>> Hi, good afternoon.
We would like to welcome you all to our update for private sector
organizations.
on the 2019 coronavirus response or COVID-19.
We are grateful for all you are doing to keep your employees and
communities safe and we are pleased to have Dr. Jay Butler here to give
updates from CDC and thank you all for who submitted questions in
advance.
We approximately appreciate your engagement.
I would like to introduce Dr. Jay Butler.
He brings a lot of expertise.
You probably heard him from previous phone calls as well.
He is the deputy director for infectious diseases.
he provides leadership to the three infectious disease centers and hopes
to -- and he brings experience, 30 years of experience both in the field
and here at CDC so has a lot of great perspective.
I will turn it over to him to provide an update on where we are at with
the coronavirus
>> Good afternoon and good morning to those on the west coast.
Today is March 30th.
It's interesting to think it was December 31 that the world was first
notified of the cluster of.
pneumonia cases that occurred in but, China -- but- Wuhan China.
We are here to talk about a pandemic caused by a virus and disease that
we didn't know existed only three months ago.
It's both humbling and fairly stunning to think how much the world can
change.
in only three months.
Of course, as of today, the virus has spread pretty much around the
world.
There are laboratory confirmed cases in over 200 countries now.
There is almost certainly some bias in that depending where testing
capacity is, but the virus has now been documented for several weeks on
all the -- all of the inhabited continents of the earth.
The majority of cases right now are being reported in Europe, but also
every jurisdiction in the Americas is involved now.
The United States actually has the most laboratory confirmed cases of
any country.
including more than were confirmed in China as well.
Here in the United States, there have been over 140,000 confirmed cases,
probably closer to 150,000 by now.
Unfortunately there have been over 2400 deaths.
Every state has seen cases.
Some more than others.
There are certainly hot spots.
New York City, the chief among them.
Also seeing some fairly dramatic increase in the activity in the Boston
area New Orleans and in other areas around the country.
I recognize that depending where you are at, it may look very different,
but there is a slough of information that's available on the status of
the epdicking at CDC.gov/COVID-19.
And also that page will be getting considerable remake later in the
week.
We want to provide useful data in a graphically -- in way that
graphically.
is presented to be able to facilitate communication.
Please do keep an eye on that website.
We continue to find that the people at highest risk of severe illness
and fatal.
outcome are those who are older, particularly over age 70 to 80.
And that people with underlying heart/lung/kidney disease are at higher
risk as well as those with diabetes.
There will be a descriptive paper coming out in the MMWR later this
week.
highlighting some of the risk factors for more severe disease.
Now that said, I think it is a couple of paradoxes here that are always
tricky in the communications.
The vast majority of people who are infected with the SARS COV2 virus
will recover completely.
We are learning more and more about the mild manifestations in some
people and also asichmatic infection.
However, younger people are not completely immune to more severe
disease.
We occasionally learn of unfortunately people in their 30s and even 40s
winding up in the ICU with COVID-19.
Let me walk through some of the emerging hot topics.
One of the issues that I just touched on is what appears to be a more.
likely roll of pre-symptomatic transmission, and even asymptomatic
transmission where we have data from cohorts of people who have been
exposed with testing.
We are finding it's not uncommon to have fairly high amounts of virus
present in the nose and throat before onset of symptoms.
In fact, people who develop symptoms, the highest amount of virus is at
the time.
of the onset of symptoms with some decline afterwards.
It may be a bit of a game changer for us as we look forward in terms of
trying to determine what are the best ways to mitigate transmission and
to slow the spread of the virus.
I think everyone is aware of the goal of flattening the curve.
That's become a household term now.
The overall goal there is to distribute the impact of the pandemic over
as long a period as possible in order to maintain critical
infrastructure, and particularly to keep the health care system from
becoming overwhelmed.
So one of the issues that we are also looking at because of that is
whether or not.
use of face covering might be of utility in the community to prevent
transmission from people who are either not yet symptomatic or
asymptomatic.
