WeStar

Online Seminar: Protect ourselves and our communities from COVID-19 -03/07/2020

 

  • Webinar: Novel Coronavirus SARS-CoV-2
  • Speaker: Michael J. Mina, MD, PhD
    • Assistant Professor, Harvard University
    • Center for Communicable Disease Dynamics (CCDD)
    • Department of Epidemiology and Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health
    • Associate Medical Director in Clinical Microbiology, Brigham and Women’s Hospital, Harvard Medical School
  • Time: March 7th, Sat, 2pm – 4pm
  • Transcribed by Maggie Kley and Lee Chen

 

I’m going to give a brief introduction to the coronavirus that is spreading. I’m going to primarily talk about the early days and where it began, and some of what we know about it as scientists and as physicians and researchers. And ultimately, I’ll talk a little bit about testing. But really I want to make this an opportunity for individuals who are out there listening right now to be able to ask questions and receive some answers, to the best of my ability.

 

To give a brief introduction to myself: I’m an Assistant Professor of Epidemiology and an Assistant Professor of Immunology and Infectious Diseases at the Harvard School of Public Health. I’m also one of the associate medical directors in the pathology laboratory where I help to oversee some of the molecular diagnostics (including the testing for this particular coronavirus) at Brigham and Women’s Hospital in Boston, which is one of the primary teaching hospitals of Harvard Medical School. Essentially what all this means is that I have expertise both in understanding how a virus is transmitted through populations and in modeling that using mathematical tools. Additionally, I work in the immunological space to understand how vaccines work and how the immune system responds to infections like this coronavirus, and ultimately we tried to coalesce these two understandings to try to figure out how to best control viruses like this. In my role as a pathology director at Brigham and Women’s Hospital we are generally involved with the development and bringing online of new tests, usually under less time restricted circumstances as this coronavirus has presented, but ultimately we work hard to make testing available to our patients in the hospital and as well to other community hospitals in the area. So just to give a little bit of background to this — and I think a lot of people who have paid attention to the news might already be well familiar with all this — this virus emerged in Hubei province in China, back in likely November or early December, and it was first detected on December 8, in the seafood market. It’s assumed at this point to have arrived via a zoonotic transmission, which means that this was a transmission event from animal to humans in the market. At this point the precise animal that it came into humans from is still unknown. The important thing to understand is: if you look at this graph here, what I’m showing on the x-axis, along this horizontal line, is the date of the outbreak. And on the vertical axis going this way is essentially the numbers of cases and what we can see is that the cases grew very, very quickly in China, into January. This is a little bit of an outdated slide now, but what I want to point out is just how remarkably fast China acted to help understand this virus and to contain it.  And I think this was really an impressive feat that China undertook.

 

China really had a very swift and remarkable ability to combat this virus initially in terms of the speed with which they acted. Of course, throughout the world there’s always going to be criticism about how many governments respond but I think China’s quick actions to quarantine both individuals and cities, and then also to get molecular testing up to be able to test people for this virus – which was a completely brand new virus and no test existed just a couple of months ago – to be able to test hundreds of thousands or millions of people within a couple of months was really a remarkable achievement by the Chinese government, and it truly has served to buy the rest of the world quite a bit of time, at least a month or so, to really slow down the spread of the disease.

 

So we believe we can use lots of genetic testing, which means we can actually look at the genome sequence or the way that these viruses are made up and we can actually figure out when exactly this virus likely came into humans from an animal, and it was probably from around somewhere in November that we believe that the virus actually jumped into humans. There’s been a lot of media, especially early on, saying that this virus might be a product — like a bioterrorism type of product — from China, and I want to just make it very clear that there’s absolutely no evidence for this. The virus is very similar to many viruses that we have detected in the past that live in bats and other animals. And so the idea that this is some sort of bioterrorism threat is not really based on any scientific data. And I think that’s more based on conspiracies, and in fact — quite the opposite — we can track genetically where this virus probably came from. And we can see that it is most likely just a virus that was transmitting in animals and unfortunately, spread into humans.

 

Once this virus really took off in China, we saw a very swift transmission outside of the initial province in which it was located and it quickly spread throughout China and then ultimately throughout the rest of the world. And we’re seeing this quick spread throughout the world now, which obviously is why we’re having this discussion currently. And I think what everyone is wondering as well is, will it impact individuals, and how will it impact us at home, and those are the questions I want to be able to answer in just a few minutes. So at the moment there’s over 70 countries with reported cases right now so it is truly spreading globally. There are now over 100,000 reported cases, and probably the number of actual cases throughout the world is really quite a lot higher. And it’s ultimately spreading quickly even within countries like the United States. And so just to put this virus in context: why is it such a bad virus? There’s been a lot of comparison of this virus with influenza. And a lot of people are asking the question, well, is it any worse than influenza?

 

So this is one of the things that we think about. And what I’m showing on this horizontal bar here is — this is a nice picture that the New York Times put out — it’s essentially how fast a virus spreads versus how severe a virus might be. Something like chicken pox spreads very quickly, for example, but doesn’t necessarily cause a lot of very severe disease. And then other infections like Ebola don’t spread very quickly — they spread through human to human actual contact — but they can be very deadly. And both of those can be dealt with, with simple strategies. So with chicken pox we either assume that everyone’s going to get it or we vaccinate, and with Ebola we try to stop the spread at the source, and that’s easier because it doesn’t spread very quickly. With this particular virus it sort of lives in the middle ground. It’s not the most transmissible virus, meaning it’s not the most contagious virus that we know, and it’s not the most deadly virus that we know, for example. But what that means is that overall, it ends up being both somewhat deadly and somewhat transmissible and that makes it a very very difficult virus to be able to contain. And a lot of that is because it’s this airborne spread whereas something like Ebola, we knew very quickly that if you just don’t touch the person then you won’t get the infection, more or less, and as well, Ebola has very severe symptoms so it was very easy to detect when somebody was infected.  This virus, however, we know is now transmitting across people even asymptomatically, meaning they don’t have symptoms – they don’t have a cough, and they don’t get sick, which is a good thing for those people, but they might go and spread it to their grandparents or some elderly people who would get sick.  So it makes this a very very difficult virus to be able to contain.  Next slide please.

