In this episode, Dr. Joe Cotterill talks about the coronavirus outbreak in the United States, and why it's so bad. He also talks about how we got here, and what we can do to prevent it from happening in the first place. Guests: Dr. Tom Frieden, infectious disease epidemiologist at Johns Hopkins University; Dr. Michael Hyatt, pediatric infectious disease physician at Columbia University Medical Center; and Dr. Robert Krieger, a professor of infectious disease at the University of Toronto. Thanks to caller Joe, and thanks to Dr. Hotez, and to everyone else who reached out to us about the outbreak. Thanks also to our sponsor, Vevolution, for sponsoring this episode and for helping us cover it. Thank you so much to everyone who has been so generous with their support, and thank you for all the people who have been sharing their stories, and who have shared their knowledge and support. We can't wait to do more of these episodes, and we hope you'll join us in coming back next week for our next episode. This episode was produced and edited by Alex Blumberg, who is a regular contributor to the New York Times, and a good friend of the show. The opinions expressed in this episode are our own, and are not related to any of the ones we mentioned in the episode. Thank you, Joe. . Joe, Joe, thank you Joe, we really appreciate you. , and we really really appreciate the support you've given us the chance to do this episode. We really appreciate all of this. And we really well, and it's a lot of work you've done for us. Cheers, Joe and Sarah, Sarah, and I appreciate you, too, Sarah. and we're looking forward to seeing you back in the next episode, too. - Thank you Joe and we'll see you next week. -- Thank you for listening to this episode of the podcast, Sarah and Joe, too! - Tom and Joe and much more! - Sarah, too much, Sarah -- thank you, Sarah & Joe, much more, and so much so much, and much, much love you, Thank you all of you, much appreciate you! -- Your support is so much more. Love you, bye, bye. xoxo, bye - MRS. XO.
00:00:12.000Yeah, as I was saying, when I tried to start wearing a regular tie for a while, it was like when Dylan started switching to electric instruments at the Newport Folk Festival, and there were just cries of outrage, so I had to...
00:00:24.000What kind of cries of outrage are you getting about your bow tie?
00:02:05.000The Rolling Stones to do a concert to bring the economy back to Toronto in 2003. And then it was Mayer's coronavirus infection in 2012, and this is the third one.
00:02:16.000So we actually realized that coronaviruses were going to become a new thing, and we embarked on a big coronavirus vaccine program a decade ago.
00:02:26.000And each time they've caused devastating hospital epidemics, they've affected healthcare workers, so The point is this unfortunately has become a new normal for the globe is terrible coronavirus epidemics and we saw this one coming up in the end of 2019 in China and I knew we were in for trouble because that's what coronaviruses do.
00:02:51.000So you knew that we were going to be in trouble because there was no way they can contain it and keep it in China?
00:02:58.000Well, the difference with this one compared to the other two was this.
00:03:02.000The other two, SARS and MERS, now we call this new one SARS-2.
00:03:07.000So there was SARS-1, then MERS, then SARS-2.
00:03:09.000So both SARS-1 and MERS... Made you so sick and had such a high case fatality rate that anybody who got it was almost immediately hospitalized and basically out of the community.
00:03:23.000The difference with this one, ironically, is it's pretty lethal.
00:03:28.000It's about five to ten times more lethal than regular flu, seasonal flu.
00:03:33.000But also, there's a big group of people who don't get very sick at all.
00:03:38.000And so you have this sort of perfect mix where it's not the most lethal infection we've ever seen.
00:03:45.000It's not the most transmissible infection we've ever seen, but it's high enough in both categories that it combines in this very toxic way.
00:03:53.000So what you have is you have a group of people who are getting very sick or in the intensive care unit like older people those with diabetes and hypertension even a group of younger people who are getting it very sick and then a larger group who are only getting mildly sick who can still walk around the community and be out and about in stores and restaurants and infecting everybody and so this is what's caused the problem it's highly transmissible and there's a big group of people
00:04:23.000walking around spreading it And a smaller subset but a big subset who are getting very sick and even dying in intensive care units.