We don't know what role asymptomatic infection might play, but as we
look at some of the experience around the world in areas where face
masks are oftentimes worn more often for the wearer's protection, there
may be a benefit because of source control with this particular virus.
So we are looking hard at the possibility of using face covering or non-
medical masks as a method to basically as an environmental control, if
you will.
Again, not something that necessarily protects the wearer, but something
that would be an additional tool in the toolbox of community mitigation
measures in addition to what's been done already for social distancing.
I imagine everyone is aware, speaking of social distancing that
guidelines coming from the White House task force have been extended
through the month of April.
As we look around the country, I think there are 17 states now that have
had some type of stay at home order statewide.
49 states that have closed schools statewide.
9 only state that hasn't -- the only state is -- 99% of the schools have
closed based on decisions made at the local level.
These community mitigation measures are part of what we do -- an
important part of what we do to flatten the curve until we know more
about the status of any chemo prophylactic agents.
right now there are basically none.
There are therapeutic agents that are under study.
we certainly can talk more about that if you would like.
A vaccine that's probably at best 12 to 18 months down the road before
that would be available for more widespread use.
I was talking about face covering.
It's important to recognize the importance of maintaining personal
protective equipment for health care workers.
There has been a lot of work done and the response that's now led out of
FEMA and the national response coordination center to be able to tap
into the strategic national stockpile and also to be able to receive
donations of PPE and other equipment such as surgical masks to be able
to get them out into the communities where they are needed by health
care providers.
Another real hot spot of concern is the long-term care facilities.
I was mentioning earlier, the persons at highest risk of severe illness
are older persons and persons with chronic underlying conditions.
Many people in long-term care facilities are both older and have under
lying conditions.
Some of the worse situations we've seen in terms of outbreaks have been
in long-term.
care facilities.
As of now we are aware of over 400 long-term care facilities.
that have had cases in a large number of states.
It's an area where we are doing everything we can to provide technical
assistance to our partners at the state and local level.
Regarding testing, testing using the PCR and other nucleic acid assays
continues to become more available there are 20 platforms that have
emergency use auto sx granted by the FDA.
The number of tests that the test results that have come back are over
400,000 so far.
There is a lot -- the capacity in the commercial labs is greater than in
the public health labs.
So far about a third of all of the tests that have been completed have
been in the public health labs.
So I really want to acknowledge the important role that commercial labs
have played in terms of meeting the demand for testing.
There are in addition to more than just traditional PCR, I was
mentioning nucleic acid assays, this is helping us move toward being
able to push testing as far out into the health care system as possible.
And also get a faster turnaround on results.
The latest EUA granted is for a nucleic acid assay that can be performed
in many laboratories that are present in larger community centers, and
perhaps in the larger specialty clinics and can return a result in as
little as 15 minutes.
Ultimately the goal will to be have some sort of true point of care test
that would be performed by a provider and have a result back before the
patient leaves either the emergency department or the clinic.
There is a lot of work that is occurring now to move us in that
direction.
Of course, that is normally how influenza is usually diagnosed in this
country.
Also, HIV and hepatitis C testing is performed that way also.
We also have a lot of interest in serlogical testing.
Here at CDC we have an ELISA assay developed and serology is not going
to be.
very useful in terms of diagnosing acute infections.
It will be more useful for epidemiological assessments that answer the
questions about how often sub clinical or asymptomatic infection occurs
and to be able to assess population based immunity levels as the
pandemic continues to spread.
There are some -- there is some interest in the commercial sector to be
developing serlogical assays as well.
I would have to defer to FDA to discuss any saitous of emergency use
authorization applications.
I know there has been some development of rapid serlogical tests that
have been marketed in other countries.
A question we often get, are they any good?
At this point we don't have a lot of data or assessment on those.
It's a very pressing issue we know, and we are very much involved in
being able to evaluate the utility of serologic assays as well.
So at this point in time, maybe this is a good chance for me to stop
talking and start going through some of the questions.