 

So, the severity of this illness. There is a good thing about it, that it’s really not doing much harm to younger people, so people under the age of 20 really are not having severe disease. What I’m showing on this graph on the left are different age categories so on the left side is 0-9 years old, 10-19 years old, all the way up to 90-99 years old. And what I’m showing are the fraction of people [in each age group] who are actually getting the illness. And although the severity isn’t so bad in 30-50 year olds, for example, there are a lot of 30-50 year olds who are getting this disease. So it’s really concentrating within that age group, but on the right in these red bars you can actually see how that translates into severe disease and mortality. And what you see there is that the people under the age of 40 generally are not having very severe disease and dying from this infection. But as you go up in age, the actual percentage of people who are reported to have the disease, and ultimately have to present to a hospital, and the actual percentages that end up dying can be very high. In particular, people who get who get infected and have to show up to a doctor’s office who are above the age of 80 — they have mortality rates and they seem to be dying at very high rates, and these are people who, as health care professionals, we want to be focusing a lot of attention on ensuring that they that they can remain healthy and get the proper care that they need. As well, there are lots of underlying conditions or medical problems that people might have. These are heart disease (cardiovascular disease), diabetes, chronic respiratory disease or lung problems, hypertension (high blood pressure), and cancer — are all associated with higher disease severity and infection and mortality, meaning that these people with these other conditions are potentially at greater risk of having severe disease if they become infected. So people who have these sorts of other conditions, which are very common in our populations, need to try to take extra care to prevent from getting sick. Next slide please.

 

So, there’s been a lot of discussion about testing, and how we how we are testing. And I don’t want to go into too much detail here because I think most people are too unfamiliar with the details to really appreciate the nitty gritty of this — but essentially we use a molecular technique called PCR which you may have read about in the media. This is a molecular technique that allows us to take a swab from somebody’s nose, and take it, which is a bit like a Q-tip that you have to clean out an ear with, but it’s a swab for a nose or a mouth. We will swab somebody and then use a little molecular instrument to look for the presence or absence of the virus in somebody’s nose or mouth. There have been two major protocols — two tests — that have really been used worldwide. The World Health Organization has one test, and this has been a test that has been used now in hundreds of thousands or millions of people have now been tested with this. And then the CDC has developed another test, which is slightly different. It’s based on the same technologies and procedures, but it just the way that it finds the virus in the sample is a little bit different. And that’s the test that has been really all over the news about not being available. And that was because in early February, the CDC actually pushed the test out to all the state labs, so state laboratories in Massachusetts, state laboratories in New York and California. And all of these different state laboratories received a kit from the CDC, and each kit contained about 700 tests’ worth of material. But unfortunately that kit didn’t work very well, and the CDC had to recall it. So ultimately what that did was it led to a long delay in getting testing to where we need it to be in the United States. And we are now in a position where we can really increase testing, much more rapidly. But it’s going to still be a few weeks before we have very wide scale testing available. And so currently we’re still focusing on testing people who are sick and are showing up at the doctor’s office or the hospital, rather than doing what we would call screening, where we just test even healthy people in the environment to know if the virus is transmitting without symptoms. Next slide please.

 

So just to clarify a little bit, I know that there’s been so much confusion surrounding the testing and what happened, and I want to just address that. In late January the CDC declared this coronavirus epidemic a public health emergency. And that effectively created a situation where the CDC and federal government takes some control over the testing processes, the idea to make testing more rigorous and to ensure good quality tests are being performed. But what that had the unanticipated consequence of doing was limiting testing from being performed in individual laboratories, like the hospitals around the Boston area. And so there are now changes being made to allow laboratories like the Partners hospitals and other hospitals throughout the states to be able to perform the tests themselves. But ultimately the slowdown was due to a manufacturing defect, which has since been corrected, and we anticipate that testing is going to become much more available over the coming weeks. Next Slide.

 

So the protocol that we have today is — I just want to give an example of what we’re doing today, which is a real time PCR and this is the test that everyone’s using and it’s a little bit of a difficult type of test to utilize. The PCR test that we’re using actually requires a lot of skilled technologists in the hospital to perform, and that makes it very difficult to scale up and to be able to perform lots of tests each day, and this is part of the reason why it’s been so difficult to actually get testing brought out to large portions of the population quickly. And part of the reason also is that we have sort of a fragmented healthcare system, where we’re not necessarily all working as well together as we could. Next slide please.

 

So there’s going to — in short time, and we hope that in this will be in the next few weeks — we’ll start to see different types of tests come into the hospitals and into clinics near where people live. And these are going to be simple to use, what we call cartridge-based tests. Once these become available by the companies that produce them — I am showing four of them here — you can expect the availability of the tests will become much more commonplace and we should have greater access to testing. These products will still be at least two to three weeks away before we actually can get them into clinics and hospitals and doctors’ offices, and until that happens I think we are going to be relying on a smaller number of tests within each state in the United States, but these are just some of the instruments that that will be coming on and they are very quick to use and very simple and hopefully we can get these types of tests from the companies as soon as possible. To put it into perspective, normally to get a new test from a company built and sold to individual laboratories or clinics or doctors’ offices is usually a multi-year process. And these companies are racing to get all of this performed and done within just a matter of a couple of months so it’s really an impressive amount of effort that’s going in to hopefully help everyone deal with this virus and to keep all of us safe. Next slide.

 

Additionally, what I think we can anticipate, and there’s a lot of Boston based companies who are working on new technologies — and I’m working on some of these new technologies myself — are antibody based tests and then what we call CRISPR based tests, and a few others. But ultimately, these are hopefully going to come out in the next couple of months or few months, and these will almost be like a pregnancy test, but for this virus or for multiple viruses, and they’ll be something that maybe you can perform in your own home without having to go to the doctor’s office, and these are the kinds of tests that I think we can look forward to seeing in the near future — but I don’t think that they will be available within the next month or two, but maybe within the next three or four months — we should, potentially see some of them being able to be purchased and these would go a long way to help people know if they are infected. So then they don’t have to go to the doctor’s office if they are infected, where they run the risk of potentially infecting other people. So the more we can do at home, the better, I think. Next slide please.

 

So, what’s going on nearby? There was recently a positive case of coronavirus in Wellesley, Massachusetts. And additionally, there has been local spread, beginning in Boston, potentially. There was a conference where there were quite a few people from a company named Biogen that had a conference and just yesterday it was all over the news that that many people had to come to a hospital in Boston to get tested for this virus. So, much of what we’ve been seeing around the world and even around this country, in particular lately in Seattle. I think that we can anticipate that we will begin seeing cases more and more in the Boston and broader Massachusetts area over the coming weeks. This is just something not meant to scare people, but I think it’s important to be open and honest about what the situation looks like and to try to give people the correct information so that they can plan accordingly and understand that this is a virus that will probably be in many of our hometowns soon, and we should be prepared for that. Things like working from home if possible will be increasingly important. Potentially closing down schools might have to be one option for preventing onward spread of this virus. And so these are the things that we’ve been talking about, as researchers and policy experts. Everyone has been involved. The Massachusetts Senate recently had a hearing to try to get advice from people like myself and other experts from the Boston and greater Massachusetts area to understand what should be the appropriate public health responses. The university systems in the city are all working towards this, and really across Massachusetts, this is something that is not going unnoticed by the people who are the policy makers in our towns and counties and state. And so I think that there’s going to be increasingly more messaging and direction for individual cities to work with. Next slide.