00:04:31.000So that's what's playing out in New York City right now for instance.
00:04:34.000Do we know why so many people are asymptomatic?
00:04:40.000There's a rough correlation with age, so younger people seem to do better and actually kids seem to do really well with this infection.
00:04:49.000They don't get, with one exception that I'll tell you about in a minute, most kids don't get very sick at all but they're helping with the community spread and we don't quite know why.
00:05:00.000Also, but something that's very important and one of the reasons why I really wanted to come on and talk to you about COVID There's this buzz out there in the community that it's only old people that are getting sick and dying and going to ICUs.
00:05:16.000But in fact, the Centers for Disease Control came out with this very chilling document a few weeks ago showing that about a third of the very sick people in the hospital are under the age of 40 or 44. So between 20 and 44 young adults are getting very sick and that word has not gotten out adequately because when the disinfection first appeared in central China it was all about older individuals over the age of 70,
00:05:43.000those with diabetes and hypertension and we didn't hear about the young adults But then for reasons that we don't understand, we saw this big group in Italy and France and Spain of younger adults, and we're seeing that play out in the U.S. And I know the people who listen to you and watch you,
00:06:01.000it's a big group between that age of 20 and 44, and they really need to hear that they're at risk for severe illness, despite what they might have heard previously.
00:06:09.000Well, we have a friend, Michael Yeo, who was actually on a podcast with me the week before he went to New York.
00:06:59.000So there's been a lot of buzz on the internet about ibuprofen and then the World Health Organization came out with a specific statement saying those are rumors.
00:07:08.000So there's not a lot of evidence to say that you get worse with ibuprofen.
00:07:12.000Probably he was just One of those young adults that's going to get very sick, and that's what this virus does.
00:07:18.000It has the ability to get deep into the pulmonary system in your lungs, binds to receptors on the cells of your lungs, and causes a terrible pneumonia, and on top of it you get a big inflammatory response.
00:07:32.000So severe pneumonia can even prevent your ability to breathe, and that's why so many people who are getting really sick with this virus have to go on respirators.
00:07:42.000That's exactly what happened to Michael.
00:08:00.000And what is the concern with ibuprofen?
00:08:02.000And then you've got the problem, you know, some people, you know, Also say don't take aspirin, because if this is a respiratory virus infection, there could be a severe reaction with aspirin as well.
00:08:14.000So for now, you know, and I say the other thing, Joe, is anything we say today...
00:08:21.000I might look like the biggest idiot in the world tomorrow or next week, and that's because this is a brand new virus and we've never seen before, right?
00:08:31.000So we're learning new things about this virus every day.
00:08:34.000So that's why, you know, so many things I'm going to say today, if I sound like I'm waffling or hedging, it's because I am.
00:08:42.000We're learning so much that's new about this virus.
00:08:45.000So it's really important that everybody be really mindful and pay attention to real health information from accurate sources because things move, things change as we learn more about this.
00:08:58.000This is a virus that we didn't even know existed.
00:09:01.000About four months ago, and we've learned about it in an incredible period of time.
00:09:06.000The Chinese put up a lot of information on these preprint servers about what the virus is, what the sequence is, the genetic code, what the receptor binds to.
00:09:16.000When we had the original SARS, we call this new one SARS-2, the disease is called COVID-19, the virus is called SARS-2, SARS-Coronavirus-2.
00:09:26.000When we had the original SARS-1, It took us over a year to learn all that information.
00:09:31.000Now everything's been compressed in a few weeks, so it's really extraordinary, but there's still so much we're learning right now.
00:09:38.000I'm so glad you brought that up because that is really important for people to understand, people that maybe haven't looked into the complications that are involved in trying to recognize treatments and cures for a virus, that everyone's learning.
00:09:53.000Yeah, and also, you know, and everything we have known so far about the virus is what happened in China.
00:09:59.000And it turns out the Chinese have some genetic differences to Europeans and Americans, and things can change depending on, it's not just the pathogen, it's also what we call the host, the person too.
00:10:12.000So the fact, you know, that the virus affected young adults in Europe and the U.S. in a way that Did not necessarily occur in China is important.
