>> Good afternoon and thank you for joining us today.
My name is Diane Hall and I'm a senior scientist in the
CDC director's policy and strategy office.
I also serve as CDC's point of contact and coordinator
for our rural health bar.
As part of our work on this response we have been in
regular communication with federal partners such as the
federal office of rural health policy, USDA's national
institute of food and agriculture, and the VA office of
rural health as well as nongovernmental partners as
well as the world health information in the world
health information.
We have had tremendous interest in this briefing and we
have received many questions ahead of time.
Please note if the question is not within the CDC
purview we have shared it with the relevant agency and
we will continue to do so.
Also note that CMS launched a website on Medicaid gov
which includes a new checklist to make it easier for
states to receive federal waivers and implement
flexibilities in their programs.
If you search Medicaid COVID-19 you should be able to
find it.
If you have additional questions you may continue to
send them to rural had that CDC dot gov.
I would like to think Scott Miller in my CBC colleagues
working on the coronavirus response reporting is
breathing together.
I would also like to thank CDC's Captain Margo Rick and
the federal office of rural health policy and their
assistants for curating questions and assisting with
talking points.
And thank you to our partners to help disseminate the
invitation.
And I would like to welcome Health and Human Services
Deputy Secretary Eric Hargan, hopefully he is on the
line.
Okay, it sounds like he is not on the line yet.
So I would like to turn it over to Dr.
Jay Butler it was the Deputy Director of infectious
diseases here at CDC and then maybe when the deputy
secretary comes on we can pause.
>> All right, thank you Diane, and I will certainly
yield to the deputy secretary Hargan if needed.
So good afternoon to those of you in the East, good
morning to fellow Westerners, and thank you for taking
time to join this call today.
We are in the midst of a global pandemic of a disease,
COVID-19, caused by a newly recognized virus.
And all evidence is this is a virus that has only
recently achieved the ability to infect humans.
Coronavirus in general exist in nature, particularly in
bats, and certain coronaviruses adapt to infect people.
As some of you are aware if you are in poultry science
or you manage swine, influenza behaves somewhat like
that.
While the epidemic first evolved out of China, it has
spread globally now and some of the real global
hotspots now are in Europe and in the Americas.
All around the world nearly 300,000 cases have been
confirmed and we are sure that many more cases than
that are actually occurring.
Unfortunately nearly 13,000 people have lost their
lives to COVID-19.
It's important to recognize that the experience of
people around the world suggest that people who risk
complication send death are those who are advanced in
age as well as those with chronic heart lung kidney
disease as well as those with diabetes.
However, I want to stress that younger people also may
have more severe disease and while the overall
mortality may be very low among younger people, the
impact can still be significant.
Here in the United States there have been over 33,000
cases and there have been cases reported from all 50
states.
While a significant proportion right now are from New
York City or from New York State, I want to stress that
this is indeed a pandemic that has spread across the
country and across Canada as well, so really all of
North America.
I understand that Deputy Secretary Hargan is on so I am
going to pause and Mr.
Hardin, would you like to say a few words?
>>
>> Well, I apologize for the dead air and if the deputy
secretary is able to join we will let you know and
interrupt again.
Nationally here in the United States that have also
been deaths as well as severe illnesses, over 390
people have succumbed to COVID-19.
A significant proportion of those have been residents
of long-term care facilities which I think again
highlights the fact that those who are at greatest risk
are those who are older and have underlying conditions.
The long-term care facility outbreaks have now been
reported from 27 different states.
We do expect to see a continued increase in the number
of cases both as there is increased transmission and
increased capacity to test.
As of yesterday 91 state and local public health labs
basically representing all 50 states plus the District
of Columbia and Guam had capacity to do testing.
There were also five commercial labs that are
performing these tests as well.
As we looked at the mix of cases around the country,
some are travel related and when I say travel I mean
travel from other parts of the United States.
Others are community associated, and so it is important
to recognize that this is an infection that really is
threatening the entire country.
One of the challenges in controlling the disease is
that it is apparent that some people also have very
mild disease associated with infection and it may be
possible that people are shedding the virus prior to
onset of symptoms, and some people may have no symptoms
at all.
Just today CDC finalized and put out a report on some
of the cruise ship clusters and at least in one of the
cruise ships, 18 percent of people who have documented
infection never developed any kind of symptoms.
Over the past week there has been increasing focus on
social distancing and the things that we can do to
mitigate spread in our communities.