>> Great.
Thank you.
I would like to remind folks this call is intended for partners in the
private sector if you are media, we won't be answering media questions
and you get questions that should be sent to the media @CDC.gov
>> A very clever web address
>> So I have some questions here about mail and incoming packages.
Are they safe?
Should business being doing anything particular in those
>> Excellent question.
So people may be aware that there was a paper published by both CDC and
NIH a couple of weeks ago looking at what are the maximal survival times
for the SARS COV virus in the environment on various surfaces at various
temperatures on different materials.
And it's important to recognize that this paper really looked at
maximizing the opportunity for the virus to survive.
So it's an important paper, but also has to be interpreted in light of
the real world situation.
In that paper it was possible tounder the right conditions could get
virus that could be recovered from cardboard or paper.
The epidemiology of COVID-19 doesn't point to rapid dissemination.
of the virus through the mail.
Given the amount of mail and various produced goods that come out of
China in particularly out of the province where Wuhan is located, if
this were an important mode of transmission, I think we would have seen
earlier popping up of, if you will, metastatic foci of transmgs around
the world.
what we saw during January and the first half of February was spread
outside of China primarily by way of travelers who had become infected
in China and who had traveled while asymptomatic but developed symptoms
after return.
In the cases that occurred secondary to those travelers were mostly
among.
household contacts.
So this points away from really widespread transmission through
contaminated goods that were sent around the world.
Currently the bulk of the evidence still points towards respiratory
droplets as primary mode of transmission.
These droplets are generated, of course, during coughing and sneezing.
Even as I sit here coughing, I'm producing a small amount of respiratory
droplets as well.
So this is of concern as we begin to learn more about the amount of
virus that may be present in the Naso pharynx prior to onset of symptoms
the other possible mode of transmission that I have touched on already
is contamination of surfaces, and I think for at least a month now
everybody has become very familiar with the concept of hand hygiene.
Knowing that hands are an important mode of transmission for a number.
of respiratory viruses and we would expect it's likely for the SARS CoV2
virus as well and decontamination of surfaces particularly high touch
surfaces such as doorknobs touch pads.
I've notice in a restaurant that's takeout service they have a whole jar
of pins.
for people to sign their credit card notices and move it over to the
dirty pile and then there is someone who goes through about once an hour
or so and wipes down the pens with an alcohol wipe and moves them back
to the clean side again.
These are some of the kinds of things that are being done to be able to
reduce the risk of transmission by fomites.
Another question is whether or not airborne transmission is occurring.
The difference between airborne and respiratory droplets is airben is
more -- is like what occurs with tuberculosis or the measles virus.
It's not just a matter of droplets that fly through the air until
gravity takes over and they fall to the ground.
It actually becomes a airborne particle that potentially infectious and
can float around the room.
It can be entrained into the ventilation system and spread through that
route.
There is not a lot of evidence for that at this point in time.
Again, the caveat in all of this is that we are talking about a virus
and a disease that we did not know exist three months ago.
The emerging epidemiology still does not support a prominent role for
airborne transmission.
That said, we do recommend particularly in health care environments
especially when there is a possibility of Airosol producing procedures
being performed that airborne precautions be takennen by health care
workers
>> We have questions about asymptomatic and pre-symptomatic.
and if we know anything when a person might be most infectious.
>> That's a good question and one of the things that over the past
couple.
of weeks as we have more experience with this new disease where the SARS
CoV virus may behave sirchly than the SARS coronavirus.
In SARS, the peak level of virus.
and peak level of infecttivity, the peak of illness several days after
onset for for SARS CoV, the highest amount of virus in Naso financial
appears to be at -- Naso fir reasonings at symptom on set.
In those people we have samples upon symptom onset.
the viral load can be fairly high.
Exactly when does someone become infectious is not entirely clear,.
but I think it's entirely plausible that it could even be as early as a
couple of days before onset.
This is fairly unusual for respiratory viruses.
