COVID-19 Expert Reality Check

Image: Ezra Acayan/Getty
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Image: Ezra Acayan/Getty

As the media swarms the coronavirus story, most news articles focus on numbers of cases and deaths, new locations of cases, etc. 

Lost in the shuffle are the important public health insights about how viruses work and humans respond. To help improve understanding of an emerging outbreak’s complex dynamics, GHN has reached out to some of the world’s most respected global health experts for their quick "reality checks" on key issues related to the outbreak.

The Latest

What are some of the major challenges to global cooperation in this coronavirus outbreak? By Sarah McCool

What is the best way to counter misinformation in the media? By Amesh Adalja

How does a virus shift from zoonotic to human-to-human transmission? By David Quammen

Virus

How does a virus shift from zoonotic to human-to-human transmission? By David Quammen

How do you go about creating a vaccine against a new virus? By Peter Hotez

How does this particular coronavirus compare with other coronaviruses like SARS and MERS? By Tom Frieden

Outbreak

Why are wild animals believed to be the source of this outbreak? By Sonia Shah

How do disease detectives find the source of an outbreak like this? By Michael Mina

What does successful risk communications look like? By Amanda McClelland

When does an outbreak become a pandemic? By Eric Toner

Response

What is it like inside a hospital biocontainment room? By Lauren Sauer

What’s the best way to respond to the coronavirus outbreak? By Tom Inglesby

Can travel restrictions and quarantines stem the spread of the coronavirus? By Jennifer B. Nuzzo

What should a country like the US be doing to prepare when an outbreak like this begins to spread globally? By Tom Frieden

Are strong national health systems all we need for pandemic preparedness? By Gavin Yamey

What do frontline health care workers need most when they face an outbreak like this? By Amanda McClelland

What are the ethical considerations of using quarantines? By Jeffrey Kahn

 

Have more questions? Please send GHN any questions you'd like to see answered related to the coronavirus outbreak. Just email Dayna (dkerecm1 at jhu.edu). And, for GHN's latest coverage of the coronavirus, visit hereand, if you don't already subscribe to our free daily enewsletter, you can sign up here.  

 

Virus

How does a virus shift from zoonotic to human-to-human transmission?

When a virus passes from a nonhuman animal into a human, we call that moment of spillover a zoonotic transmission. It’s an ecological event. What happens next depends on evolutionary potential and chance. If the virus is adaptable, it may succeed in replicating and proliferating in the new human host. Maybe it kills the person and the line of transmission comes to an end there—as happens with rabies. But if the virus is even more adaptable, it may acquire the ability to pass from one human host to another, perhaps by sexual contact (as with HIV), perhaps in bodily fluids such as blood (as with Ebola), perhaps in respiratory droplets launched by coughing or sneezing (as with influenza or SARS). What makes a virus adaptable? The changeability of its genome, plus Darwinian natural selection. Those viruses with single-stranded RNA genomes, which replicate themselves inaccurately and therefore have highly changeable genomes, are among the most adaptable. Coronaviruses belong to that group.

David Quammen is the author of more than a dozen books, including Spillover: Animal Infections and the Next Human Pandemic, and hundreds of articles for publications including National Geographic, The Atlantic, Harper’s, Rolling Stone, and many others.

 

How do you go about creating a vaccine against a new virus?

Every virus has its unique challenges. In the case of n-coronavirus, the vaccine challenges are 2-fold. First, you have to interfere with the virus’s ability to dock with a specific receptor in the lungs called ACE2. 

Then, you need to reduce the problem of antibody-dependent enhancement. ADE means that some respiratory virus vaccines can actually make things worse. There are multiple ways to solve this problem. One option is creating a vaccine that only uses parts of the pathogen to stimulate the immune system. One approach is to do this by producing recombinant protein subunit vaccines.  

We have found that these vaccines that use a part of a protein of the virus (the spike protein) and known as the receptor binding domain (RBD) are optimal for 2 reasons: Recombinant proteins are a standard technology that has resulted in other licensed vaccines, including the hepatitis B and HPV vaccines; and it’s possible to produce this vaccine in abundance and at low cost. 

Moreover, this approach, unlike many others, reduces ADE and has a potential for being safe.  