And the reason for that is we want to be able to
protect critical infrastructure, especially our health
care system, recognizing that there is a small but
significant portion of people who will become seriously
ill and we want to make sure that they are able to get
the care they need.
You may see different actions taken in different states
and in different communities, and actually that makes
sense because even though the virus is present around
the country, in some states the transition rates are
higher than in others.
Here at the CDC we are working with all of our federal
partners across the department and also with FEMA, and
our particular role is to collect and analyze data, to
be able to provide technical advice to states,
counties, and other partners to make good decisions.
This is truly a learning curve and it's very humbling
to recognize how despite the best science sometimes
what happens in nature can outsmart us, and in some
ways a viruslike this is like a tornado or a hailstorm.
There is not much that we can do other than be as
prepared as possible and then be ready to mitigate the
impact as much as we can.
Of course as I mentioned we work closely with state,
local, and tribal leaders who are also organizing the
local responses.
We also work with the private sector, particularly
focused on ways we can help support development of
drugs that are effective for treatment, develop new
ways to make the diagnosis, and ultimately to have a
safe and protective vaccine.
So all of this involves us working together.
We recognize that there are particular challenges in
rural areas.
There is a lot of dependence right now on things like
the Internet for communications, whether it is with
family or for teleworking, and in our rural areas as
well as especially in frontier areas, broadband and
Internet access can be quite limited.
We also know that providers are oftentimes already
overtaxed in our rural areas and we want to do
everything we can to help support them.
Also some of the things that are true when it is sunny
and 70 degrees are true now in a pandemic such as how
difficult it can be to transport patients that are in
need of a higher level of care.
So with that maybe I will pause.
I can try to pause one more time to see if Deputy
Secretary Hargan has been able to join us in an unmuted
fashion and if you would like to say a few words.
Otherwise I will turn it back to you, Diane, and we can
begin taking some questions.
>> Great, it sounds like we are having some techie
issues, the deputy secretary is on the line but he is
muted and we will wait to see if we can get that taken
care of.
Do we want to start with checkbox or take questions on
the phone?
>> Sure, we can go ahead with the chat box.
What is the current trajectory and Outlook for patient
search around the country?
>> It is quite variable depending on where you are at
in the country.
In some areas hospitals are approaching maximum
capacity already, but I mentioned earlier New York City
seems to be particularly impacted and there has been a
focus on being able to provide emergency additional
rooms, particularly for people who are only mildly ill
but still needing hospital care.
It's also a chance to point out that most people who
become ill can isolate at home and don't need to be in
the hospital.
So again it is important to understand the vast
majority of people who become sick will have relatively
mild illness and can self manage at home.
However, because we are talking about a virus that may
be able to infect everybody even if the risk of the
overall proportion who develop severe illnesses
relatively small, we may be talking about a significant
number of people.
So we want to make sure that we can provide care for
those who are more severely ill, and he gets back to
the discussion a little earlier about the role of
social distancing and community mitigation.
We are trying to flatten that curve and I think now
everybody has heard that term, it's a household word
now, but to put it another way, if you are, say,
running a hospital and you need to admit 100 patients
over a one week period, that might overwhelm the
system.
But if it is 100 patients over a two month period, that
might be something that can be handled very, very well.
>> Thank you.
Another question, that asks do we know what the
aftereffects are for those who are infected?
Is this like the flu, once it is over or do we have
lasting effects?
>> Well, that's a great question and it's a great
question because that is one of the ones we are
exploring also.
The context of our discussion today, it is important to
keep in mind that we are talking about a disease and a
virus that was unknown to us only three months ago.
We were all getting ready for the holidays and COVID-19
was not in our vocabulary.
Those of us in health care new of coronaviruses but we
only knew of six and now we have 1/7 that we have had
to learn about very quickly.
So at this point in time we don't have a lot of
information.
What information we have is mostly what has come out of
China which has seen the most cases occurring the
longest time back.
So far it appears that many people do recover
completely, although some may have persistent cough
primarily.
So again not everyone who develops the infection costs,
but some who do and develop more severe respiratory
tract symptoms sometimes have a persistent cough
afterwards.
>> Will there be any guidance from the CDC provided to
states regarding limitations to travel across states?
>> Yes, that's also a very good question because it
sounds like that is somebody who has looked at the CDC
travel alert page which traditionally focuses on
international travel.
Currently the recommendations are very broad with an
increasing number of countries to which we recommend
all nonessential travel be deferred.
Really globally we recommend anyone who is at higher
risk of infection to further travel until a later date.