We know that flu sometimes starts being shed a few hours before onset of
symptoms.
This is particularly concerning with coV19 there is a period of days of
infectiousness.
The other difference of COVID-19 and influenza, is the onset can be
fairly subtle.
In fact so many people the disease can be very subtle.
I chatted with one gentleman in his 40s that had a documented infection.
He actually never had any cough at all.
He felt a little off.
The next day he felt more off.
Had a little bit of a headache.
Muscle ache.
Thought he might have had the flu.
Took his temperature and he had a low grade fever.
And then he thought about some of the international travel that had
involved Europe at that time.
He became concerned that he might have COVID-19.
And was tested here in the United States where he was at and was found
to be positive.
He recovered after about four days.
And never really had cough or shortness of breath.
A little bit of runny nose he was unsure if that was attributable to
COVID-19 or not.
So it's one of the challenges with control of this virus.
It actually is a challenge to some of our initial approach of test and
isolate to know that the virus may spread.
from people that are not yet symptomatic.
The reason why community mitigation, social distancing and some of these
things that we have been instituting and have been talking about over
the last 20 minutes may be so important.
So you mentioned in your comments perhaps face coverings for either
essential work force.
non-health care workers or the general public.
And it seems like clarification on who that might be protecting.
Can you comment on that?
Sure.
Actually has been some discussion nor at least a week or two -- for at
least a week or two now for people who have been exposed who are part of
the critical infrastructure work force being able to monitor for
symptoms but continue to work while wearing face cover.
That was more just because the symptom onset can seem to be -- fairly
subtle sometimes.
With the newer data suggesting that there the potential for transmission
prior to symptom onset and possibly even from asymptomatic people, it
does raise the question about what role face covering would play more
broadly.
One other observation its comparing the U.S. to the experience in South
Korea where there was some very aggressive test and isolate procedures,
but there has been widespread use of masks.
I think many of us have looked at the rates of infection that are
confirmed in South Korea, particularly over the past week or so with a
great deal of envy because it did seem to plateau off very well.
Many people were attributing that to test and isolate which certainly
did play.
a role, but it also raises the question about the frequency of mask use
in communities in South Korea.
Which in some of the communities where there were high rates of disease
were even mandatory.
And so it does raise the question of whether or not face masks even
whatever reason they were being worn, might have played a role in
mitigating basically source control.
So to summarize that, I think putting the lift of observations together,
it does begin to raise the question of the utility of using masks as
source control to be able to limit spread from people who are infectious
knowing that we may not be able to have good clinical markers for who is
infectious.
I think this is an extension of something that we commonly do when
someone is symptomatic and even with COVID-19 has been recommended all
along.
If someone is coughing and sneezing and needs to be in public or going
into the health care system, they should have a mask on to be able to
limit the spread of those respiratory droplets.
that may very well be something that we need to be expanding to a
broader swath of the community.
I think there are questions that we are trying to sort through very
quickly in terms of what are the thresholds to make that recommendation?
When should it be worn?
And what are the measures to decide when it's no longer needed?
There are some questions both on-line and received in advance about
close contact and how is that defined and what's prolong and how is it
defined
>> Yeah, I feel like I've seen this concept of the six feet develop over
the past 20 years.
starting with SARS and maybe a little before that.
And I'm sure many people on this call are aware that if you are in the
EU they will say two meters.
It's not a magic number of 72 inches is not good, and 73 is a problem.
So it's getting back to that concept of how respiratory droplets are
spread as they come out of the source person they fall to the ground.
So the closer, the greater likelihood exposure, the more time you spend
in that close proximity the greater likelihood there is of an infectious
exposure.
In terms of what's a minimum time, the data are such that it's a
continuum.
I think I would be hesitant to break it out too much, but in general the
way we've looked at it is comparing a quick passage of tbreetings being
low -- greetings being low risk whereas sitting next to one another at
dinner would be a moderate risk.
