COVID-19 Webinar Series Session 1 – Flattening the Curve

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)

Hello and welcome to today’s webinar. My name is Sarah – and I’m president and CEO of the Alliance for Health policy. We know that many of you listening today are on the front lines of managing The Cove in nineteen emergency as it continues to evolve at rapid Speed The Alliance is committed to remaining a resource amidst this turbulent time.

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Over the next three days from noon to 12:30 Eastern times. We will bring you experts to discuss the trajectory of the pandemic and the risks of a surge in cases. Our speakers will provide perspective from the front lines as the Healthcare System response to the crisis and highlight policy levers available to slow the spread of the novel coronavirus today. I am pleased to present the first session in a rapid response series during today’s webinar.

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We will discuss flattening the curve a term that has emerged as both a rallying cry for a collective response to the outbreak as well as a public health imperative to reduce the severity of covet 19 in the US and around the world. I’m so pleased to be joined.

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Who is an assistant professor in the department of epidemiology at the University of Kentucky College of Public Health? She is an expert in immunizations and vaccine-preventable diseases prior to joining the college in 2016. Dr. Winter worked as an epidemiologist in the immunization branch of the California Department of Public Health and have more than 15 years of experience.

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It communicable disease surveillance prevention and control she is also a guilty affiliate with the University of Kentucky perinatal research and Wellness Center Before We Begin The Alliance for Health policy gratefully acknowledges the National Institute for Healthcare Management foundation for supporting today’s webinar. If you are interested in joining the Twitter conversation use the hashtag all Health lives and follow us at all Health policy. I’m going to briefly Orient you all to the go to webinar platform and review some technical notes. We’ve taken a screenshot of the attendee interface.

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You should see something that looks Like this on your computer desktop and the upper right corner. You can click the orange arrow to minimize and maximize this menu. When you join today’s webinar, you are muted and you will be throughout the presentation. Please use the question panel to chat with us about any technical issues. You may be experiencing you may send in questions for the panelists at any time and we will collect them and address them during the broadcast now, dr. Winter Kathleen is going to make a few.

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It’s of opening remarks and then we will turn to your questions again submit questions give them question section in the audience interface at any time during the webinar later today. You will also find all of the materials that accompany this webinar, including the slides and selected experts about giving 19 on our website. We will be updating the resources list as additional articles and analyses are released and a recording of today’s webinar will be made available as well. Now. I am pleased to turn it over to dr. Kathleen winter.

3:22

You make her presentation. Thank you.

3:27

Thank you, Sarah. And thank you for having me today. It’s a pleasure to be here and to present to all of you this very urgent last minute presentation. So there may be some little errors here. We’re pulling the data together as quickly as it’s becoming published. So please bear with me go on to the next slide.

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So globally we’ve had over 200,000 cases reported. Thus far nearly. Every continent has been affected over 8,000 fatalities have been reported. So that’s a global case fatality rate of 4% I’m sure many of you are familiar with this map that’s shown below.

4:12

These data are being tracked through Johns Hopkins University and it’s a great way to get up-to-date information on what’s Happening and what cases have been reported across The world and in the u.s. So we have major epidemics occurring now with sustained local transmission and many countries and continents all over Europe China. Of course Iran South Korea and in the US and we continue we will continue to see further spread next slide.

4:49

So as of yesterday in the u.s.

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There were over 4,000 confirmed cases, including 75 deaths at least 17 possibly night 18 of those deaths were seated with the long-term care facility in Seattle Washington, and that’s where the first major introduction and outbreak occurred in the US and the one a long-term care facility with a very vulnerable population is affected we can see cut and explosive and very Outbreak occurring and lots of fatalities nearly every state has reported a case of thus far and many states are reporting sustained local transmission next slide.

5:32

This is the epidemic curve of cases that have been reported here in the United States. These data are coming in quickly and piecemeal. So it’s not complete and we also know that people who are just now starting to become sick probably have not yet been diagnosed and reported. So we expect curve to continue to be sustained or potentially increase and not not decline as you see there, but we are seeing increases across the board next slide.

6:03

So the current data on the infectiousness of kovin 19 often, we use a metric called the reproduction number or the are not to estimate this and the this indicates. The number of individuals each case is expected to infect in a population where everybody is susceptible. So the are not estimate for Cove. It is somewhere around 2.2 2.3 depending on the different studies that have looked at.

