerable. And this is a question that, really– I heard the president’s speech yesterday and the comments that didn’t include this today. This is where citizenship really counts. This is where solidarity of– we’re all in this together and having 10 more rolls of toilet paper or disinfectant in my household isn’t going to make anybody any safer. But it’s going to put other people at risk.

And until we can get people to really think about, yes, protect you and your family first. But you don’t have to buy off the store in every cereal. I can’t get cereal in my local market. This is a matter of my view of what citizenship is about. And protecting everybody, not just yourself, is what being a good citizen is.

And I know it sounds platitudinous. But that’s the spirit that I have heard from colleagues in Korea and after the fact in China. There’s less complaining than you would imagine about social distancing. Because there is this sense that what I spare for myself may make available to somebody else. We need that spirit. And we need leaders that every level, not just political and government, but entertainment, and medicine, and elsewhere, to encourage people to be good citizens.

OPERATOR: Next question.

Q: Barry, I want to go back to the wet markets for a second. Do you think for the infectious disease researchers worldwide, knowing what they know about the wet markets, should join forces and call for the shutting down of all the wet markets across Southeast Asia and China? Because the health risks are there. People know about it.

BARRY BLOOM: Oh, people do know about it. And they’ve known about it for a very long time. I would direct the question at a different level. I’m not sure the government of China is going to listen to a bunch of public health people who write a petition. I think they would have to listen to the World Health Organization. And I am not aware– I’m not that in touch with what’s going on at the moment at WHO– I am not aware that that’s been a major thrust to get WHO to take a position on it.

WHO doesn’t like to take a position that is targeted to individual countries. And since there are countries in Africa that do have open markets and sell things like non-human primates for food, bushmeat, in essence, it is possible that in this occasion without directly targeting it to China they could get the World Health Assembly to pass a resolution. And I’d love to see the United States of America government, which is represented there, to support such a resolution.

We should not have open markets where species of different animals are in constant contact with one another. It’s too great a hazard to the whole world to allow that cultural tradition to continue.

OPERATOR: This concludes the question and answer session. I will now turn it back over to Dr. Bloom for any closing remarks.

BARRY BLOOM: I am most appreciative of the thoughtfulness of the questions and, obviously, the knowledge of the people who asked them, particularly in the press. I hope the answers were helpful. And I am hopeful that this series of broadcasts from the Harvard T.H. Chan School of Public Health will continue to be helpful to you in your work at informing America of how we can respond to this epidemic. Thank you all for your input.

This concludes the Thursday, March 19 press conference.

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