It really is a continuum of the variable of how close you are, whether
or not the source person is coughing or sneezing.
And then the amount of time together as well as the susceptibility of
the person who is exposed.
>> There are some questions in here if you are a business that's open.
and maybe have an employee who is sick.
What kind of things should you do, put into place?
The most important is someone is at work and becomes symptomatic is they
should be isolated away from other employees.
and customers.
This is one of the areas where we have recommended use of face covering.
in the community for quite sometime now.
It does not have to be a surgical mask or an N95.
Preserve those.
We would recommend against it.
Again, basically just trying to cover the nose and the mouth to limit
generation of respiratory droplets.
You want to be able to get the employee either home to self-isolate or
if they are ill to a place to be evaluated, to determine whether or not
hospital care is needed.
In terms of other employees, notification within the appropriate
parameters of representing privacy is important.
And I encourage everybody, particularly with larger corporations that
have HR legal support to review what are your corporate policies as well
as any state or local regulations that may apply in this situation.
In terms of the environment, ideally I think this is an area where the
ground is shifting some as we learn.
more about COVID-19.
We have guidelines on the website about cleaning and able to
decontaminate.
areas and I think those those will continue to be updated as we continue
through the experience with the pandemic.
I think with our newer learning it raises the question about how much
already.
people in any public area may be infected with COVID-19.
I know the practices that I just observed is that a number of stores
that remain open such as grocery stores which are critical to maintain
food supply, many are cutting back on hours so they can have more time
invested in being able to do very thorough cleanings to keep the work
space as well as the customer areas as safe as possible.
>> I feel like you answered in some ways when you were talking about
before about mail and packaging but I think it would benefit.
So the question we got is can I catch it from food?
That's a great question.
In the traditional sense of what is a foodborne pathogen that appears to
be very unlikely.
So catching it from food is probably going to be more in the situation
where you're eating with somebody and there are respiratory droplets
that fall on food as you are eating it.
Right now there is not evidence that there is contamination of food that
goes through.
the food distribution system.
So I think the bottom line is that it's not known to be a route of
transmission for COVID-19 so it's certainly something to consider.
I think the basic rules for food safety, hot food is 409, cold food
is -- hot food is hot and cold food is cold.
Just because we are in the middle of a COVID-19 pandemic doesn't mean we
are protected from Salmonella norovirus or any of the traditionally
thought of foodborne pathogens.
>> These are music to my ears.
We have a series of questions.
But sort of in the same spirit like, how do we know if the curve is
flattening?
When do we know if this pause is working or not?
When can we wake up again?
>> Those are great questions.
It seems like modelers, the new dinner guests you have as soon as you
can have dinner guests again.
They play a critical role.
If we look at case counts and laboratory confirmed cases, it becomes
challenging because ideally we want to put the resources that are
available in the spot that are transmission is occurring or about to
start occurring.
When cases -- case counts are going up, it's important to recognize that
alone as a measure is basically reflecting transmission that occurred
ten to 14 days ago.
Why do I say that?
It's important to recognize that this is -- while this is an acute
infection, it has an incubation period.
The range is two to 14 days.
The probably the peak is around five days, six days.
The onset can be subtle.
So people may not seek care or testing until after three or four days
into the illness.
Although it looks like turnaround times are on average down to about a
day or two particularly as that initial surge that hit the commercial
labs is being addressed.
It still adds up to a number of days.
So this is where modelers come into play and will be helpful not only in
identifying what are the areas that are on the upsurge, but also when
things begin to wind down again.
So unfortunately in many ways this is different from influenza where we
know basically most all of the influenza viruses behave similarly and we
would be more confident in that type of projections.
We are always learning new things about the SARS CoV2.
So it will be a learning process as we go forward that's determined.
optimal ways to give the -- I'm not going to say the all safe.
it's probably a more scale back of the interventions.
For instance, when is it appropriate to re-open schools?
When is it appropriate to loosen up and have more businesses open?
, particularly to be able to keep the economy going?