And the third thing that I want to make sure is very
clear, we also recommend that no one should go on
cruises right now.
The industry is actually in the process of suspending
cruises although there are still a couple of dozen
ships that are at sea with people on board, including
Americans.
In terms of domestic travel, our recommendation right
now is primarily where we talk about how to stay well
if you are at higher risk, and those of the people who
are older, have underlying conditions, and we recommend
that as much as possible you stay home.
Limit your interaction with other people, and that
would also certainly apply to getting on an airplane
which can oftentimes be a crowded situation and flying
to another part of the country.
Is also very important to know what other
recommendations and sometimes even regulations that
have been passed on an emergency basis at your point of
destination.
A number of jurisdictions are now requiring people who
come in from other parts of the country to self
quarantine at home for a period of 14 days and not
return just straight back to work.
>> Will you please discuss current and future testing
capacity?
>> Yes, testing capacity is an area where there has
been progress.
I mentioned earlier the number of state public health
labs that are now up and running with the CDC test,
into many of those actually have been able to clear
backlogs and are turning around test results fairly
rapidly.
We really appreciate the volume of tests that the
commercial labs are able to do.
That is a big heavy lift that is helping in this
response.
They are using some other methodologies but as far as
we know these are going to be good results.
There is a bit of the backlog in some of the commercial
labs, so we are hearing of instances where the test
results from commercial labs are taking a few days to
return.
We have also been told that that backlog should be
cleared fairly soon.
The other areas regarding diagnostic testing where CDC
has been involved is making the virus isolate available
to people in the commercial sector to be able to
develop new tests, and I think the ultimate goal is to
move past the PCR-based technology which is fairly high
tech and is harder to perform in smaller and more
remote locations, and I think the ultimate goal would
be a test that might function more like a rapid flu
test that could be in your health care provider's
office.
We are not there yet but I know there are many people
who recognize that that is a very high priority.
One of the challenges, though, and I think this is
impacting all of us is that after some of the initial
challenges we had with re reagents at CDC we next moved
into the next age of complications when many of the
reagents as well as the supplies to run the tests began
to become in short supply as the global supply chain
has been limited.
So I know that is frustrating for all of us and there
was a lot of smart people thinking about how do we best
address these problems so that the diagnosis can be
confirmed.
And I think that is particularly important in areas
that have not had widespread transmission of the virus
yet.
In some places you have probably seen in the paper,
particularly in urban areas where there has been a
number of cases, oftentimes providers and public health
are moving more to a syndrome surveillance where cases
are identified based on the symptoms.
The caveat and that is I will say we I still learning
what some of the symptoms of this infection are.
>> Could you explain more thoroughly the term and
shedding the virus?
Do particles remain airborne for long?
>> Another great question.
So shedding basically means that the virus is in
secretions and are potentially infectious.
The way we can assess that are a couple of different
ways.
One is using the diagnostic PCR, but the caution I
would offer there is the PCR, polymerase chain
reaction, detects the viral RNA.
It does not tell us whether or not the virus is
actually capable of infecting another person.
What is probably more predictive of the risk of
transmission is actually recovery of the virus through
viral cultures.
That is more labor-intensive and actually takes a lot
longer to get the results back, but it suggests that
the peak level based on the data we have so far, the
peak infectiousness is probably very early in the
course of the illness, and then we also have concerns
that there may be a period of infectiousness prior to
the onset of symptoms which makes the control of the
infection through diagnosis and quick isolation or
quarantine much more challenging.
And this may account in part for how we have seen a
fairly rapid spread of this virus around the globe.
In terms of survival in the environment, there is two
lines of evidence.
One is what can we do in the laboratory under ideal
conditions, and then what are we seeing in real-world
conditions.
In the laboratory we can make the virus survive on
surfaces if the temperature is just right and the
humidity is just right and the surface is just right.
We can aerosolize it into the air if the conditions are
just right, but the primary mode of transition is
probably respiratory droplets meaning when I cost or
sneeze I make a spray which has the virus in it and be
able to pass on to somebody was near me, generally
within a range of about six feet.
It also suggests that I could contaminate surfaces, and
it seems reasonable based on what we would observe so
far as well as experience with other coronaviruses to
say that these contaminated surfaces may play a role as
well.
That's why when we talk about control measures there is
such a focus on if you are sick, stay home, wash your
hands for 20 seconds with soap and water or use an
alcohol-based hand cleaner with at least 60 percent
alcohol, cover costs and sneezes and wipe down surfaces
with commonly available household disinfectants.
