The Round Barn: Coronavirus: Is It Safe To Leave the House?
Dr. Ashley Mitek: Hey, Jim. Did you hear the news?
Dr. Jim Lowe: Hi, Ashley. What news?
Mitek: The University is sending students home to prevent the coronavirus from spreading.
Lowe: Ah. Yes, I did. #FlattenTheCurve.
Mitek: #FlattenTheCurve? Jim, I didn't know you were a tweeter!
Lowe: I've been called worse.
Mitek: Hi, I'm Ashley Mitek, and by now you've probably heard about the suspension of face-to-face classes at colleges; the cancellation of conferences, music events, and even the NBA season; and, of course, the saddest part of it all: Pearl Jam canceled their tour. Today, I'm talking with Jim Lowe from the University of Illinois to discuss the measures that are being taken to prevent the spread of the novel coronavirus, and the thinking behind these strategies.
Welcome to The Round Barn.
Just so everyone's aware, we're recording this on Thursday, March 12th, and things are changing rapidly, so stay tuned for any updates.
So, Jim, let's get started. Many universities, including ours, have announced they're canceling in-person classes, and other events with large gatherings have also been canceled. Does this make any sense?
Lowe: Well, Ashley, it's a challenge, right, because we don't have a vaccine, the virus is spreading rapidly -- we are in an epidemic -- and so, we are trying to flatten the epidemic curve. We're trying to have fewer cases.
Mitek: What do you mean by flatten the epidemic curve?
Lowe: That's the fancy medical term we use when we think about new cases. And so, we tend to track the number of new cases per day. The last week, it's been going up very rapidly. And so, if you think about putting the number of cases per day on a chart, and just drawing a line graph, we're going up. It tends to go up, and then at some point, we run out of infected people or infected animals in the world you and I live in every day, and then the number of new cases starts to drop every day. So, it's kind of like a mountain. You go up the mountain and then you come down the mountain. The goal with all of these strategies is to make the mountain a little shorter.
We're not going to stop this disease. The genie is clearly out of the bottle. It's moving around. So, the challenge now, as we talked last time on one of these podcasts, is how do we minimize its impact? And that really means, how do I have fewer total cases? Even if I don't change the number, how do I make those cases occur over a longer period of time so I don't overwhelm the healthcare system and really put a lot of pressure on highly at-risk populations? They were just talking this morning on the news that the case fatality rate in people over 80 is higher than it is in people over 60, and etc, etc. So, how do we protect -- we've seen the mess in Seattle in the nursing home, which unfortunately is probably what is to be expected. You put a novel disease in a group that's probably not very immunocompetent, in a really close location with a lot of contact, and you're going to see a massive outbreak, and unfortunately a high rate of mortality, much higher than other cases.
And so, all of these things we're doing are all designed to lower that. My favorite term is social distancing.
Mitek: That means we shouldn't be sitting as close as we are now.
Lowe: Yeah, one meter we have to stay apart. So, those people that are huggers, this is going to be really hard for them.
Mitek: No hugging, no kissing.
Lowe: That's right. So, all those challenges. And so, we think about that, and why does the nursing home become a problem? Well, if you need help in bed, or you need help getting out of bed, well, social distancing is obviously a problem, because I need to touch to get you out of bed and to help you with that. So, we're just trying to minimize that impact. And all of this is, how do we decrease the chance of contact between infecteds and susceptibles? And really, how do we minimize the contact between infecteds and really vulnerable?
Mitek: So, that's why the universities have come out and said, "We're going to essentially cancel classes or switch to an online environment," and essentially now, we're trying to minimize those interactions. But I guess the question is, is that really going to benefit us as a community? Or is it just sending the disease back to wherever they're from?
Lowe: I think the interesting bit is -- so, we're sitting in Champaign, Illinois, and we haven't had any reported cases in the community yet. I think the emphasis is reported cases. We haven't tested anybody that's positive in the area yet. That doesn't mean we don't have any infections. But I think the real thought is that we're heading into spring break season. If you look at all these universities that are stopping class being taught in person, it's all associated with spring break. So, we're going to send people from this campus all over, and then bring them back. So, the fear is, we live in a community of 100,000 people, and so all of a sudden, we bring 50,000 students back -- or whatever the number of those that are traveling. It wouldn't be all of them, obviously, but some percentage. So, do we put our community at risk, that we live in? And do we put them at risk? Because it's really commingling, it's this mixing. We take it from all over the place and bring them back.
So, I think if we were post-spring break and this was happening, we might see a different response, because, "Well, they're already here, so let's not send them off into the wild." But because they're going to go into the wild, because we're in this spot that they're going to leave, I think it does make some sense not to bring them back and put them at risk and put the community at risk, etc.