 

So I think just some final thoughts before we take before I take questions.

 

[Inaudible] virus is going to continue spreading across the globe. And I think that the US should really continue preparing and working under the assumption that local spread will be occurring. And I think testing must get up to speed, and surveillance really needs to be rolled out accordingly and we’re working very hard to do that.

 

So that’s the end of the slides and I’m happy to take questions from people.

 

Q: [paraphrased] After attending a UN conference in New York, with a couple hundred people attending, what kind of precautions should be taken?

 

Dr. Mina: At the moment I think that we are at a point in the cycle of this epidemic where we’re on this trajectory where the epidemic is really starting to swing upwards. And I think that at the moment we should be making very clear decisions to probably limit gatherings. Many institutions in Boston and throughout the country are now starting to say that gatherings greater than 50 or 100 people should no longer move forward. And that’s in fact why we are doing this particular meeting over the internet. And I think that it’s important to probably start to think very seriously about stopping and trying to prevent people from gathering in single rooms for meetings. This is a huge task and this is very outside of many of our comfort zones to stop meetings from moving forward but I think it’s absolutely going to become essential if we want to slow the spread.  If there’s somebody who comes back from a meeting where they might have been exposed, we are trying to recommend for people to start thinking about self-quarantining, which is essentially staying at home, and trying not to go out and if you have to go out then to try to limit the amount of contact you’re having with other people, try to spend as little time in public areas as possible, to prevent spread. And if there’s some reason to believe that you might actually be infected — perhaps a dry cough or a fever or a feeling of tiredness or malaise — then I think it’s very important for people to actually call their physician and explain, “I was just at a large meeting in New York City; there were people from all over the world there. And I’m concerned that I might be infected.” And then the doctor can figure out — each hospital and each clinic is going to deal with this little differently. Some are going to ask people to drive up to the clinic and have a swab taken of their mouth or nose, potentially even from their car so that they don’t have to walk into the doctor’s office. And these are some of the issues that we’re trying to deal with [inaudible] I think anyone who thinks they might be infected should be absolutely careful about what they touch, how often they’re washing their hands or keep a bottle of alcohol hand sanitizer with you. And a lot of these types of approaches can be actually very effective, even though they’re very small things: washing hands, not coughing on people, they actually when done by many people go a very long way to stop spread. It’s sort of dissatisfying of an answer, but I think it’s unfortunately one of the best options we have at the moment to slow down the spread.

 

Q: We have a couple of people here that are currently in London, but have some flights booked to China. So the first part of the question is, do you think airports flights are safe right now?

 

Dr. Mina: It’s a very difficult question. I think that airports and flights are currently largely how this virus is transmitting across the world. Will any individual flight have a very high risk of having somebody infected coming from a place like Boston or London at the moment? I think the answer to that would be that the risk would not be extremely high for any one of those flights. But the aggregated risk, the risk that there are flights that are moving back and forth, is very high that there will be people on these flights that will be infected and we know that this virus can transmit to other people on these flights. Now you mentioned that these people would be flying from London to China. I think that it’s going to be very important — I don’t know the details of their decision to travel, and if they’re going back home — but I think that if they go from London to China, at the moment, anyway, because of the wide scale transmission in China, I think that if they tried to return back they should certainly be quarantined for at least a couple of weeks upon return. And I would caution [against] current travel to China for anyone who does not need to go there, just because the risk of transmission and acquiring this virus is very very high in China, and in multiple countries. Unfortunately, in the United States — and elsewhere in Europe and other countries in the world — we anticipate that widespread transmission will also be occurring here. And so, we could find ourselves in a position where actually the risk of transmission and acquiring this virus is similar whether you’re in China or the United States or London. But at the moment the individual level risk remains lower in the United States in London than it does in China and so I think that there should be a real concern about whether or not the need to travel there is warranted.

 

Q: How about in the long term? You know, between Boston, London, Vancouver, Shanghai?

 

Dr. Mina: The question is really getting into: should we be restricting just travel, period? And this is something that I think is a decision that that frankly extends beyond my area of expertise into sort of how do how do these very. How do these disruptions to the social fabric of our economy of our society. What will be the, the ultimate impact of our society. I think anytime we take a lot of people and we push them into a small airplane or a small bus or a train, we are increasing the risk of transmission. And, in particular, in airports the process of moving through the airport and getting to your flight is also an area where transmission can occur. And so the discussion is really about, should we begin thinking about just stopping domestic or international travel? My personal feeling at this time, and I think one that’s grounded in science, is that any unnecessary travel should try to be minimized, as much as possible, and [inaudible] trying to limit spread will also mean limiting the amount that we move around and in particular the amount that we’re moving around in these public or publicly available spaces or transmission modes like flights and trains.

 

Q: Is the new vaccine development by a Boston based biology company true? I heard they started clinical trials.

 

Dr. Mina: Yes, there’s been a lot of talk about vaccines, and whether the vaccines will be available in 12 months, 15 months, 20 months, and there’s been a lot of questions surrounding when they might come out. I think it’s important to understand that there are amazing companies like Moderna, which is right here in Cambridge, that are developing vaccines for this virus. And the most important point to note here is that these companies are developing the vaccine and bringing them to Phase I trial, and these Phase I trials are just safety trials, and they actually don’t say anything about how well the vaccine might actually work to prevent transmission and to prevent infection. So they are moving forward, and in the world of vaccine research they are moving forward extremely quickly and moving at a rapid pace to try to produce them. The problem is that the estimates of one year to 18 months to get a vaccine available is based on the expectation that the biology works, and that the vaccines actually work. And that’s something that we actually won’t know for about 12 to 15 months, just how well they are working. And it could be that we get to the 15 month mark, and it turns out that the vaccines, even though they’re safe, that they turn out not to be effective, and that’s always a concern when we’re developing vaccines and so I caution everyone to not put too much weight on the comments that are being made in the media by our governments that we will have a vaccine in 12 to 18 months. I think if all things go smoothly and it works biologically we could, but it’s unclear just whether we can even find the right combination of proteins to put into a vaccine to actually elicit good immunity across people. And so this is going to be a difficult vaccine to make, and it’s probably going to take some time to find one that is very effective.

 

Q: Regarding people who potentially could spread virus without showing the symptoms, I read a lot about those things [inaudible]. Based on the information and data you receive, what’s your opinion on that; how high a risk that is?

 

Dr. Mina: I think that what you’re asking about is, is there what we call asymptomatic spread of this virus, meaning that people who are not very sick, if they can spread it without even knowing that they’re not sick or maybe before they have symptoms. And I think that the answer to that is yes, they can probably spread it without having many symptoms, unfortunately, and this is going to create a lot of problems for us to be able to do a very good job of containing this virus. The other side of that answer, though, is that people without symptoms will likely be less transmissible or less contagious than other people. And so we don’t necessarily anticipate that the majority of spread will come from asymptomatic cases. But we’re just not sure because they’re also most likely many more people who don’t have symptoms or who have mild symptoms. They’re probably many, many more of those people around already. And if even small fractions of those people are transmitting it can it can really go far away to cause [inaudible]. Yes, I believe that this virus is spread at least in part by individuals who have very mild or no symptoms.