I think it's very likely that for sometime for businesses that allow
teleworking they are able to maintain productivity.
That is going to be something that will continue.
And then finally, mass gatherings are important early in this pandemic
there is an important role of travel and mass gatherings.
That's ongoing work that's determined when it's best to determine those
recommendations as well.
Can you say anything about the three things that are going on right now.
Allergies and flu and coronavirus?
>> Yeah.
That's a great chance to talk about some of the challenges just in terms
of identifying when someone has COVID-19.
I mean, particularly many of us who are working long hours these days we
generally don't feel ourselves to begin with, but then add that in to
the pollen season which we are into down here in the south.
As well as the fact that we still have influenza activity around the
United States.
2 makes it very hard to -- it makes it very hard to know just based on
symptoms of respiratory illness whether or not it's COVID-19 or not.
This is one of the reasons why we have keen interests in not only being
able to increase the availabilities of diagnostic testing.
using the platforms that exist now, but also being able to support the
availability of more rapid and widely available testing.
I know there has been talk about home testing.
That's ongoing research as well.
If those tests are validated, it could be a good way for people to have
a little more guidance of when to self-isolate and when it will be
critical to stay home from work.
And maybe one last thought along those lines.
And maybe harkening back to the earlier question about and reinterpret
that question when is this all over?
We look at influenza pandemics in the past, particularly 1918, you know
it went on for about two years before it tailed down and then that H1N1
virus was the predominant flu strain circulating causing seasonal flu
until shortly after World War II, in 1947, when there was a shift in the
H1N1 type.
So it will not be over in a few weeks, but what we hope we can be able
to do is loosen some of the community mitigation so that we can hit that
sweet spot of doing the things it takes to be able to save lives and to
reduce transmission, but also not have the untoward effects of people
not being able to have the appropriate care of their chronic conditions
or their additional emerging health conditions as well as the impact on
the economy and our educational system.
it really is an ongoing process of balancing the cost and the benefits.
I'm going over a series of questions about PPE.
Some sort of thing they might need or where can they be accessed.
I wonder where you can comment.
The availability of PPE is being run now under the associate -- the
assistant secretary for.
preparedness and response, who had responsibility for the strategic
national stockpile since about mid-2018 now.
And then that is part of the overall FEMA response as well.
So those requests probably need to go through the state emergency
response coordinator.
to direct them up to the people that are best suited to be able to
respond and provide advice
>> We are just about at time.
I'm wondering if there is any key messages or anything you would like to
leave.
our private sector business partners
>> Sure.
First of all, thank you for your partnership.
These are difficult times and I know that's just not a statement from a
health care provider and public health professional perspective, but for
all of us and the world will never be the same again as we continue to
learn not only about what we have been learning over the last couple of
decades about emergence of the diseases that adapt to infect humans and
the potential for global spread of new viruses we've learned about the
global supply chain and how during a pandemic response it's much broader
than just the health issues that are impacted.
It also goes the other way.
I think many of us in health are aware that economy has an important
influence on the health of the population.
Are seeing that in ways that are very real and painful that we've never
seen before.
So I hope that out of all of this, we will learn that we are all in this
together, and that through the relationships and the planning that
involve both health and the private sector-- the private sector un
related to health care will be more prepared for the next event like
this that happens.
And not to end on a sour note, but we have seen the influenza pandemics
before.
We will see them again.
I would not be surprised if we don't see more events with 9 pandemic
disease.
caused by other viruses.
This one -- viruses.
This one seems particularly bad one.
Let's all stay in it together because I think together we can address
this although, of course, standing together six feet apart.
Thank you for the chance to talk with you.
I hope everyone is well.
And so I wish you well
>> Thank you Dr. Butter and thank you all for joining us today.
This concludes our call.
We will continue to update guidance as we continue working on this issue
and we will also continue having calls.
Your input and questions if not answered today are informing our future
works and understanding if there are gaps in our guidance.
So thank you again and have a great day.