Mitek: One of the questions that our college is getting asked a lot is, can dogs and other pets get COVID-19? And we've been trying really hard to educate the public not to panic about this; that there is no evidence that dogs can become sick from this disease and that they can spread it to humans. How do we combat what seems to be now a panic state of this virus -- everybody thinking they're going to get this virus, and it has a very high potential mortality rate, compared to the flu at least? What should be the right message of panic level to the public right now?
Lowe: The human mind is an interesting thing, isn't it? Right? We talk about this, and we kill -- well, "we kill," that's the wrong word. We have tens of thousands of people that die from influenza. Influenza kills tens of thousands of people a year. And that doesn't make the news. This makes the news because it's new and we talk about it. So, as an infectious disease person, it's really easy to be a bit cynical and say, "Yeah, this is what we'd expect, and it's not that big a deal." But that's really good as long as you’re not the one who dies, right? The mortality rate's really low, but if you're the one who dies, or someone who's really important to you dies ... So, I think those are the challenges.
I think there's been some messaging challenges because we haven't been able to test as much as we'd like to. We really don't know the number of infections. There are probably tens or hundreds or thousands more infections than we've reported as cases. Cases are basically what we've tested positive. We know there are people who are asymptomatically affected, or very mildly affected, and they didn't get tested, and those aren't getting reported, etc, etc. So, the actual percentage of people who are dying of those that are infected is much, much, much lower, several orders of magnitude lower, than what's happening. But there are still mortalities, and there's still concern, and because we don't have a great control strategy, that's become the challenge.
Having dealt with this on the livestock side -- which is obviously a whole lot less important than a human pandemic -- we dealt with a novel disease introduction in pig populations here in 2013, 2014. It was a pandemic within the pigs. It spread across to all the pigs in the country with relatively high mortality rates. And we're talking about African swine fever coming to the U.S. I mean, it's the same conversation. You see the same behavior with those groups that are affected. Panic sets in, and we really start to make what are probably some irrational decisions. And so, we've talked about all these movements. We put travel bans in, and blah, blah, blah. We put a travel ban in last night with Europe for 30 days. Whether that's reasonable or not is way, way above my paygrade.
Mitek: Is that what you would do with pigs in this type of situation?
Lowe: Yeah, absolutely. It's so much easier in our world because we would just say, "We're going to quit moving things."
Mitek: You can just shut down the pig farm and say, "Nothing in."
Lowe: We'd shut down the pig farm and say, "Nothing comes in, nothing comes out, or the things that are going out only go to harvest." It's obviously easy to do that with livestock -- well, it's not perfectly easy with livestock, but there aren't all the moral and ethical issues around that. And so, one of the challenges in the country we live in, we can't make those big edicts and say, "No one goes anywhere, anytime." Not only are there economic consequences, right, but we do live in America, and we have a Constitution, and we have personal freedoms and those things. And those things are really, really important. So, how I would just scientifically line up my head and say, "We need to go do X, Y, and Z," we know those tools work. We're going to quit moving anything, we're going to go to strict disinfection. We wouldn't let people come in and out of a pig farm without taking a shower and changing their clothes. If I ask you, "Hey, you can't come to work without taking a shower and changing your clothes when you come in. You have to wear the clothes of the company, the University, when you're here," that's going to be a, "No, not doing that."
We know the hyper-effective tools that work when they're implemented aren't really practical in this case, aren't within our ethics and values. And so, we have to try some of these other things, in terms of, let's not have people go to class, let's not have people at meetings, let's stop travel, how do we have meetings virtually?
Mitek: It seems like the two biggest things that we really can do at this point is to prevent people movement, or exposure to large crowds, or commingling; and then also just basic common sense of wash your hands type thing. Is there anything else in that message to the communities that are going to be affected by this, of what they can do?
Lowe: I think we have to prioritize, right? If we have high-risk individuals -- people who are older or people who have underlying health conditions, or both; and unfortunately, those go together often -- we need to put a lot of extra emphasis around those folks, and say, how do we really do outreach, and how do we do improved infection control, hand hygiene, around those kinds of folks? So, we're closing nursing homes and communities and that kind of stuff. And there's been some uproar. But that makes a tremendous amount of sense. Let's not expose people who the outcome is likely to be much worse for.
I think the other thing is that we do need the message that most of the people that are infected, nothing happens. You and I are of reasonable health and reasonable age, and so we're probably not a huge risk, and so we probably need to wash our hands and go on with our day. Now, we need to be smart. We don't need to get on an airplane and fly to China, or fly to Italy, where these other hotspots are. I'm not suggesting that. But our lives need to go on.