 

Q: If that is the case, sounds like there’s a decent risk on that.  Should we now start contacting — especially now Boston/Cambridge is becoming kind of a hot spot for the virus — should we start contacting the school districts and suggesting to maybe cancel school for a few days just to have things calm down and we get a clearer, a better picture of where things are heading?

 

Dr. Mina: Yeah, this is a very good question. And it’s a question that not just the school systems but also the universities are talking about. There is one complication with that particular question – well, there’s many — but one biological question is, we believe that at least some adults are spreading this virus asymptomatically. What we don’t yet know is just how important spread is from children. We believe that it’s a component, but if it’s a very very small part of transmission chains, then it could end up being that the disruptions to society from closing down school systems could cause even more problems than the virus itself. On the other hand, if we find that children are very transmissible and are actually making up a large portion of the transmission chains, for example like they do with other pathogens (pneumonia, bacterial pathogens, and flu), then closing down a school system might be a good idea. And I wouldn’t be surprised if over the coming week or so, we do see that school systems begin to consider this question even more seriously and we should anticipate that some school systems will close down. And I think I would probably from an epidemiological perspective and from a scientific perspective and physician perspective I would say that this is probably a good way to stop spread. And we should think about it very carefully. But from a social perspective there are many, many people who have to work, who are especially people who are living on low incomes. And if schools are closed, and those individuals can no longer work, there are many economic consequences that fall out of this in terms of if people cannot pay their mortgages and rent and you know all of these other things that have to be weighed against the potential benefit of closing schools from a health perspective. So it’s an extraordinarily complicated question when all of that is wrapped up into one answer, but certainly from an infectious disease spread perspective, I think that closing schools would help to mitigate the transmission.

 

Q: So, to continue that question. I’m thinking, not only school but also extracurricular activities. My daughter is in the Boston Youth Symphony Orchestra, and they rehearse every weekend, and also, they are going to have a concert.  So should we consider not to attend the concert because that will be like, I guess [inaudible] a hundred people in the room?

 

Dr. Mina: Yeah, I do think that extracurriculars and nonessential activity should, at this point in time, probably be put on hold, especially things like concerts where everyone will pack into a concert hall, or the students will all get together, potentially 60, 70, or 100 of them to practice on weekends. These are all areas where spread can occur and I think — again, I hate to be the bearer of bad news, and these are huge disruptions to our social fabric — but I do believe that these will be the types of steps we should all be trying to take to stop the spread and [inaudible]

 

Q: So how long should — how many weeks – also I’m teaching at Newton Chinese school. So, just wondering, how many weeks should we stop these activities before we can think about resuming these extracurricular activities? Typically two weeks? What’s your recommendation?

There’s another thing – will you share the slides?

 

Dr. Mina: Sure, I can share those slides. So, I think that it is very difficult right now to say how long we should be planning for things to be placed on hold. I think we are only at the beginning of this outbreak in Boston and Massachusetts, and in the United States in general. And I think we can absolutely anticipate that this will only grow in size over the coming weeks. And we can all do our individual parts to try to stop spread through these things we’re talking about. But I think anytime within the next month should be considered unlikely and probably, maybe through May we might have to consider how we are interacting with each other for the next month or two. And I think we can only keep reevaluating as the weeks progress. If people act swiftly. And if school systems and universities and industry partners all act very swiftly and present and ask people to stop going to work in person, if possible, there’s a chance that we could actually slow spread considerably and maybe be able to start slowly reintroducing normal activities. But at the moment I think it’s very difficult to say just how long it’s going to last, but I think we can at the very least assume one to two months from now, we should be planning on having this virus continue moving through the population. I did want to mention something along this line, and that’s that the greatest risk in my opinion for this virus — these are going to be people who have very high susceptibility to severe disease and these are going to be the elderly population in the public, and these will be people who are immunocompromised and have immune system dysfunction. So those people are at particularly high risk of the virus. I think the greater risk, to a certain extent, across the population is the burden that this virus might have on our health care system, and so this comes into why we want to slow the spread. We might not be able to prevent the spread but if we can slow it down and go from having a really spiky peak of like a lot of people getting infected at once, and maybe drawing out the epidemic longer.  Although we don’t want to draw things out longer than they need to be, the benefit of doing so is that we, is that we can prevent a huge crisis and burden on our healthcare system, and on our social economy. We want to try to at least just slow the spread down so that we have fewer people each day having to require medical care or having to stay home from school, or staying home from work because they’re ill with the expectation that although it might draw the epidemic longer we won’t have a very bad impact at any given time. And this is one of the mitigating strategies that we’ve talked about a lot in public health is not so much stopping the number of people who will get infected but increasing the duration of time over which people will become infected.

 

Q: I have two questions. One is about SARS and MERS. Do they already have vaccines?  And there was a question earlier about how long it takes to develop a vaccine. So, in your opinion, probably more than six months to have a vaccine for Coronavirus? So that’s my question number one. My question number two. Are there any medicine that can cure this virus?

 

Dr. Mina: Yeah, so, I mentioned the vaccine a few moments ago. There is currently no vaccine for it, and there’s no vaccine for MERS or SARS, which are two viruses that are very similar but different than this one. And the fact that those vaccines don’t exist in part shows just how difficult this virus is to create a vaccine for and I don’t think we should anticipate having any vaccine for a minimum of 12 to 15 months, if everything works properly biologically. And my personal expectation is that it will likely be quite a bit longer than that before we get a vaccine that is truly protective. But if the biology works; if the companies developing the vaccines can produce a vaccine that actually protects, and that is protective and safe, then I think we can expect that within the next year or year and a half we will have a vaccine. There are few ways that I can see a vaccine being available within the next six months. And I don’t think that that’s realistic, at least not within the regulatory guidelines of the United States, but also just within the technological abilities that we have to test and ensure safety. I don’t think we can anticipate a very quick one. Now there, there are different — This virus, like I mentioned at the very beginning, is not the most lethal or severe virus we deal with and there’s a lot of concern being raised about this virus, of course, and that’s why we’re talking about it here. But this virus is not like Ebola, and it’s doesn’t have an 80% mortality rate. And what that means is that we can’t take the same risks in developing a vaccine and trialing it without being extraordinarily sure that it’s going to be safe. And the last thing we want to do is to harm people with the vaccine, so there’s going to have to be a lot of effort placed into that, versus if for example the risk was very high, like with Ebola, then we can have a slightly lower threshold to say if you’re at high risk of getting it then we can give you an experimental vaccine. But this virus is not like that; because it’s less severe we have to keep the bar for safety extraordinarily high still and that means we have to wait quite a while before we get anything that works.