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That which is about as bad as what we saw during the SARS outbreak. It’s very similar and this is more infectious than what is estimated with regular influenza and that we see seasonally and even the pandemic flu estimates a scene next slide.

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The inky period which is the time from which an individual opposed to the de when they go on onset of you can go to the previous slide. Please is estimated to be between 2 and 14 days so individual, but the average is around five days. So we expect from the time that somebody is exposed to when they start to show symptoms. It’s around five days, but can be up to two weeks. You go to the previous slide.

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artists ours, we saw deviation period of around and we use serial interval I’m from the onset.

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the onset of a okay, so from the propagation Are there and that’s a proxy?

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Dr.

8:09

Winn I’d have to pause.

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Just pause the webinar.

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This is Kathleen. Can you hear me now?

10:16

Okay. I’m going to go ahead and continue.

10:23

So the initial symptoms of kova that we’ve seen thus far reported primarily from China and Italy is that the initial symptoms start with fever cough and shortness of breath. So very nonspecific illnesses that you see with many other viruses including the flu. But what happens with this is it can progress to a viral pneumonia over the course of the next several days the the radiographic images.

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Are very characteristic they seem to have a ground glass appearance. However, we know that some infection.

11:02

And among children and young adults and we know that asymptomatic transmission is known to occur and this can be an individual tour before they have become symptomatic or individuals who never become symptomatic next slide.

11:23

So these data come from a study from China looking at hospitalized cases. And what I want to point out here is that there are these individuals were sick for a very long time. So of the hundred ninety-one hospitalized individuals 26 percent of them were admitted to the ICU there. They were in the ICU for an average of eight days.

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And the time from their disease onset to their ICU admission was 12 days and the time from their onset to when their final disposition occurred whether they died or were discharged was three weeks. So it’s a it’s a slow illness. It’s not kind of a rapid progressing aggressive illness that we saw was Stars. This seems to be a little bit slower progressing initially with the more severe presentation occurring several days into the illness.

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this next slide So our current estimates on the severity are a little hard to interpret because we don’t know the overall denominator of who is infected with this virus. So we use the case fatality rate, which is the number of deaths divided by the number of individuals who are lab confirmed or diagnosed, but we know that the more severe cases or even just the symptomatic cases are the ones that get included typically in that denominator.

12:51

So if this the scope to which the asymptotic that it cases are occurring is still very much unknown, but of the study of the first 72 thousand cases in China 2.3 percent of those confirmed cases were fatal and of of those cases not the Fatal cases, but of will host the 45,000 cases 8-round 80% were considered mild to moderate disease which meant that they did not require hospitalization. So they may have been quite ill for you know extended period of time but they ultimately did not require hospitalization 14% did require hospitalization and tip five percent were critically ill requiring ICU care.

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there was a higher fee case fatality rate reported among individuals with pre-existing conditions such as cardiovascular disease diabetes chronic respiratory disease hypertension and Cancer and a much higher fatality rate reported among elderly individuals over the age of 80 and over the age of 70 and you can see on the graph to the right the comparison of the the death rate by age with regular flu compared to Coal bed so you can You can see quite a dramatic increase particularly and the middle-aged and older adult age group. Now, what’s interesting is that of the first forty five thousand cases from China only two percent of those cases where younger than 20 years of age and we saw a brown 4% where healthcare workers next slide.

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Irises are of particular concern when they come into a population because they have never before infected humans. And so once they emerge they can burn through a population and in fact a lot of people quickly because nobody no one has background immunity to that virus. Everyone is susceptible.

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And this is different from something like seasonal flu, which is depicted below that the more more accurate model of transmission because with seasonal A we do have some partial immunity in the population. Some people have been vaccinated. Some people have been exposed to the same virus previously. And so when we do have transmission, it doesn’t spread through like wildfire. Typically it usually is a little bit slower progressing. So even though influenza is infectious. It’s not as infectious as Cove Ed and codes that can can spread through the population much faster next slide.

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And this is why we have such an important emphasis on trying to slow transmission through social distancing measures. So this is where this whole expression of flatten the curve is coming from, even though widespread transmission of this virus may be inevitable. It is critically important that we slow the spread of this virus in the population because if it if it spreads quickly, we will have a major increase in cases.

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Are in critical care and we simply do not have the health care capacity to meet that need. However, if we can slow the spread and and have cases come in more as a trickle instead of a you know, a fire then we can start to really treat each patient appropriately and we do not exceed the Healthcare System capacity next slide.