Peter Hotez, MD, PhD, is dean of the National School of Tropical Medicine at Baylor College of Medicine and Co-Director, Texas Children’s Hospital Center for Vaccine Development.

 

How does this particular coronavirus compare with other coronaviruses like SARS and MERS?

“We are learning more about the virus every day. On the continuum of the common cold to SARS, it’s now clear that the novel coronavirus is more contagious than SARS, but less deadly. We don’t yet know how much more contagious, or how much less deadly. The number of confirmed infections with nCoV has already far outpaced the total number of suspected SARS cases.”

Tom Frieden is President & CEO of Resolve to Save Lives, an initiative of Vital Strategies, and the former Director of the US CDC and Commissioner of the New York City Health Department.

 

Outbreak

When does an outbreak become a pandemic?

The word pandemic literally means “all people” in Greek. But clearly not all people become sick even in the worst pandemics. Epidemiologists typically mean an infectious disease epidemic that has spread or is spreading globally.

Usually we refer to a pandemic only when it involves a new disease. So, for example, we talk about an influenza pandemic when there is a new strain of flu spreading around the world. In contrast, we do not refer to the global outbreak of seasonal influenza as a pandemic because the strains are not new.

There is no strict definition of when an epidemic becomes a pandemic—but usually it means that the disease is actively spreading on several continents with likely continued spread to other continents.

Eric S. Toner, MD is a Senior Scholar with the Johns Hopkins Center for Health Security and a Senior Scientist in the Johns Hopkins Bloomberg School of Public Health, Department of Environmental Health and Engineering. He is an internist and emergency physician.

 

Why are wild animals believed to be the source of this outbreak?

About 60% of newly emerged and re-emerging pathogens share a common origin: the bodies of animals. Genetic and epidemiological evidence suggest that the novel coronavirus, like SARS, may have emerged from a so-called “wet market,” where wild species that would rarely encounter each other in nature are crammed together, allowing microbes to spread between species and into humans. China claimed to have cracked down on these markets after the SARS outbreak, but when I visited a few years later, it wasn’t hard to find one. 

But such markets are only part of the problem. The loss of wildlife habitat around the world more generally is forcing wild species to cram into closer proximity to human settlements. Bats, for example, have been fingered as the source of Ebola, SARS, and a host of other pathogens. When we cut down the forests where they live, they come roost in our backyards and farms instead. It’s this kind of novel, intimate contact that provides opportunities for the microbes that live in their bodies to spread into ours.

Sonia Shah is a science journalist and author of Pandemic: tracking contagions from cholera to Ebola and beyond. Her new book, The Next Great Migration: the Beauty and Terror of Life on the Move, will be published in June 2020. 

 

What does successful risk communications look like?

“When you think of containing an epidemic, from Ebola to coronavirus, labs and disease surveillance are often top of mind. Risk communications, however, is a key aspect in shaping the course of an epidemic, and how prepared people are to combat it.

People need timely, accurate and easy-to-understand information that encourages protective behavior without inciting panic. Information based on the changing risk of transmission and not politics, fear or stigma is critical.

As coronavirus spreads, government, media and others need to elevate accurate information sources and built community trust while combatting misinformation.”

Amanda McClelland is the Senior Vice President, Prevent Epidemics at Resolve to Save Lives an Initiative of Vital Strategies, and has more than 15 years of experience in international public health management and emergency response.

 

How do disease detectives find the source of an outbreak like this?

Once two or more people are identified, disease detectives (such as those in the CDC’s Epidemic Intelligence Service) look for what these people have in common. Do they live together? Work together? Shop at the same market? Points of overlap could indicate sources of the pathogen.

At the same time, infectious disease doctors and scientists try figure out what the pathogen is. In the case of the novel coronavirus, scientists isolated and genetically sequenced the virus, revealing its close relationship to SARS, which originated in bats but was transmitted to humans through another species.

Pinpointing the precise animal species will take time and a lot of testing: It took more than a year to identify civets as the intermediary host between bats and humans for SARS.

Michael Mina, MD, PhD, is an assistant professor in the Center for Communicable Disease Dynamics at Harvard T.H. Chan School of Public Health and associate medical director of Clinical Microbiology at Brigham and Women’s Hospital and Harvard Medical School.