One question we get quite a bit is what about things
like mail or products that are sent around the world.
Even though in the laboratory virus can be detected on
things like paper and cardboard, we are not seeing a
lot of evidence of that from the real world.
Otherwise I think we would've seen a lot more instances
of the infection popping up in remote areas far away
from China back in January, whereas when the infection
was primarily in China we were mostly seeing cases that
occurred in travelers coming out of China or in their
household contacts, people who had fairly intensive
exposure with people who returned home and subsequently
became sick.
That's why early in the response we had so much focus
on travelers and restricting travel to be able to slow
the entry of the virus into the US and around the
world.
>> What can we do to support and help our farmers who
are actively engaged in spring planting?
>> Yes, in terms of the actual act of spring planting I
think that is actually a very good example of a work
activity, as I think back on number of years ago now
when I was working on a farm when I was an
undergraduate student on Monday, Wednesday, Friday, and
Saturday I mostly spent my time on a tractor hauling
hay.
That is the kind of activity that should be able to
continue because it is not so hard to social distance
as it might be in an office.
Clearly it is also an activity where teleworking is not
going to put the seed in the ground.
The measures that can be taken is to avoid a lot of
interpersonal contact when you come back and off the
field.
And also do everything you can to make hand hygiene
possible ideally with water and soap, but if that is
not available an alcohol-based hand cleaner.
>> We are hearing a lot in the news about shortages of
supplies and rural providers and hospitals, clinics,
FQHCs often having even more of a shortage in terms of
workforce and actual supplies that are needed.
Can you speak to more rural specific suggestions?
>> Yes, and I think toilet paper is in short supply
everywhere, urban or rural.
But the issue of shortages of critical supplies such as
medications, such as personal protective equipment for
health care settings, and particularly for our FH QCs,
the federally qualified health centers is an area of
concern.
This is where the national response I think is going to
be very helpful in terms of the work that is going on
at FEMA in partnership with HHS, the Department of
Health and Human Services, to be able to look at
alternative supply chains to get some of that personal
protective equipment out, and also us working with HRSA
to be able to do everything we can to support the FQHCs
to not only have supplies but also be able to manage
the potential increase in patients as well as apply
good infection control practices particularly when PPE
may come into short supply.
CDC's particular role in terms of PPE is addressing the
demand side of the equation.
What are the things we can do to help preserve PPE.
We've got a couple of tools online that I think can be
useful to clinics and hospitals, whether they are rural
or urban, to be able to assess the PPE burn rate and to
be able to project what their needs are going to be
down the road.
The response through the assistant secretary of
preparedness and response is focused more on the supply
side and ways to supplement what is available including
being able to provide what provisions are available
through the strategic National stockpile.
>> Great, thank you.
What should rural hospitals and clinics be doing to
prepare for research?
>> Preparedness is a very important part of all of this
now that we are actually in response mode.
Almost all hospitals have done some type of pandemic
influenza planning exercise and they actually have a
plan that is written out.
Of course they say plans are no good if they just sit
on the shelf, so I hope everybody who is running these
hospitals has had a chance to pull their plans,
pulldown their plans and think about what they learned
during pre-pandemic tabletop exercises, and then how
they will do with some of the unique aspects of this
particular pandemic.
Some of those unique aspects include health care
workers who are unable to come to work because of
school closures and lack of child care for their
families, and then of course the concern that health
care workers themselves can become ill and not only do
we want to make sure that health care workers are
healthy and able to keep working, but also that they
don't then become a mode of transmission to high-risk
patients.
>> Thank you.
How come Nutella difference between flu, COVID-19, and
allergies because allergies are still active in a lot
of areas.
>> Yes, there is a lot of overlap.
Let me start with that and of course with COVID-19 it
is a brand-new disease so we are still learning a lot
about it.
Flu and COVID-19 probably have the most overlap because
fever, cough, muscle aching, headache, can be prominent
parts of both.
Allergies generally don't cause fever but I have also
talked to a number of patients who had very little
fever with COVID-19, or it was not the first symptom.
So it's I think virtually impossible to anybody who
walks in the door complaining of a runny nose to say
for sure which is allergy, which is influenza, which is
COVID-19, but we continue to learn more about it.
I know there is some reports now about things like
altered sense of smell or a funny taste in the mouth
being more common with COVID-19.
I think at this point in time those are really
anecdotal reports and they are intriguing and certainly
merit more study, but we have no idea how predictive
those types of symptoms might be for COVID-19.