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So we use different measures for containment and mitigation with infectious disease containment strategies are when we’re really trying to stop the spread all together and we use strategies like isolating the stick and quarantine in the exposed those involved very intensive case investigations routine infection control practices contact tracing and putting individuals and isolation and quarantine there.

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Very labor-intensive and require lots of personnel to do this and will not ultimately be feasible Once a community reaches a point where there is sustained ongoing transmission with lots of cases reported. So then we’re really forced into only using social distancing closing schools canceling public events closing public spaces and restaurants and all these different now closures that we’re seeing Nationwide and we’ve seen all over the world next slide.

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A lot of the data on social distancing actually comes from the 1918 influenza pandemic the Spanish flu and this pandemic occurred in a few different waves, but several cities implemented very aggressive social distancing measures like we are doing now and you can see the graph the smaller graph on the bottom shows two different cities st. Louis which did use more social distancing measures versus Philadelphia that did not and you can see the progression.

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And the different curves occurring in those two cities next slide.

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so we’ve had a lot of questions about Laboratory Testing and why we are not doing more testing and why can’t we just wrap that up in order to do better case-finding certainly having lots of testing and accurate case finding would would be optimal in terms of really understanding the spread of this disease and the best ways to not about the testing kits and we’ve heard a lot about that in the news, but that’s only one part of the story. So testing kits are available at all state and some local public health Laboratories, but the capacity in each of those sites varies some have lots of a lot more capacity than others and there’s different criteria being applied to determine which patients qualify for those those tests based on the local capacity.

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There are now commercial Labs that are offering Jane Doe the turnaround time for many of those is around 3 to 4 days. And so that’s very difficult. If you’re dealing with an infectious potentially infectious patient in a health care setting or anywhere someone who’s in a sensitive location, and we really need to know whether or not they’re a case.

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But the other piece that’s important is that we have a limited supply of specimen collection kits. We use a nasopharyngeal swab to do this test and you need viral transport media.

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These are not supplies that every single provider has and the most important piece is that not all providers have access to the essential personal protective equipment that is needed to do the specimen collection and this includes an n95 respirator or a surgical mask when supplies are limited and They are limited. We they need eye protection which must be goggles or face shield gown and gloves next to the next slide. You can see the different elements of the PPE that are required and these are not supplies that would be typically seen in every single provider office and even in hospitals where they do have access to these types of supplies. It’s not necessarily readily available at all times next slide.

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I’d next sign no works in the pie.

20:57

It was several different reasons. There has been a can.

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14 which is perfect.

21:07

You know the virus.

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Phase 1 trials or beginning Phase 1 trials are to the least.

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information and Well in the fifth slide.

21:36

So just inclusion.

21:37

I wanted like the dismissed and press it in and I think we I’m leaving.

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thunking across what’s also important?

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this outbreak here in the using too slow burden on the Healthcare System and actually flatten that known about this virus and we don’t fool.

22:15

much asymptomatic I’m going to stop this.

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Great. Thank you so much to you dr. Winter for a great overview of this issue and just as a reminder to everybody the slides will be posted on the alliance website following the session. So it’s now time for a QA. If you have a question, please do post it in the question session on and just because of some of the technical issues that we were experiencing. I’m just going to ask.

22:54

If dr. winter if you are able to stay for an extra five or so minutes after the end of the webinar just to answer additional questions. Would that be okay?

23:09

Well, hope so. Alright, so sure. Thank you so much. All right, I want to ask you a question about this question about timing you talked about social distancing is being essentially the best tool that we have at the moment to contain the spread of the virus and to flatten the curve how important is timing how much time?

23:36

I’m do we have to make these kinds of decisions to close schools restaurants bars Etc.

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And I’m sorry I cannot hear.

24:15

Kathleen we still can’t hear you. I am sorry. I’m going to ask you to call back in if you can.

24:25

Just going to ask you to call back in again everybody. We apologize. Okay?

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And here yeah.

24:37

All right. Well Kathleen is calling back in can can we get some more questions from the audience in the Q&A panel?

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Hi, this is Kathleen. Can you hear me now? Yes.

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Okay, I think I overloaded the three books after this question on how much time do we have to make these decisions on social distancing and understanding that they’re obviously very challenging decisions for people economically and otherwise, that’s right. Yes, that’s right. And so we do know with social distancing that when we apply a lots of different measures and we do it aggressively in the beginning.