 

What are some of the major challenges to global cooperation in this coronavirus outbreak?

Data transparency and political sensitivity are two of the most critical challenges to effective global cooperation on the COVID-19 outbreak—and they are deeply entwined.

China has a history of concealing, delaying or refusing to share data and information (this happened with SARS in 2002-2003 and in 2018, when China reportedly refused to share samples of a bird flu with pandemic potential). Leading global health agencies have praised China’s response to COVID-19, while other experts doubt the accuracy of the reported data. Data transparency is key to building much-needed trust—and preventing the misallocation of resources, which could slow the response.

Some countries in Asia—where China holds significant economic and political influence—have carefully crafted their public coronavirus responses, aware that criticizing China could hinder cooperation. And all stakeholders face a difficult task: balancing effective disease response with the political sensitivity necessary for a successful, cooperative, global response.

Sarah McCool, PhD, MPH, MHA is a clinical assistant professor of Health Policy & Behavioral Sciences at the Georgia State University School of Public Health in Atlanta, GA.
 

Response

What is the best way to counter misinformation in the media?

The best way to counter misinformation in the media is with an aggressive onslaught of facts. During an outbreak, information may be shifting, guidance changing, and questions multiplying, but the process is guided by adherence to reality and logic. Uncertainty is not an excuse for entertaining arbitrary assertions offered in defiance of the need for evidence. They should be identified as such and dismissed.

Experts, in addition to relating facts, should also explain the evidence that supports their conclusions and how recommendations are rooted in that evidence. This is a daunting task, as it involves more than information dissemination. It requires attention to what counts as evidence and an understanding of how to evaluate competing claims—some of which are grounded in evidence and some of which clearly are not.

Amesh Adalja, MD, is a senior scholar at the Johns Hopkins Center for Health Security.

 

What is it like inside a hospital biocontainment room?

At first glance, patient rooms in the Johns Hopkins Biocontainment Unit look no different than any hospital patient room—until you see the doors. They’re color-coded for health care worker safety. The colors signify required safety procedures to gain entry to a room. Red, for example, might alert a provider to change their personal protective gear.

We work so hard to make sure we can safely care for any patient, at any time, and simple safety cues like our doors help us do just that.

The design of the 7,900 square-foot unit, including three patient rooms, an onsite lab, shower facilities and clean-in/clean-out anterooms, helps us care for patients safely while protecting our staff and our community. A patient might be feeling scared and disoriented, so making sure they are safe and cared for is the number one priority of our team. 

Lauren Sauer, MSc, is the director of Research with the Johns Hopkins Biocontainment Unit and director of Operations with Johns Hopkins Office of Critical Event Preparedness and Response. 

 

What’s the best way to respond to the coronavirus outbreak?

Early in a coronavirus outbreak, unknowns are a given. But the global health community can’t afford to wait to see if a best- or worst-case scenario unfolds. Some post-haste priorities:

  • Vaccine development: Make this is a top priority. Vaccines can dramatically slow disease spread though they can take at least a year to develop. Plans for large-scale production at different sites worldwide are also needed.

  • Find treatments: Test possible antivirals—such as flu and HIV medications—for treatment options.
  • Expand diagnostic capacity: Manufacture and distribute rapid diagnostic kits so cases can be identified quickly.
  • Boost hospital readiness: Strengthen infection control procedures, train health workers, and keep masks, gowns, and gloves stocked.
  • Communicate: Share facts (and unknowns) clearly with the public, and resist the temptation to withhold bad news.

If the virus is ultimately less lethal than feared, or more easily contained, the extra effort will pay off when the next one strikes.

Tom Inglesby, MD is the Director of the Center for Health Security of the Johns Hopkins Bloomberg School of Public Health. This perspective was adapted from a piece he wrote in Foreign Affairs. 

 

What should a country like the US be doing to prepare when an outbreak like this begins to spread globally?

“Beginning preparedness activities when an epidemics hits is too late.  Although the US has a relatively strong health system, we need to be better prepared for an epidemic, particularly by strengthening state and local health departments and connections with health care providers and facilities. But we can’t protect ourselves only within our own borders. Our biggest vulnerability is spread in countries with weak health systems – viruses don’t need visas. The US should double down on support for countries in Africa and Asia so the health workers in these countries can find, stop and prevent epidemics. In the US and globally, there are important and simple things we can do that will prevent illness now and also protect against coronavirus: improve hand hygiene (handwashing), cough hygiene (cover coughs), don’t expose others if we’re feeling ill, and improve health care infection control.”