>> Thank you.
Since we are more rural and spreadout are we at less
risk?
>> That's a very good question and it depends on more
on your local environment then say your county
environment.
So if you are in a county with only two people per
every square mile, that's a good start, but if you were
in a household that has say 20 people in it, your risk
may be similar to what it might be in a more urban
area.
I think in general we will see slower entry into
particularly the frontier areas because of lower
volumes of traffic, but it's important to look at
history and what we have learned from that.
When we consider the flu pandemic of 1918, before we
even had air travel, that was an infection that spread
far and wide and by November 1918, after the virus
first was fairly prominent on the East Coast of the
United States in September, it had spread even as far
as the Seward Peninsula in far western Alaska.
So I think it is reasonable to assume that while the
entry into rural areas may be lower and it may be
easier to do some social distancing because of the
lower population, we should not assume that any part of
the country is going to be spared.
>> Thank you.
Do we think this will go away during the summer, during
warmer temperatures?
>> The question about seasonality is one that I think
we always -- we would like to think it's going to go
away, but it's important that -- we can hope for the
best but we have to be prepared for the worst.
It gets back to our opening discussion about this is a
brand-new disease and a virus, and while most
respiratory viruses are less common in the summer, we
don't know just how this one will behave.
>> Thank you.
So for rural providers should they be keeping
well-child appointments, physicals, etc.
?
>> The decision of keeping -- I will call them elective
visits -- it really depends on the local situation.
And it's concerning because we know that there are
women who are pregnant now, they are still going to
deliver.
We know there are people with high blood pressure who
still need to have their blood pressure checked, we
know there are people with diabetes who still need to
have their diabetes managed, and we know also that we
want to keep our kids healthy.
So being able to have those well-child checks and get
on time immunizations is critically important.
So it really is a decision that will ultimately be
decided locally.
Just very broadly our recommendation from the CDC is to
consider deferring nonemergent procedures or elective
surgeries or visits to a provider, but just when to do
that depends on the local situation because we don't
want to do think so early that then things that are not
emergent become emergent by the time we are seeing a
lot of spread of the virus locally.
>> Thank you.
How should providers, hospitals, and clinics respond if
patients called and reporting exposure or symptoms?
>> First of all that's what you want to have happen,
have people call ahead rather than show up and maybe
sit in the waiting room for a little while and they
come back and say they have been coughing and have
fever and particularly if they have been around someone
known to have COVID-19.
So that call ahead is important.
For clinics and hospitals, they need to have a plan for
how will you assess those people and also make a
determination of whether or not they need to come in at
all.
There is a tool available that CDC has provided online
that allows someone to check their symptoms and
determine whether or not it is important that they get
into see a provider right away.
But of course someone who is severely ill, short of
breath, chest pain, blue lips, these are symptoms of
potentially a very serious condition which might be
COVID-19.
That's a situation where a phone call is nice but the
phone call that needs to be made is really to 911.
>> Thank you.
There were some questions about language clarification
around isolation versus quarantine, what does it mean
to self isolate versus a Florentine and what should
people be doing and not doing when they either self
isolate herself quarantine.
>> Okay, let's start with the definitions.
I know this is confusing because many people use these
terms interchangeably and they actually have technical
meanings and there is a reason why they are different
words.
Quarantine means you are removing people who have been
exposed to an infection from those who have not been
exposed.
So both groups are not ill.
Isolation is when you have someone who is known to be
infected and you are separating them from people who
are not known to be infected.
So usually in the hospital that is very common, whether
it be actually an infectious disease or even just
something that is grown out in culture.
Quarantine is much less common.
In fact the COVID-19 outbreak is the first time there
have been federal quarantine orders signed in over 50
years.
So we really are in a very unusual situation.
In terms of do's and don'ts, I think do as much as
possible but you have been asked to do.
In both instances you need to try and minimize your
contact with other people, particularly in situations
of isolation because those other situations where we
can be quite confident that there is a high likelihood
of infectiousness for someone who has documented
COVID-19 and who has symptoms.
Some of the other things that can be done is making
sure that people have enough food, that they have other
medications, the things they need to continue life
until either they have recovered or are through the 14
day quarantine period.
This is an example of how we have to be together as
much as possible even though it may be done at a
distance.
So if you have a neighbor, check on them by phone
ideally, or just a knock on the door and take a few
steps back from the door to see how they are doing.