00:10:23.000And then who knows what happens when this virus goes into Latin America or India or Sub-Saharan Africa.
00:10:29.000And it's not because the virus is mutating necessarily, it's just that there's also the host component as well, which is quite important.
00:10:37.000Well, that's one of the issues that people are having in terms of blood type.
00:10:42.000There's all this talk of certain blood types may be more susceptible to the virus, particularly blood type A. Well, actually, this is actually well known in the infectious disease literature.
00:10:55.000I put one up on Twitter, I think, a week or so ago.
00:10:58.000There's dozens of different pathogens, including viruses and bacteria, that behave differently depending on a person's blood type.
00:11:07.000So host genetics influences things quite a bit.
00:11:12.000Now, let's talk about Germany, because I found that really fascinating when I was reading on Germany and their low mortality rate.
00:11:23.000Is that the extraordinary healthcare they have there, or what is that?
00:11:30.000Well, let me give you first the opposite side of the coin, and then we'll talk about Germany.
00:11:34.000So the opposite side of the coin, what's happening in Italy and Spain, 10% mortality.
00:11:40.00010% of the people who are being diagnosed with COVID-19 have died, which is higher than just about anywhere else.
00:11:49.000I think what's happened there is when the health system gets so overwhelmed...
00:11:56.000In other words, if transmission goes on for a long time and you haven't picked it up, and then all of a sudden people start showing up in the ICU, then it's too late.
00:12:06.000Then you start having massive numbers of people come into the ICU. The hospital can't take care of everybody.
00:12:13.000They can't give everyone the highest quality care possible.
00:12:16.000It's no fault of the doctors and nurses.
00:12:18.000They're heroes, but the fact that they're completely overwhelmed with patients, that's when mortality starts to Really rise.
00:12:27.000So we saw this in parts of Wuhan, and we saw this in Italy, and that was the big worry about New York, that the same thing would happen to New York, but I'll hold that thought for a second.
00:12:36.000In Germany, so far, we think it's a combination of that it's been more younger people getting it.
00:12:42.000And the fact that the hospital system was getting ready and they've got that infrastructure in place to manage that surge, although they're worried now, too, that it may start going up and overwhelming things.
00:12:55.000And then you look at, okay, so if that's true, what's the story on the mortality rate in the United States?
00:13:00.000And interestingly, so far, one of the highest has been New Orleans.
00:13:05.000And I think what happened there was they kept the Mardi Gras open, they had lots of mixing, and large numbers of people getting infected.
00:13:14.000Number one, it overwhelmed the health system, just like in Italy.
00:13:18.000So in New Orleans, right now, the case fatality rate is between 4 and 5. But there's another factor going on in New Orleans, lots of people living in extreme poverty.
00:13:29.000And poverty is very linked to diabetes and hypertension.
00:13:33.000And we know diabetes and hypertension is a big risk factor for death.
00:15:12.000And could that be linked somehow to all the young adults that we're seeing In the United States who are getting hospitalized.
00:15:20.000They actually don't have higher mortality, but they're still getting very sick and their lives are being saved because they're being intubated and put on the vent.
00:15:31.000It's something that's going to have to be looked at.
00:15:33.000Boy, there's going to be a lot to unravel when all this is over.
00:15:37.000And along the way, people are dealing with a lot of misinformation, which is one of the reasons, one of many reasons why I'm so thankful for you for coming on the podcast and trying to educate us on this thing.
00:15:49.000Yeah, that's the reason I've been going on...
00:15:53.000In between, I co-lead a team with my 20-year science partner, Dr. Marilena Bottazzi.
00:16:00.000We develop vaccines, including coronavirus vaccines.
00:16:04.000We're trying to get those out the door in clinical trials.
00:16:06.000In between, I'm going on Fox News, MSNBC, and CNN. That's not an easy needle to thread either, going on Fox News, MSNBC, and CNN. That's been really interesting, but I love the opportunity.
00:16:22.000And I'm doing it because there's a lot of bullshit out there.