 

Q: What is the treatment like now?

 

Dr. Mina: There are some clinical trials that are ongoing. The treatments that have been developed have utilized some therapies that were developed for different infectious diseases like HIV, for example, and we are still waiting to get reports and results from some of the clinical trials to know whether or not these are effective and just how effective they are. The current treatment though is what we call supportive care, and that’s that if somebody goes into the hospital with this virus, we generally are treating their symptoms and we’re trying to ensure that they don’t get worse by potentially having to give them extra oxygen, give them fluids. And until we get better data coming from the clinical studies that are being done — Remdesivir for example is one drug that is being trialed at the NIH and there’s a number of them that are being trialed throughout the world now; I think there’s actually quite a large number of clinical studies going on. And I would anticipate though that the clinical studies — that the therapeutics and these treatments will come out far earlier than the vaccines. I think we can anticipate that treatments will be made available, hopefully in some regard in the next few months, maybe a little bit more than that, and we can anticipate seeing that type of treatment being available, besides just supportive care.

 

Q: There are reports and observations that some patients who have been treated and then the test results [after treatment] show negative. However, after a couple of days, two weeks, or when they repeat the test, then it shows positive again. How do we cope with that?

 

Dr. Mina: We still don’t fully understand what drove those results. What we are thinking, though, and what biology would probably be more likely to tell us, is — we don’t believe that those people necessarily got a new infection. But they did probably still have some of the virus left in them even after they recovered. What we don’t know though, is whether or not those people with some of the virus still able to be detected — after a couple of weeks, post-recovery — whether that virus is actually transmissible. And I’ll give you an example. We know that when children get measles — measles infects a child and they usually recover about two weeks afterwards — we can use the same detection techniques like PCR. And we actually find that the RNA or the nucleic acids virus still exists in the people for up to six months, post-recovery. But during that period of time these individuals are not transmitting the virus; it’s just that small pieces of the virus are lingering in the body, and I am hopeful that that’s what we’re seeing here and that’s what’s driving these reports. But we at the moment are not sure just how important extra long presence of virus after recovery, what the what the real transmissibility of those viruses will be, if any.

 

Q: [paraphrased] In your slide you showed that individuals suffering from cardiovascular conditions seem to have a higher mortality rate, significantly more so than the others. Cardiovascular is a large disease area. Can you explain real quick what defines cardiovascular disease – is it general, everything related to the heart, and why?

 

Dr. Mina: Unfortunately, we don’t have the right data at this point to really parse that out and say exactly what is really putting people at risk who have cardiovascular disease, but in this case it would be anything from things like hypertension, that would fall into cardiovascular disease (although on that slide that’s a different group), myocarditis (inflammation of cardiac cells), atherosclerosis, and issues where you have cholesterol build-up that could be exacerbated by inflammation. A lot of these are where inflammation could exacerbate problems. A lot of these types of cardiovascular disease, we’re thinking about people who might get ACE inhibitors or angiotensin receptor blockers like Lisinopril, which is an ACE inhibitor; these types of drugs, which millions of people in America are taking across the world. It’s very nonspecific cardiovascular disease that we are referring to here and I think it’s going to take getting more information from clinical studies as we start to get more and more patients in the United States with this disease, and as we’re able to monitor and track them, we should start to be able to get more information about specific types of cardiovascular or kidney disease. These types of things might end up causing more issues and we should be able to narrow it down but at the moment the data is mostly aggregated into these big groups of cardiovascular disease.

 

I have my own theories of why this might be, for any physicians who are on the line, for example, who might understand what I’m talking about. The receptor for the virus binds to something called ACE2. ACE2 is a protein that is complicit in this whole pathway that leads to hypertension, and the virus essentially turns ACE2 down, which ultimately has consequences on exacerbating underlying cardiovascular disease. So these are the types of issues that are still trying to be understood, whether these are real and whether they also offer opportunity to intervene with treatment modalities.

 

Q: My second question is also related to one of the questions that has been asked… if we would implement some of the hard measures, like what the other countries are doing, that would cause social disruption issues mentioned. Hopefully, one of the things we could do is to slow this down. But I realize that the government right now is very simply telling individuals — and this goes all the way down to students at schools and what have you — that only in instances when you are showing symptoms and you know you’re sick, you should be wearing face masks. So I’m a little bit annoyed by the fact that we know that this particular disease is transmitted, although you said, low transmission rate, if you are positive but show no symptoms. There’s a huge stigma associated with wearing face masks in this country. Do you think as epidemiologist, does it make sense to correct that?

 

Dr. Mina: The messaging surrounding face masks has been one of the most confusing messages during this epidemic and it’s I think it’s designed — the way that public health messaging has to move forward is in a way because you’re talking to so many millions of people; the CDC, or the White House when they give a message they have to almost make things black and white for people and say yes or no. But your question about facemasks is a very good one. From a medical and epidemiological perspective, we can expect that face masks will help from acquiring or becoming infected when worn appropriately. The problem is that overall many individuals will not wear face masks properly, and many face masks will be loose fitting. And it could end up causing people to have a false sense of security that they would not necessarily have to worry about becoming infected if they have a face mask. So that has driven in large part the decision to not suggest to people who are not sick yet to wear a face mask. However, the other issue is that we don’t want everyone who doesn’t have sickness to go out and purchase one or grab a face mask because we know that face masks have their greatest benefit when somebody who is sick is wearing it. So that has all led to this decision for public health messaging to suggest that we want only people who are sick to wear it. And I think it’s a good message from a public health perspective, but, for example, if I had an immunocompromised parent or grandparent, I would probably ask them to wear a face mask if they had to get on a plane. Now your question was also about the idea that individuals can be asymptomatic and potentially transmit and, and I think this is also a very good point — especially as I just went to touch my face — facemasks help people to not touch their face and help them then not to transmit further potentially by touching a surface that somebody else will touch. So I do think that overall there could be a benefit, but we are extremely concerned right now about running out of face masks and not having them for healthcare people and some people who are very clearly sick and coughing. So it’s a very difficult decision to make: do we recommend it for everyone and deal with this false sense of security but also help limit some spread or acquisition, or do we just say if they should only be worn if you’re sick? These are the things that we think about, and I think in general the public health community has fallen on the line of deciding to say to people to not bother with a face mask unless you’re sick but I agree with you that there is a benefit for others as well.

 

Q: To be honest, I live in a neighborhood where none of the stores carry face masks; the whole rack is empty. So I think that should just take time. I would like to get maybe a makeshift [mask] — anything at all to get the thing that would be good to prevent – but I don’t think it would be any use, right? We probably want something that is properly made.

 

Dr. Mina: Right.