It's also an opportunity for particularly supporting
older people are particularly people in isolation that
we don't really want them to be going out to the
grocery store to be able to get food and basic supplies
to them.
This is a role that I have observed that many
faith-based organizations have taken on in terms of how
they can do leg ministry, particularly with her younger
people who are at lower risk, and taking appropriate
steps to prevent the risk of transmission of infection
but also making sure that people who are in quarantine
or isolation are getting what they need.
>> Great, thank you.
Many rural communities have seen the hospital's close
or decrease the number of services or amount of
services they are able to provide.
What are your suggestions for those communities were
out of a hospital has closed are they not providing a
full range of services?
>> This actually points out a larger issue of the
things that were challenging for us in rural and
frontier areas when it is sunny and 70 degrees have not
gone away, and things like hospital closures and lack
of access to care are only worse during a time like
this.
So this is where planning, if you are not get impacted
in terms of how people might be transported or how they
might get care is critically important.
Sometimes if the hospital is cut back or even if it has
closed, if the building can still be occupied there may
be opportunities to reopen to at least provide low
levels of care.
If there is a volunteer staff that could be made
available.
I don't know of rural examples of that yet but that
actually did happen in Chicago where a hospital that
had closed a number of months the back was actually
able to reopen to provide care for people who were
relatively mildly ill but unable to take care of
themselves at home.
>> What are your suggestions for rural communities
regarding setting up isolation and quarantine spaces?
>> The thoughts on isolation and quarantine is ideally
to be able to do it at home, particularly people who
are infectious or potentially infectious can be
separated from those at higher risk.
Beyond that it comes down to what resources you have in
terms of where people can be housed.
The issue of mass housing is I think always problematic
in a situation like this, while after a tornado or an
earthquake people might be housed in a gymnasium and
fairly close together, that's not a good option during
a pandemic, particularly for isolation of people who
are actually actively ill.
So it's going to depend on what is available locally.
>> Great.
We have a bunch of questions about testing.
Where would providers, hospitals, or health clinics in
rural areas get testing kits.
>> The providers would not get testing kits, and I
think this is where the term kit is misleading.
Going back to when we started using it in describing
what was being provided to state health departments.
The current PCR technology, when we were using the term
kits, it was basically a package of reagents and
certain supplies that could test anywhere from 400 up
to 1000 people.
So it's not like a home pregnancy test kit or a rapid
flu test, something that can be done in anybody's
office.
It's actually a fairly high tech procedure.
As the FDA has worked to approve a broader range of the
nucleic acid amplification tests and things like PCR,
that has helped to push it out further, but still in
general these are going to be tests that are mainly
available either in state public health labs, large
commercial labs, larger hospitals, and sometimes in
larger clinics.
So that's why earlier I was saying that I think what we
are all really hoping for as soon as possible is
something more like that rapid assay that can be done
in the provider's office.
Right now providers have a couple of options.
One is to work through the local or state health
department to get specimens to the state lab, or to
work with the commercial providers that they work with
who also many of them are now running the assays as
well.
>> Can anyone get tested if they want to or should we
be prioritizing certain groups for testing?
>> The CDC has put out some guidelines for
prioritization recognizing that the global supply of
some of the reagents and equipment are in fairly short
supply.
The people that we would recommend prioritizing our
people at higher risk of severe illness, people who are
hospitalized so appropriate infection control
procedures can be in place, and then also health care
providers because we want to make sure that no one who
is sick and potentially infectious is taking care of
patients and potentially exposing larger numbers of
people.
In general if the test -- in some areas the testing is
more available than in others, but we do recommend it
be limited to people who are actually experiencing
symptoms of infection because we really don't know what
the meaning of a test is in someone without symptoms.
A negative test in particular doesn't tell us anything
and we would be concerned that someone might feel an
unreasonable sense of safety because they may still be
in the incubation period and the results of that
negative test in the face of limited resources for
testing may not be very helpful.
>> You have talked about rapid testing.
What's involved in actually getting tested and when are
the results available at this point?
>> We have changed those guidelines as we have learned
more about the results that we are getting with the
assays.
Now it is a single swab, it is what we called a
nasopharyngeal swab or and NG swab which involves
passing the swab back through the nose, literally
almost as far back as it will go although we are
getting more and more data that it can also go back
just an inch or two and we might be able to get good
results as well.
It's actually a very safe procedure.
I once did over 500 of them in a rural Alaskan village
in one day, so it's not very time-consuming and the
testing -- the swab goes into a viral transport media
or some type of vial and then goes to a laboratory.