And then, I think the third bit, this really comes out of what I see when we work with pig farms. Just let me take the analogy a bit. When we have desperate economic situations, we tend to make decisions that are a bit of a disaster for disease management. Because when there's significant economic pressure, we do what's in our self-interest in the short term, not what's in the community interest in the long term. So, I think that's the other spot. I mean, as I'm thinking about, what can we do differently, people are going to be affected economically. That's why it's important you and I continue to go to the store and shop and drive the economy. Because if we start closing stores, people who are living paycheck to paycheck, don't have a job, they're going to start to make some decisions that aren't necessarily good for the rest of us. And so, I think there's this underlying economic toll we've got to think about. How do we not put people in decisions that they have a choice of bad and worse?
Mitek: Sure, that makes sense. You talked about the infection rate, or, that from the standpoint of you and me, this virus -- knock on wood -- hopefully isn't going to be that detrimental to our health. The German Prime Minister just predicted that the infection rate there could reach 70%. Is there a difference between being infected and then having the disease?
Lowe: That's really a key component when we think about this. When we think about cases, we typically are talking about those that got infected and they didn't clear the infection. So, they have a disease event after that. So, just like the common cold that goes around every year -- and this is not the common cold, but -- you and I may be in the same room, and my wife had a cold here two or three weeks ago. It went on for weeks, it seemed like, like everybody's cold has gone this year. I never had a sniffle out of this. I felt bad maybe for 24 hours, but I cleared it, right? I was probably infected, but not diseased, because my immune system kicked it out. I'd seen it before, or whatever. She was not, and she got disease.
That's really what's going on with this. We're going to have a lot of people that are infected. They see the virus, their immune system deals with it, they move on. And there are other people who see it and their immune system doesn't get rid of it right away, and now they're going to end up having disease. They're going to be sick.
And so, I think when Angela Merkel is talking about a 70% infection rate, she's really talking about the number of people who are going to see the virus and clear the virus; not the number of people that are going to actually have -- 70% of Germany is not going to get sick. I would predict that. If you just look at epidemic theory, it's probably going to be a lot higher than 70%. At some point over the next couple of years, right, we're probably all going to see the virus because we all commingle and we all move around. But we're not all going to get diseased.
Mitek: Let's talk about testing here for a little bit, which I feel like is a hot topic also in the media, because there seem to be some issues with, do we have enough tests available? Are we going to have to ration the tests? And who gets priority to be tested? So, can you talk a little bit about, why is it important to test, and how are we going to use that as an asset to control this?
Lowe: Let's just go to our fantasyland -- ideally, we would test all over the United States all the time, somewhat regularly.
Mitek: Random population sampling?
Lowe: Random population sampling. Because what I really want to know in an outbreak is, where's the disease? Where's the virus at, in this case? So, where's the pathogen at, and where is it moving?
Mitek: Why do you need to test people? Why couldn't you just test all the doorknobs in the grocery store or something like that?
Lowe: We could sample doorknobs. That's exactly right. We just need samples globally. Now, there's diversity and sensitivity, but what you're really asking there is, where's the virus? Because if I know where the virus is, then I'm going to design my limited movement orders, or, "Hey, don't go here," to stop the spread. That's the idea.
So, why didn't we do that, is the question. Well, this is like any new disease -- we didn't have a test. So, we had to make a test. Then we had to make sure the test worked. And then we had to get the test to labs. Then we had to train those labs to get all those bits to happen. And if I look at novel disease introductions in the animal world, where we're less regulated, it's not a human disease -- and for good reason, we're less regulated -- we can gear up pretty quickly, but ... We do a lot of testing. We deal with a lot of infectious disease. We submit samples for infectious diseases all the time. This is not a human thing. We don't have infectious disease routinely in the U.S., so we don't sample and test aggressively. We sample and test really aggressively, particularly in the livestock world. And even us, we can't gear up that fast, and we have this existing lab infrastructure. So, there's some real limitations on scaling up a test, and scaling up a test that works, and scaling up a test that gives you accurate results. Because if I test you and it comes back positive, and that's a false positive, that's detrimental to you, right? Because now you're going to be quarantined, you're going to think, "Oh my God, I'm going to die!" or whatever. So, we want a test it's accurate. So, there's some gear-up bits.
So then you really have to start making the hard choices of, who should I test and who should I not test? And their strategy has been, in a really limited testing availability, available lab capacity, to test those that are diseased to know where they're at. It's above my paygrade to decide if that was the right strategy. I mean, conceptually, I would have done some different things, but I don't fully understand the limitations that they've had. There's certainly been a tremendous amount of criticism in the press about what's gone with testing. I think no matter what they did, they were going to get criticized. And I'm sure if you ask them, would they tweak it, would they do it different another time, sure. I'm sure they would. Hindsight is 20-20. But ideally, we like to know where the infection's at, and we just haven't had the testing resources to get that done.
Mitek: What's the endgame here? What's the goal, if you're in charge of this outbreak in the U.S.? Is it just, we want to eradicate this thing? Or control it?