00:16:25.000There's a lot of misinformation trying to get accurate information and also explaining the science behind it.
00:16:31.000Because sometimes you hear something that doesn't sound right, and it sometimes takes a couple of minutes to explain that.
00:16:36.000And those three cable news networks have been great about giving me some time to explain the thinking behind it, which they ordinarily wouldn't do.
00:16:55.000And what went horribly wrong with the couple that took the wrong kind of chloroquine and turned out to be a koi pond cleaner?
00:17:04.000Okay, so let me give you the framework for that so it makes some sense.
00:17:09.000When we talk about all the interventions, you have things that are going to be ready down the line, things that are going to be ready a little closer, and things ready now.
00:17:17.000And then we can talk about one-on-one.
00:17:20.000Let me give you the framework, then I'll answer your chloroquine question.
00:17:25.000So the highest bar there is in terms of financial investment required and time to show safety is a vaccine.
00:17:32.000So that's what we're doing and other groups are doing.
00:17:36.000Next tier down, that's going to be, you know, a year, 18 months away, according to Dr. Fauci.
00:17:43.000Next tier down are what we call small molecule drugs, new drugs that have never been discovered before.
00:17:49.000Still takes a while, maybe not as high a bar as vaccine in terms of time.
00:17:54.000The next tier down is repurposing Existing medicines that we already know are relatively safe, and then showing that those drugs also work against the coronavirus.
00:18:07.000And that's going to be the chloroquine category, and I'll get to your question.
00:18:10.000And then the nearest ones, the one that we could do now, is what's called this convalescent antibody therapy, which I've been pushing very hard on because I think we can actually have it going right now.
00:19:09.000We know it can cause arrhythmias in some patients and other toxicities, but it generally has a pretty good safety profile.
00:19:17.000We know that this drug can block the replication of the virus in the test tube, so it inhibits the virus.
00:19:26.000What we call in vitro in the test tube.
00:19:28.000Second, we know this drug reduces inflammation.
00:19:31.000And that's nice because one of the things you get with COVID-19 pneumonia is you not only get the virus infection in the lung, you got a lot of inflammation.
00:19:39.000So it checks a couple of boxes in terms of why it's attractive to look at it.
00:19:43.000And then the Chinese did a small study.
00:19:45.000And then a colleague of mine is a fascinating guy.
00:19:49.000I really appreciate his work as a scientist.
00:19:54.000He's a very serious scientist in Marseille, in France, named Didier Raoult.
00:20:00.000I don't know, it must have published at least two or three dozen papers in the journal that I found it called PLOS Neglected Tropical Diseases.
00:20:07.000He's a serious scientist, works on all sorts of intracellular bacteria and that kind of thing, tick-borne diseases, did a small study showing that it worked in COVID patients.
00:20:16.000And what he did was he combined hydroxychloroquine with I'm not sure that's going to turn out to be the case.
00:20:36.000I mean, we really need to do large studies to show that it really works.
00:20:40.000And the reason I'm holding back Is, you know, nothing to do with Dr. Professor Raul, who's a really important scientist, but it's a small study.
00:20:49.000We were there about a decade ago with influenza, that this hydroxychloroquine also inhibited the influenza virus in the test tube, but then it didn't pan out in larger clinical studies.
00:21:02.000So I think we have to be really careful and don't Be too quick to say, okay, this is going to be it.
00:21:09.000We're not even close to that yet, but we'll know in the next few weeks because we're working hard to scale up clinical trials looking at that medicine.
00:21:23.000There is something new, though, that we can do right now that I'll talk to you about.
00:21:29.000So this is something called convalescent antibody therapy, and it was It's been known for over a hundred years and it was really scaled up during the 1918 influenza pandemic, you know, that terrible pandemic that killed hundreds,
00:21:49.000It was shown that if you took individuals who had recovered from the disease, who had got infected, they survived, they had antibodies in their blood, you could remove their blood, in some cases give them back their red cells, and take the plasma component and use that as a therapy to treat patients.
00:22:07.000And in fact, during the 2003 SARS epidemic, the first SARS, SARS-1, There's been a number of studies showing that it worked.