The turnaround time after that depends on a couple of
factors such as shipping time and whether or not the
lab has caught up on any backlogs.
Here at CDC we can do the extractions in about 4 to 6
hours and usually running the assay is just a few hours
after that.
There are some newer high throughput technologies that
can provide more rapid results as well, so I think
there was a lot of progress made in terms of being able
to increase the throughput and get more timely results,
but it's still not all the way out in the providers'
hands.
>> Great, thank you.
There is some questions about when people if they are
sick with COVID-19, or they have been exposed, whenever
they no longer contagious, when can they go back to
work.
>> Yes, we are still learning a bit about that and this
gets back to the earlier question about viral shedding.
The PCR will remain or can remain positive in some
people even after recovery.
The data on actual recovery of the virus suggests that
it's much lower than that.
Currently the guidelines provide two options.
One is to get two swabs 24 hours apart that are
negative, and again this is after a positive test, this
is not just any nose that walked in off the street.
Some of the challenges in getting tested is that it
would be at least three days after recovery of
symptoms, particularly fever, and at least seven days
after onset of illness.
The one provision in all of that is if someone is a
health care provider, because it is possible they would
still be shedding virus although less since they would
not be coughing or sneezing, they should wear a mask
when they return to work.
In that situation the mask is not to protect person
wearing it but rather to protect the people they are in
contact with.
And for any health care providers who were listening,
it is now more than ever hand hygiene is important, so
20 minutes -- sorry, 20 seconds with soap and water or
using an alcohol-based gel.
I de-recognize if you are seeing patients all day, soap
and water that many times can be pretty hard on the
hands and lead to a lot of chapping, so fortunately
there are a lot of products out there that will help
protect your skin and also do an appropriate
disinfection.
>> Can people be reinfected if they have been exposed
or been ill or do we think that they would be immune?
>> Again it is a brand-new disease and virus and so we
are still learning.
What we know about the common coronaviruses, and this
is a family of about four coronaviruses that causes
cold symptoms, there is an immune response for a period
of time but there is a risk of reinfection down the
road, usually a period of years and not weeks.
At this point in time we are learning about the immune
response to infection.
There is an antibody response and that also opens up
some doors for how we might assess better how this
infection spreads and what is the spectrum of illness
that it causes, but we really don't know for sure if
people can become reinfected or when that risk of
reinfection may occur.
At this point in time we really don't have documented
instances of reinfection.
There have been reports of people who are PCR positive
and then PCR negative, PCR positive again.
But we really don't know exactly what that means
because as we were talking about earlier, the PCR
detects the RNA, the genetic material of the virus, and
does not necessarily tell us what is present is
infectious virus itself.
>> You mentioned masks, should hospitals and clinics be
stocking up on mask and should people be using masks?
>> Hospital situations are different and to be very
blunt, if you can get it it's a good idea to get it.
But a lot of the PPE is a very short supply right now,
so it's important that whenever PPE is available that
it is managed very carefully because we know again
getting back to some of these global supply chain
issues it can be depleted and then we are going to have
to be talking about what are some of the next best
options to be able to protect our health care workers.
In a health care setting the focus has primarily been
on filtration masks, things like the N 95 and that is
particularly important with something that will ever so
lies the virus, like a procedure that involves
respiratory secretion, probably even suctioning a
patient on a ventilator.
In terms of what might be useful in the community, in
general CDC has no firm guidelines on that one way or
the other.
There is not a lot of evidence that wearing a mask in
the community provides any additional protection over
just basic hand hygiene, and I don't think I have
mentioned trying to keep your hands away from your face
but that is part of how you get back if your hands are
infected that can be part of how the virus gets into
your body and causes the infection.
There may be a role for people who are exposed or who
are in recovery to wear masks, again not to protect
themselves but to protect those around them.
And that is an area where we are doing some very active
research and there may be newer guidelines coming out.
Having said that I think even though we have touched on
this a few times, it's important to recognize this is a
new disease.
We are learning as we go.
It's very humbling as we recognize that sometimes what
we learned two weeks ago, we learn something new and
the recommendations may need to change.
So I really encourage you as much as possible, keep an
eye on what is coming out either from your state health
department website or at CDC dot gov COVID-19.
>> The next question is about treatment or management.
Does [can't understand] help as treatment or
prophylaxis for frontline health care providers per
Jeff let me start with a very broad statement.
Currently there are no proven medications that will
treat COVID-19 and that have documented improvement in
outcomes.