 

Q: You probably know in China, everybody, even though we have such huge population for this one, everybody is required – mandatory — to wear them, and it really doesn’t make sense we don’t utilize that very cheap method to have continuous protection against getting it and spreading to others, right? I know recently the MBTA, the T system, says they are going to disinfect every four hours, but what about those four hours in between? People in and out, squeezed in together – I think even though you’re not sick, during the day you still have a couple coughs, clear your throat, sneeze because of dust – if somebody’s not having symptoms or has mild symptoms, still could through that action spread it. The reason we disinfect the T is because I assume somebody is sick and spreads on the surfaces so why not wear them all the time? Cities like Boston have a very crowded public transportation. So what I’m thinking about is that

if the experts could speak out like you said, recognize the help with face masks, you know, if it’s just, preventing your hands touching your face, it is still valuable to recognize it. If you have face masks and you like to wear them, like Chinese people are accustomed to do, we should be allowed to do that instead of – if we don’t have this voice, people get discriminated [against]. And I think that’s not right. So I really hope there is that voice that says if you feel like you want to protect yourself, or if your immune system has those problems… – what do you think if we just promote wearing masks in the Chinese community – like Chinese school or Chinese church — they may feel safer to go to regular events and activities?

 

Dr. Mina: Yeah, I think the mask issue is really a crucial one to consider and I think you’re absolutely right that there is a lot of stigma surrounding the use of masks in our society in the United States in particular. Again, I think that the reason that it is not promoted is because we don’t want to give a false sense of security and we don’t want to run out. But we also should be considering if there were an abundance of masks, I think that it’s also not a bad idea to promote them. And I do think though — the last question you asked — I do think that we should probably very seriously consider not having these normal functions, at least if they’re large gatherings of people. There’s a good reason to stop doing that at least for the time being. Thank you for your comments.

 

 

Q: We always like to make an informed decision and you’re helping us today for that. Thank you again. I have one quick question that is not directly related to the COVID-19 virus but is kind of relevant.  I live in Wellesley and yesterday there was big news in our community, right?  And actually starting at least a week ago we have been trying to establish a community organization, a kind of grassroots organization to try to do something for when the situation gets worse. There is one question I need your help with. We are trying to form a kind of medical line, in case when the worst scenario happens and all the existing facilities and resources are going to be exhausted.  And some people, when they really need advice but couldn’t get it from official or government channels… is it OK for a grassroots organization to provide medical related advice?  What’s the legal term for this kind of action in the US?

 

Dr. Mina: I think you’re asking primarily about advice and not about the actual care of people.  And I think as long as there are very clear messages about what are the qualifications of the people delivering that advice and ensuring that everyone who’s potentially receiving that advice is aware of those limitations… if there are experts in the group I think that can go a long way to helping spread good information and I would suggest that that does move forward, in particular, if you have for example physicians in the group or other health care professionals who do understand the details surrounding this infection.  I think I would refrain personally from giving very personal, medical advice to somebody about exactly what they should do, or telling them not to go to the hospital for example.  I would refrain from giving that type of advice and I don’t think that there would be legal ramifications unless you’re giving advice in some formal capacity.  But I would be very cautious about just how the information is provided to others, to ensure that they understand what type of detail they’re getting and just what kind of care they can anticipate getting from these kinds of grassroots efforts. So I think that done appropriately it can be very much a platform for social messaging.  A lot of people are confused about what the symptoms might be, and what the chances are that they have an infection or don’t, and putting together informative packets or information or hosting things like we’re doing now, it can be very important.  But I would refrain from giving individuals absolute health care advice if you’re not their physician.  That said, you did preface the question by saying this is under the worst case scenario where the health care professionals and resources are completely sapped up by this epidemic and if that happens I think we would need to really consider what those consequences might be.  And at what point do we ask for non-medical professionals to step in and start helping in any sort of medical capacity.  I just hope that we don’t end up at that point where things are so strained that we really have to go in that direction.

 

Q: There’s a question in the chat group asking about various strains of virus in terms of their infectiousness.

 

Dr. Mina: So there was a paper that came out that was discussing an L and an S strain I think and I would put very little weight on these reports – it’s not clear yet if they’re correct and right now we are assuming that this virus has generally been more or less consistent. If there truly are two different strains then we will have to consider but I don’t think our approach would change at all either way, although it could potentially but at the moment I think that the reports that are suggesting two different strains, I think that those should be put on the back burner in terms of how much you believe those reports.  I unfortunately have only seen the headlines of them in the last couple of days; I’ve been far too busy unfortunately to really read up about it but I have conversed a bit with colleagues who are doing some of the genetic studies on the virus and I think those reports about two strains should be probably considered to not be credible at this point.

 

Q: There’s another question in the chat window asking about the timing of stopping sending kids to schools. Are there any criteria you would like to advise?

 

Dr. Mina: I think that if your child seems sick or if somebody in your family seems sick that I would absolutely ask and plead that you not have the child go to school for fear of spreading it further. But beyond that, I think that the school directors are conversing with the county leaders who are conversing with state leaders, and all of whom are talking to people like myself and others. And I think that before before individuals start just not sending their children to school I would wait to get messaging from the towns, but certainly if cases start showing up in towns and school systems are not acting to message at all about it and to give proper information about what the appropriate actions are I think at that point that it is worthwhile to start making grassroots efforts to and making the decision on a per family basis to not have the children attend. But this is most important if there’s any sense that the child in a particular household might have been exposed by somebody else in their household. So I think in the next couple of weeks we should anticipate that schools will start to be closing down temporarily, potentially for a month or more though, and people should start planning accordingly, potentially working amongst themselves to try to figure if there’s some way to have small groups of individuals get together so that some parents who really need to go to work can continue to go to work. But it’s going to be a big disruption to too many people’s current status quo.

 

Q: Another question asking if this coronavirus can be carried by humans long term as HIV or Hepatitis B?

 

Dr. Mina: No, we still believe that this will be a short term virus that will probably transmit for about a week after somebody will get it — they will go about a week without symptoms, start to present symptoms, and probably be able to transmit it for another week or two, potentially. And then hopefully after they have recovered, they shouldn’t be able to transmit it and then and certainly not too far after that we believe that the virus will probably disappear altogether from the person. There’s no reason to believe that this will be anything like HIV for example, where the virus harbors away inside of a person. This is still a virus that we’re used to seeing, in a way, it’s still a coronavirus and it plays by similar rules as many coronaviruses, meaning that it’s still an acute respiratory infection that will that will be cleared, and doesn’t have an ability to live inside of the body for months or years. So I would anticipate that that should not be a problem. Somebody just posted a question that’s very related: does one develop immunity against the virus after recovering from it? I believe that we should anticipate that people will develop immunity. Just how good that immunity is and how long it lasts is still an open scientific question we’re trying to understand as quick as we can. We know, for example, or at least there’s evidence, that coronavirus immunity might decrease for the seasonal coronaviruses — these are viruses that normally cause the common cold; they’re different from this one that we’re referring to now, but the seasonal coronaviruses, we believe that the immunity to them increase right after infection and then decrease over the course of the year, and allow people to be infected multiple times with a given coronavirus throughout their life. It is very likely that a similar effect might occur with this particular virus as well, but we don’t have enough information to know for sure if this will be something like measles where once you get it once, or if you get the vaccine, you never can get it again. Or if this will be like the other coronaviruses where you might be able to get it multiple times through life and, unfortunately, we will have to see how our immune systems deal with it and that’s something that my laboratory and other laboratories at Harvard and MIT and Stanford and all over are trying to better understand at this very moment.