Lowe: Well, we'd love to eradicate it, but that's not going to happen. The genie's out of the bottle. So, we're really in this idea of flattening the curve. How do we have fewer cases or extend those cases? If we think about controlling mortality, and we see what's happened in Italy -- and that's a good healthcare system, right? I mean, that's not some backwards, non-industrialized country that doesn't have anything going on. No, this is a modern healthcare system that would be well-respected. They just overwhelmed it. They didn't stop transmission. They appeared to be aggressive, but it wasn't aggressive enough. It really got out of control. Which is what happens when you first get outbreaks of diseases in regions, right? I mean, you don't fully get your head around it, and it's hard to be aggressive. I get it. We do it all the time, so I'm not being critical. That's just a fact of what happened. So now, that's overwhelmed the healthcare system. They don't have enough ventilators for the people that need them. So, I think goal one is, how do we not overwhelm the healthcare system at once?
Mitek: And that goes back to flattening the curve, trying to prolong this.
Lowe: That goes back to flattening the curve. And then, how do we really focus on protecting those that are most likely to die? Because if you're just going to get sick, and you miss a couple of days at work, and I've got to prioritize that against someone who's going to die, we need to shift our resources, which are limited, to protect those that are really going to die. This is much like influenza. How do we protect the vulnerable? That's really what we're going to have to focus on. It's a "suck less" program, for lack of a better term.
Mitek: Where do vaccines fall into us controlling this?
Lowe: I think that's where we're going to really get ahead in control. But, as we've talked previously, that's not going to happen tomorrow. Vaccines are hard. We don't want to put a vaccine out there that doesn't work. We don't want to put a vaccine out there that's not safe. Really, that's a big issue, right? Safety first. We don't want to do any harm. And so, we've got to get a vaccine built. They're working day and night on that. We've got really, really smart people working on that. I just continue to be impressed, as you read the stories -- I'm a nerd, so I sit around and read over the scientific literature -- the stuff they've done in the last two months is mind-boggling. There are really, really smart people working really, really hard on this. But it still only goes so fast.
Mitek: It's going to and take us 1.5 to 2 years.
Lowe: It's going to take us 1.5 to 2 years before we get mass distribution of a vaccine. But that will slow it down, and that'll help. And probably at some time, the virus will burn itself out. We'll get herd immunity. We'll get everybody immune enough that the probability of contact between an infected and a susceptible drops low enough that every infected person creates less than one new infection, and that's the end of the outbreak.
Mitek: So, that's the end of when we would start to be in this panic phase -- not that we should be in a panic phase right now, but that's the question. When is this over? It's over when we have herd immunity. Is that the right way to think of it?
Lowe: That's exactly right. What we don't know is, when are we going to get herd immunity? If I knew the answer to that, I'm sure I would be a multimillionaire and not sitting here. I'd be flying around on my own private jet, right?
Mitek: Can I go with you?
Lowe: Yes. You can sit in the back, Ashley. Yes.
Lowe: But, I mean, that's where we'd be at, because if you knew that amount of information ahead of time, that'd be really critical for these decision-makers. We started this talking about, we've closed all the colleges, and now we're going to have to bring students back, open them back up. That's a pig term, so that's horrible, I shouldn't be using it. But, when are we going to decide to open classes --
Mitek: Why is "open back up" a pig term?
Lowe: Well, I close the herd. Then I'm going to open the herd to movements again.
Mitek: I see.
Lowe: Well, this isn't a herd, this is a college campus, and we have students. But we're going to have to make a decision one day to say, "Nope, we're going to have in-person classes again." When do you do that? Ideally, that would be at the end of the epidemic. So, if I knew that, that'd be really cool. I would predict, if you look at every other infectious disease -- and this is just pattern recognition of what's happened with other ones -- respiratory diseases tend to get better in the summer. We have sunlight. The virus doesn't survive outside the host quite as well, outside a person quite as well. We're all outside, we open the windows, yada yada yada. We're not inside, hanging on doorknobs, etc. It'll probably get better this summer, regardless of what we do.
Mitek: We should go film these podcasts in Florida or Cancun.
Lowe: Yes, very much. Yes, that's exactly right. We should be doing all of these podcasts near the equator.
Mitek: OK. I'll put a request in.
Lowe: Preferably with a Mai Tai, that would just make this better. But, no, I think it's going to get warmer, right? It'll get better. And then the question is, did we get enough herd immunity so when we all come back inside next fall, do we see another burp? Do we see another bump in the epidemic curve? I don't know that. Nobody knows that. And I think that's why everybody's trying to really be aggressive now, to say, "Can we control this thing enough that we don't go through another increase, another epidemic curve, come winter again?"
Mitek: Alright. Thank you, Jim, for all that information. Here's to flattening the curve in the future.
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