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It has the best impact on reducing the Mission there’s no exact answer on what measures have to be implemented and and where and how but it’s the best tool that we have and being aggressive does seem to work better. But of course it is very challenging and I think there are so many different elements to this that we are only just starting to understand what the long-term ramifications might be. Great. Thank you. Okay. We have an audience question.

26:12

Ian, can you get covet 19 twice or do people have immunity if we have it once I think we’ve seen some reports of people who initially recovered and may be tested negative and then suddenly got sick again. What do we know about that so far?

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Yeah, so that’s another area. That’s not fully understood. So we do know that the virus is shed in different sites, you know, either in the oral pharyngeal, you know, respiratory secretions or in feces at different points in time throughout the course of the illness.

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It’s also possible when we’re doing laboratory detection with a PCR that you’re you’re capturing viral material, but it’s not viable so If somebody tested negative and then positive it’s possible. They have a very kind of low-level vibrating. So, you know, we hope that that there is long-term immunity from exposure to coronaviruses coronavirus, but it’s not not fully known yet what that will look like and and that’s still under investigation.

27:21

Great. Thanks. We have another question that is just a little bit of a follow-up to the social distance and question based off of what we know on the social distancing and quarantine measures taking place in China. How long do we expect the us will have just social distance. Will there be a time at which it is no longer useful.

27:44

That’s a great question and it’s a difficult one to answer because I’m not sure anyone really knows so in China they are beginning to lift some of their very stringent social distancing measures and whether or not we will see another increase in disease and other ways will probably inform what we decide to do in the US and and what is done in other countries.

28:08

So we the nice thing about social distancing is that week People away from each other. But once you start letting them back into contact with each other we can still see another spike in disease incidence.

28:23

Great. So question about question about testing. We know the testing is limited right now. Can you talk a little bit about what impact is that having on the epidemiology on the case numbers that are being reported and as more tests are deployed or if more tests are deployed in the near future. Can you talk about that impact as more cases are reported. And what does that do to the projections?

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So as we have better access to testing, we will start detecting more and more mild disease even potentially asymptomatic disease affecting were able to be deployed to that level. We’re individual to we’re not sick were able to get tested. But at this time we do not have access to testing to be able to do widespread testing.

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So even individuals who are sick who are having symptoms that are suspicious for David many of them do not have access to testing because their primary care physicians do not have the capacity to do the specimen collection. And even if they were to do it, it would put them in their staff at risk of Contracting the virus. So we don’t want that to happen. We want to make sure the only providers who are fully protected are doing the specimen collection.

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So if we can ramp up testing and figure out a way to get people Specimens collected safely, then we will have increase in cases reported and it probably will see a decline in the case fatality rate because many of those cases will be more mild and occurring in the outcomes of setting.

30:07

Great. Thanks. So let’s let’s talk just a little bit more about testing because I think there’s a lot of interest in that you mentioned several barriers to testing the lack of supplies being one of them. Not only the testing supplies themselves, but protective equipment for the healthcare providers doing the testing. Can you talk a little bit about what will it take going forward to get the testing supplies and equipment and infrastructure that we need going forward?

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Word. What what what and what is being done?

30:42

So I would say that the answers to those questions are a little bit outside of my expertise because you know, they’re really healthy. They’re really Health Care question and the public health does not have the infrastructure to do the widespread patient testing. That’s just not something that they have capacity for and the healthcare the public health infrastructure in the United States.

31:10

So the real question Soon as how can can individuals patient access testing through their their regular Healthcare networks. And that is very challenging and I think a lot of Health Care Systems really want to limit testing because if it’s not going to change how you treat the patient, there’s no treatments to offer patients who test positive for coded.

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So if the recommendation from your provider is going to be 2 to stay home and get some rest and you know, keep a good watch of your symptoms. If you’re having trouble breathing come back to the hospital then we don’t really need to test we can just tell people to do that anyway and not put the health care providers at risk by having the testing done. Okay, and we’re going to get a little bit more into that and tomorrow’s webinar where we’re going to have the CEO of Ascension Health is a major health system and and a public health expert getting into a little bit more of those Dynamics.

32:13

Can you talk just a little bit from your perspective, you know knowing that we don’t really have a Treatment available just briefly if you could touch on anything related to vaccine development and why that’s going to be important to the epidemiology. And again, we’ll get in some more of the details of where we are with vaccine development at a later time.

32:37

Yeah, I think our goal would be discussing down sufficiently that once a vaccine becomes available and could be deployed that could be distributed to those people at highest risk, you know the health care workers and those with pre-existing conditions or other complications that might put them at higher risk.