 

Q: There’s a new question in the chat window about pregnant women and baby delivery. How to keep a newborn safe?

 

Dr. Mina: There has been some evidence that the moms have transmitted to the baby. But the good thing and I think there hasn’t been enough data to really suggest what sort of safety measures should be put in place in an in a delivery ward for example, and this is perhaps a better question for somebody who spends more of their time in a delivery ward than I do… I haven’t been in one since I was in medical school. But to really understand how to keep the baby safe I think one thing is to recognize at least that this particular virus doesn’t seem to be causing even to very young babies, it doesn’t seem to be causing really bad effects, which is a very very good thing here. Just whether or not babies are entirely protected or just largely protected we’re not sure, but in general they think that’s one important piece to consider is that the youngest of our population don’t seem to be having severe disease, and that is a very good silver lining with this virus. The mother should ensure to try to stay safe, and certainly I would suggest that anyone during pregnancy be trying to remain at home for as much as possible and try to restrict movement outside, or at least try to restrict movement out in public places where there might be a lot of people, particularly at the moment in cities. But as this continues to spread, then the same would apply into more rural areas of the country. And currently the best practice to prevent mothers and babies from getting infected is to try to stay up to date with the same sort of procedures — washing hands, not getting too close to people and just hopefully doing everything we can to not become exposed. And I would say if somebody has a face mask and they’re pregnant or in especially in later stages of pregnancy I would potentially suggest wearing one. If you find that you need to go out. But that is not — I want to stress — is not based on any hard data that we have at the moment. This is still an open question but traditionally pregnant women are considered a vulnerable risk group for infectious diseases and I would expect only the same for this virus as well.

 

Q: There is another question asking about potential seasonality of this outbreak; will the virus spread stop in the summer?

 

Dr. Mina: So, the virus. This is also – I feel like I’m just continuing to say this is a question we’re also trying to figure out, there’s so little known, but I don’t believe that we should anticipate that this will stop in summer. And there are so many susceptible people in the world and in the country that just the force of transmission because of this, the large number of susceptible people, will probably keep this transmitting throughout the summer. We can look at more warm climate countries throughout the world and we have seen that in those places transmission has continued without hesitation. And so I don’t think there is good evidence at this point in time to expect that transmission will dramatically be reduced once the warmer months come, but we will hope that it will and we’ll hope that this virus will act more like other respiratory viruses that are normally in our population, but we can’t say for sure whether or not there’s actually going to be any noticeable effect. One hope is that even if transmission stays high throughout the summer there is some suggestion and some evidence that could suggest that the severity of disease might decrease and this might be because of the more humid weather and the more humid air that we’re breathing in could help keep the lungs in a better state to not have such severe symptoms and we’re just not sure if that’s going to happen. I think many of us hope that that will be the case when summer comes but at this point I think we should all be anticipating that spread will continue into the summer.

 

Q: Does this disease end with what people call “white lungs?”

 

Dr. Mina: We don’t think that it always leads to that… There are a lot of people who won’t have many symptoms at all and we wouldn’t anticipate that they have this “ground glass” appearance – that’s the appearance of whiteness on the chest X ray or the CT scan. But what we’re seeing is that many people do have it — and, in particular, people who are symptomatic at all, including young people with very mild symptoms. We’ve even seen that young people will have those types of appearances on the CT scan, which suggests that the virus is replicating and causing inflammation in the lungs. So yes, and that’s why in many countries they’ve actually used the chest CT scan to diagnose this virus in the absence of having the molecular test available. And that is something we can think about doing here as well if testing is not as widely available as we would hope. It’s of course not the easiest test to perform; you have to put somebody into a CT scanner, but it does seem to be fairly specific for this virus. If the virus is transmitting in a population, I think we could potentially use it as a diagnostic.

 

Q: Another follow up question on your advice to put extracurricular activities on hold. Does it apply to outdoor athletic games and tournaments?

 

Dr. Mina: I think if those outdoor games and tournaments have spectators, then probably. That probably. There’s been a lot of discussion, especially now that March Madness, and these types of basketball games are coming up, could games progress. If there were no spectators would it still be okay for the games to move forward. And if they’re outdoors, I think… it’s hard to say; transmission can still occur outdoors. And one of the questions should we be canceling. Little League baseball games or soccer games for our kids. And I think that we might get to that point, if only because anytime there’s going to be a gathering of people outside there’s going to be people mingling on the sidelines. And that could be a cause for transmission. But we’ll have to see; I mean we also have to keep going on as a society throughout this, and we can’t stop everything. But we’ll have to see if this is really something we have to take seriously in terms of stopping all activities outdoors. I think I would prioritize taking indoor activities outdoors as possible. And then eventually, consider slowing down the types of outdoor activities that are happening as well.

 

Q:  There’s another question asking what’s the major difference between coronavirus and the common flu in terms of symptoms.

 

Dr. Mina: This coronavirus — one of the major symptoms has been a dry cough. And many people don’t have a runny nose. In fact, the minority of people with this infection have a runny nose. So it seems to be an infection that’s more causing some fever and and respiratory issues like coughing, more than some of the other flu-like symptoms. Some people can have a fever just like they do with flu. But flu, if anyone’s had it, it also really causes a lot of drainage and can cause runny nose and in particular bacterial co-infections. And we’re just not seeing those types of symptoms, as much as the dry cough with this virus and in particular from mild cases. So those are some of the major differences in the symptoms, is that not everyone will have a runny nose and a really wet cough, it will be more like a raspy dry cough. But otherwise there are a lot of similarities between the two infections from a symptomatic perspective, and so, it’s one of the reasons why when patients come into the hospital with symptoms. The first thing we do is we test for flu, and if they’re flu negative, then we can test for the coronavirus. So there’s enough similarities that we can’t always tell the difference.

 

Q: Are there are enough test kits? Will a doctor’s office check for coronavirus if one has mild symptoms?