Let me start actually with hydroxychloroquine, the
generic name, there are some mostly uncontrolled data
coming out that are encouraging.
The nice thing about hydroxychloroquine is it actually
is FDA approved for other purposes, mostly treating
different types of autoimmune or rheumatic diseases
such as psoriasis.
So it is available.
There is not a lot of really hard data for treatment
yet and we are working very closely with NIH to develop
guidelines and be able to gather whatever data is
available, particularly from China where there has been
more experience with this.
Chloroquinoline is another drug that is fairly readily
available.
Last data as well.
There is an antiviral drug called [can't understand]
which is not approved for any purpose right now but is
in randomized clinical trials right now particularly
for treatment of more severe infections.
And we hope to have data on that soon because some of
those trial started in China nearly 2 months ago.
There has been at least one fairly large trial
completed and mostly data that is coming out of China
again about some of the protease inhibitors, the class
of drugs used for treating HIV, Le Pen of fear and
ritonavir combination.
Unfortunately they are fairly disappointing in terms of
documenting there was improvement in symptoms or
outcome and actually there was no evidence that it
reduced viral shedding.
So I think this is an area where we have to monitor the
science closely and hopefully we will know more soon,
but at this point in time there is no proven treatment
that's going to make outcomes better.
The question about prophylaxis is a very good one
because I think many of us are familiar with that with
where we were at in 2009 with the influenza pandemic.
We had time of year and antiviral drug that was useful
for treating exposures or critical infrastructure
individuals prior to the onset of symptoms to prevent
infection, there is basically no data on that with
COVID-19 at this time.
>> To cyber profit exacerbate symptoms of COVID-19?
>> Think for asking that question too because I know
that is come up based on some reports that came out of
France.
Those were really anecdotal reports and have not been
observed as much elsewhere.
So at this point in time we have no recommendations
against the use of ibuprofen or other nonsteroidal
anti-inflammatory drugs.
>> We have received several questions about smoking and
tobacco use.
So either sharing of tobacco products increasing risk
of transmission, people who are trying to quit are
becoming potentially more anxious and maybe smoking
more or relapsing -- what recommendations would you
have for somebody has quit to stay in that status.
>> Let's start with the question about sharing
cigarettes or whatever.
In general sharing anything that goes into your mouth
is probably not a great idea, but it's an even worse
idea right now.
It certainly could be a way that COVID-19 is
transmitted.
In terms of a question that I think many of us are
looking at the data very closely about is whether or
not cigarette smoking itself is a risk factor for more
severe infection.
What's really intriguing is the epidemiology from China
where the death rates among older individuals are much
higher, but they are much higher among men than among
women.
And the smoking rates among men in China are quite
high, whereas among women they are much lower.
And so certainly one of the hypotheses is that there
may be a very particular role that cigarette smoking is
playing in increasing the risk of severe COVID-19.
So I think the bottom line there is maybe more for
providers is we need to do everything we can to be able
to support people who have ceased smoking, to be able
to prevent restarting smoking.
And this also I think highlights that these are
stressful times and there are ways other than using
tobacco that can be useful to manage stress.
>> We have a couple of minutes but we still have a
couple of questions on prevention.
What can community members do, churches, restaurants,
civic leaders, people in the community, what can they
be doing right now?
A couple of areas.
First of all we have talked about social distancing,
that is very important.
To be able to as I say stand together but at least six
feet apart because it's going to take a community
response to be able to address this.
Being able to limit or postpone gatherings is
important.
I saw kind of an amusing picture of a wedding that was
held outdoors and there was actually a grid on the
ground where all of the participants stood at least six
feet apart.
I think the groom did get to kiss the bride, but other
than that no one was in contact with anyone else.
Although in general it is probably better to postpone
any kind of gathering like that.
The impact on small businesses and restaurants cannot
be underestimated.
If you are able to support your restaurants that are
providing take out services, a number of them actually
now have donations, ways to be able to help their
employees that may currently not be getting paid.
That's important.
And I think as we were discussing earlier, know your
neighbor and find out if they have particular needs
because there's a lot we can do remotely and even with
minimal face to face contact to be able to help one
another through these difficult times.
>> Great.
Thank you so much, Dr.
Butler.
We at CDC hope that this information has been helpful
to our rural partners and stakeholders.
You can continue to send questions to rural health at
CDC dot gov, that is a mailbox that we monitor
regularly.
And with that we will close this call.
Thank you.
>> Thank you everyone.