32:57

So we can protect those people now, but who says he’ll just insane and keeping them isolated. You know, that is then maybe slow the spread to those individuals and protect them later.

33:13

Great. Thanks. Let me go back to some of the the the initial data you talked about and and the projections of cases. There’s a question from our audience whether there have been any data that has projected models of where the peak of the curve might be. Are there any other there any other countries that are on the right side of the curve?

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Are there any countries that have have flattened the curve and and can you can you talk a little bit about that and maybe Go into a little bit more. You know, why is 4,000 cases concerning now? What is the what is the projection? What is the exponential growth that we’re looking at here?

33:56

Yeah, so I don’t have all the data on what’s happening globally mostly because it’s all changing so quickly and I’ve been so busy, but we do know that in Wuhan there is it bad been a dramatic decline. So a lot many fewer cases are being reported there. They still have new cases but it’s a very slow trickle compared to what it was so they certainly surpass their pee.

34:24

And they have come down now what’s difficult is the countries that are having major outbreaks now and Europe. We just don’t fully have the picture yet partly because by the time that the explosion of cases is getting to Health Care. There’s already there in Transmission in the community at that point for maybe a couple of weeks. So it’s hard to see what’s coming down the line there have been a number of papers.

34:54

Is that have looked at different modeling estimates? So there are some predictions out there, but I just don’t have the data available to me. Great. Well, let me as we get ready to close.

35:08

Let’s just ask one one more questions from the audience and it goes back to the question around social distancing and you mentioned communication and the challenges of communicating to people given that so much of this has to do with individual level decisions as well as businesses local and state governments. What is the best strategy to take when trying to convince somebody to to take social distancing seriously and do you have practical tips? There’s lots of people at home right now with kids who are begging for playdates, you know, is it safe to like wave hello to your neighbor? Can you just share a little bit more of what where the evidence stands on that?

35:56

And how can people Um, how can people apply this in their life today?

36:04

I think the problem with social distancing is that every individual households access to so many different types of resources. So some families are very able very easily able to stay home and then I’ll be easy you may have kids bouncing off the walls, but at least you have potentially flexible jobs, or you can keep them. However, there are lots and lots of simply do not have that.

36:34

These people are essential personnel and this health care and public health response and government service workers sanitation workers that that just simply cannot be away from their appointment at this time and really do need to be working. So, you know, it’s okay for children to be in contact with other children, but they should be healthy and you should try to limit the overall number of contacts that they have.

37:02

So if you need to cherish their childcare try to do so with maybe one or two other household so that the overall network is small if you need to bring in a babysitter, you know that can be done but certainly try to not have their V10 babysitter’s or 20 babysitter’s, you know, try to pick one or two that are the primary contact. We encourage people to go outside.

37:27

So we’re talking about disease transmission and when you’re in an outdoor setting Transmitting as much much reduced. So children playing outside should be safe. They going on bike rides and walks and Hikes and all of that is should be not not of concern. So get the kids out people need to be out walking biking doing the things that they need to do in order to still maintain their their own health and wellness and their mental health during its really challenging time.

38:01

So, I think it really depends on what the hell To do it also depends on if there’s anyone who’s high risk in the household so we know that the elderly and those with underlying severe conditions that might make them more susceptible more medically fragile. They’re at higher risk. So if you have someone like that in your household try even harder to keep your house.

38:34

And if anyone in the household is sick have themself isolate so that they do not spread to that potentially vulnerable person. So these are all strategies that can be tried it is it is challenging for sure and we’re just doing our best.

38:52

Thank you so much. Well on that note. We really appreciate you joining us today, dr. Winter and and thank you again for sharing your time. So generously we know you are spending double time helping your local health department and others grapple with this crisis. So we really appreciate it for our audience. Thank you thus today for it with our technical difficulties, but we are so glad you joined us. Please do join us again here tomorrow from noon to 12:30.

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For webinar featuring representatives from Ascension and the National Association of County and City Health officials who will discuss the challenges facing Health Systems and public health and how they are intersecting on Friday. We’ll be joined by Governor Mike Leavitt who previously served as the Secretary of Health and Human Services and the governor of Utah. He will explore the path forward for policymakers at the federal state and local levels.

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And finally you can find more information and resources on our website so that Thank you again to dr. Winter for joining us. Thanks to our audience, and please be healthy and be safe. Goodbye for now.

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