Tom Frieden is President & CEO of Resolve to Save Lives, an initiative of Vital Strategies, and the former Director of the US CDC and Commissioner of the New York City Health Department.

 

Can travel restrictions and quarantines stem the spread of the coronavirus?

Travel bans can’t keep all cases of the virus out of a country. As the epidemic expands, cases may originate in any number of countries. We may already have unrecognized cases in the US.

Travel bans can actually make us less safe. They can make countries facing restrictions not want to share information about their outbreaks. They can disrupt the distribution of supplies needed to control the epidemic. Similarly, as we saw with the US’s Ebola response in 2014, quarantining returning travelers makes doctors and nurses less likely to volunteer to serve in affected countries.

This virus is likely past the point of containment. We need to focus on mitigating its impact by speeding the development of diagnostic tools, vaccines, and drugs to treat infections.

Jennifer B. Nuzzo, DrPH, SM, is an epidemiologist with the Johns Hopkins Bloomberg School of Public Health’s Center for Health Security.

 

Are strong national health systems all we need for pandemic preparedness? 

Strong health systems are certainly a crucial foundation for preparedness. All countries, rich or poor, need to have a set of core national preparedness capabilities. For example, they need strong surveillance systems in place that can detect infectious diseases with pandemic potential, robust case detection, and effective contact tracing (i.e., identifying and reaching those who may have been in contact with an infected person). 

But that’s only part of the story. By definition, pandemics cross national boundaries—they are global in nature and they require a global response, not just a national one. A whole set of “transnational” activities, called global public goods, is another critical plank in pandemic preparedness. These require collective funding by all countries. Such goods include developing medical countermeasures like pandemic vaccines, diagnostics, and treatments, stockpiling of medical supplies (including personal protective equipment), and ensuring that there is global “surge capacity” to rapidly scale up production and distribution of vaccines. 

Gavin Yamey, MD, MPH, MA, is a professor of the practice of global health and public policy and director of Duke University’s Center for Policy Impact in Global Health.

 

What do frontline health care workers need most when they face an outbreak like this?

“Health care workers are our first line of defense against disease, whether coronavirus or otherwise. In order to safely and effectively do their jobs they need to both have proper training and the right protective equipment. This keeps them safe from infection in “peace time” and during a large outbreak like we have now.

Health care workers are often the first affected by these types of outbreaks and to some extent can act as a canary in the coalmine for how infectious a new disease outbreak is.  In the past, health care workers have died from infections and also amplified initial cases spreading the outbreak quickly.  If we are to protect health workers and limit transmission, we must do more to ensure the right training and the right equipment are available all the time and not just once an outbreak has started.

Health workers are making heroic efforts in China, where they have converged on the epicenter. They can only protect us if they are protected.”

Amanda McClelland is the Senior Vice President, Prevent Epidemics at Resolve to Save Lives an Initiative of Vital Strategies, and has more than 15 years of experience in international public health management and emergency response.

 

What are the ethical considerations of using quarantines?

The tools of public health during suspected infectious outbreaks include limits or restrictions on the movement of individual citizens, ranging from travel bans, to closure of businesses and schools, to isolation of individuals in their homes, to forced quarantine in medical facilities.

The goal in implementing public health measures during suspected outbreaks is to balance the freedom of individuals against the restrictions on freedom required to achieve legitimate protections of the public's health, with public and transparent justification of policy decisions.

Whatever restrictions are implemented should be the least restrictive to accomplish the stated public health goals. Quarantine is considered a measure of last resort given the severe restrictions it imposes on individual liberty, and when misused or ineffective can severely undermine trust in government. 

Jeffrey Kahn, PhD, MPH, is the Andreas C. Dracopoulos Director of the Johns Hopkins Berman Institute of Bioethics.

 

Ed. Note: For GHN's latest coverage of the coronavirus, visit here. And, please send GHN any questions you'd like to see answered related to the coronavirus outbreak. Just email Dayna (dkerecm1 at jhu.edu). 

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