 

Dr. Mina: At the moment there are not enough test kits in the country. I should say, there are enough test kits in that I think the reagent and materials for the testing will be sufficient soon, but the actual ability to use all those and perform all the tests and have enough people and machines to do it is still lacking. And, unfortunately, I think that’s one of the problems with testing, so if somebody has mild symptoms and they have no contacts, testing might be performed. But again, what would normally be done is we would test for flu which we have plenty of tests for, test for influenza and a few other viruses first and then if those are negative, we will then test for coronavirus. I would suggest that if people are have very low symptoms and very mild, and it doesn’t seem to progress, that they might want to just remain at home, and hope that they kind of recover. The vast, vast majority of people will recover just fine from this virus. So this is, in that sense, it’s a little bit more like influenza than Ebola; most people will do just fine. So I’d say only go and try to get tested if you feel that you really need to, at least at this moment in time. Once testing gets underway and becomes more widely available then I think that recommendation will change and I would change it myself to suggest that we try to test as many people as possible. But at the moment I wouldn’t say that that is the best idea, to have everyone tested, because we would just run out with capacity.

 

Q: Another question is about the mortality rate. It seems mortality rate in some countries such as Iran, is much higher rate than other countries.  Do you have an explanation for that?

 

Dr. Mina: The mortality rate that we are measuring has a lot to do with who gets tested and how many tests are available. So it could be that the actual numbers of people getting infected and ultimately dying are very consistent, but if we’re not testing very many people, then we will see it will appear as though many more people are dying, if for example we’re only testing the highest priority patients who are very sick. So in this case, I think somebody says that it seems that many senior government officials in Iran are getting infected and some have passed away. It could be that there is a lot of spread in Iran which we know is happening, but it could be that they are prioritizing testing of senior government officials, and prioritizing testing of people who are very sick, and it could be just that that’s leading to what is observed to be a higher mortality rate but it might not actually be. And the same goes in the United States; we have a very small number of tests that are currently available across the United States given the size of our country. And what it’s doing is it’s making it look like the mortality rates here are very high as well, but actually it’s only because we don’t have enough testing to be able to have a large denominator in that fraction. And so I think that that’s probably more the way that the testing of the data is reported that’s leading to higher mortality rates. But we also know that certain populations for different viruses can have different mortality rates. So for example, we are concerned in Central Africa, sub-Saharan Africa, and parts of India, Nepal, Bangladesh — areas where health care and nutrition can sometimes be poor — we can anticipate that we might see higher mortality rates in places with poor health care or nutrition overall. This would be potentially all related to the whole social aspect of how healthy people are at baseline. So in that case I think we can anticipate that people who are weaker and malnourished might also see a higher mortality, but outside of that I think it’s too early to tell if it’s a biological reason or if it’s a data driven reason.

 

Q: Question about the virus affecting organs in the body. Does the virus affect the central nervous system?

 

Dr. Mina: We haven’t seen evidence of that; there’s no good reason to believe that that would necessarily occur, unlike some other viruses, like measles [which] can affect the brain. In this case, it seems to be doing damage to the lungs, but ultimately what that means is: once that damage begins, in particular one’s cardiovascular problems start to occur or respiratory problems start to occur that lead to cardiovascular issues, and ultimately can lead to systemic infection or systemic problems due to inflammation.  But unlike measles or chicken pox, there’s no reason to believe that this virus is going to go into the nervous system or really have major effects on other organ systems, although we have noted that people are people have positive virus for quite a while in their stool. And so, at the very least the virus can get into the GI tract and into the intestines. But how exactly and whether that’s important or not is a different question. So currently, it seems to really be affecting mostly the respiratory system, and potentially the cardiac system as well, because of the inflammation and problems associated with the virus.

 

Q: Next question is about the mutation of the virus.

 

Dr. Mina: I mentioned this a little bit ago… we should consider that these reports about the mutations of the virus into two different strains should not be, I think — you shouldn’t worry about those at this point in time; whether or not this is actually true is still very much questioned by the experts. And I think that there shouldn’t be too much importance placed upon that.

However, I think that the question about whether or not this virus can mutate is a good one. And so far we haven’t seen that it’s truly mutating a lot, but it also hasn’t been placed under any what we call selection pressure, meaning, if we had a vaccine, would it necessarily circumvent our immune systems [and] if we had a therapy, could it mutate to avoid that that treatment therapy? And we are trying to understand more about it. So far, though, I think mutation has not in this epidemic been a major problem that we’re contending with, and there’s lots of sequences that have been done to understand if it’s mutating and so far it hasn’t mutated in any way that we are necessarily thinking that it’s getting worse or better. And to be clear it could actually mutate in a good way, where it might be more transmissible, but it might be much less severe, that would be one direction that it could mutate in, and that could potentially help overall if it was becoming less and less severe through mutation. But we just don’t know exactly what direction if any will take in the future.

 

Q: There is a question asking about the severity of the disease.

 

Dr. Mina: The government is preparing for 96 million patients and 480,000 deaths across the country, as sort of a worst case scenario. I think that the 96 million patients should be worded differently. 100 million people would be about 30% of the population, a little bit less… And

most of the infections that are going to occur are going to be very mild and many will probably be very low symptoms, if any, and so I wouldn’t say that they would be considered “patients” – they would be considered people who acquire the virus and get through it just fine. So 96 million would be a tremendous number to for example have to go to a hospital. But it’s not completely out of the realm of possibility that 96 million people might actually become exposed and infected with this. And I think we should expect that if it’s not 100 million we very well may see 50 million people get exposed and we may see millions actually have symptomatic disease and have to go to the hospital and 500,000 deaths — it may be a high number for the United States but it’s not completely out of the question. I think we can all try to slow the spread so that this does not come true. Every time we slow the spread, it gives us more time to try to wait for vaccines and treatments to come on board. And if all of us try to practice good hygiene and prevent social gatherings and areas where spread might occur, I think we can work together as a population to bring that number down. If we change nothing about our communities and we go about business as usual, I think then we can expect 100 million people to become exposed to the virus but my anticipation is that it will be much less if we all work together.

 

There is another question that asks, should we suggest to the mayor to cancel the Boston Marathon? This is a question that has come up and I would suggest yes, [although] this is going to be heartbreaking for many people. This is a similar question happening with the Olympics this summer. And, if anything, it could be that the Boston Marathon changes this year and there are no spectators but people still run it, and maybe are spaced out differently than a marathon usually is — where you start one person and a little while another, and so on. I don’t know enough about event planning to say whether that’s reasonable. But I think from an epidemiological perspective something that draws the crowd of the Boston Marathon has a lot of potential to increase spread and I think that probably the mayor is thinking about this very seriously at the moment.

 

Thank you everyone for joining, and I really appreciate everyone trying to the fact that you are all trying to inform yourselves about this and all the great questions. I’m happy to be able to provide any answers I could have during this and I am more happy that you all are here and trying to learn for yourself. So, how to protect you and your loved ones so it’s good to see as a public health professional.

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