00:22:17.000Actually, you could treat patients for it Especially if you gave it early on in the course of the infection.
00:22:24.000If you waited too long, then it didn't have nearly the same benefit.
00:22:28.000But if you gave it early on in the course of infection, it could prevent more serious infection and even death, because you're actually giving back antibodies.
00:22:35.000The antibodies won't last forever, but enough to help you survive the infection.
00:22:39.000So, a good friend and colleague who I've known for a long time, Arturo Casa Duval, who's a brilliant professor of microbiology at Johns Hopkins, He started talking to me about, you know, Peter, maybe we should be doing this for COVID-19.
00:22:57.000And as the numbers started going up, I called him.
00:23:01.000I said, look, Arturo, I'm going on CNN tomorrow, I think this is an opportunity to tell people about this.
00:23:10.000So I helped amplify what he was doing.
00:23:14.000He had written a paper with a colleague from Johns Hopkins, I always get her, I always mangle her name, Profosky at Albert Einstein.
00:23:25.000I talked to them about this and that really got things moving along so I've been trying to use my voice on you know being on CNN and Fox News and it's not just to hear myself talk but to actually raise specific issues to get people to care about certain things and I used it for this purpose and I think it helped to mobilize some action and now what Arturo and his colleagues are doing together with the FDA so there's a branch of the Food and Drug Administration We're good to go.
00:24:08.000I've been talking with Dr. Peter Marks, who's the head of CBER, and he's teamed up with Arturo to get this network together going, at least among 20 academic health centers, so that they're identifying patients who recovered, taking their blood,
00:24:25.000giving them back the red cells, collecting the plasma, so that when people come in sick, They can give treatment, and they'll have some clinical trial results, I hope, in the next few weeks, but I'm really optimistic about that one for saving lives.
00:24:38.000The other thing Arturo's talked to me about is, you know, could you use it in smaller doses to give the antibody to healthcare workers and to first responders to prevent them from getting sick?
00:24:50.000Because you're hearing, I mean, I don't know the percentage now of first responders in New York, and that's why they turned the Empire State Building into a siren last night, and And to honor all of the first responders who have gotten sick.
00:25:06.000So I think that's going to be really important as well.
00:25:08.000Now, the French government, I was reading an article this morning that they've sanctioned chloroquine as an official treatment, and they're having some good results with that.
00:25:17.000Are people currently using that in the United States?
00:25:20.000Are doctors prescribing that with CPAC? There's a lot of what's called off-label use, meaning that it's not an improved indication, but they're going ahead and use it.
00:25:29.000And maybe it'll turn out to be a good treatment, but...
00:26:29.000If you remember in 2014, there was a terrible Ebola epidemic in West Africa, affected 33,000 people, 11,000 people died.
00:26:38.000That was in Guinea, Liberia, and Sierra Leone.
00:26:41.000And there were some initial vaccine trials started by Merck and company that looked pretty promising.
00:26:47.000They had licensed the technology from the Canadians, this group in Manitoba, Public Health Canada, and it looked promising.
00:26:55.000But as the trials got underway, what happened was there was an international response to put in a health system, because it turns out Ebola is not very transmissible.
00:27:04.000You just have to have some healthcare infrastructure, make certain that you're not directly handling the corpse of someone who's recently died from Ebola virus infection.
00:27:15.000And we even sent in the 101st Airborne.
00:27:19.000We sent in the Screaming Eagles, which made a big impact on helping to save West Africa from this infection.
00:27:28.000So the WHO came in, there was UNICEF, there was Doctors Without Borders, the Israeli Army came in, the Israeli Defense Force came in, a lot of groups came in to help West Africa.
00:27:41.000And so the vaccine never really got fully tested before.
00:27:45.000But then five years later, when there was the terrible epidemic in Democratic Republic of Congo, that's when the vaccine really came into widespread use.
00:27:54.000And it's probably one of the most important public health stories never told, which was under conditions of terrible conflict and war and political strife and Civil war, they vaccinated 200,000 people with this vaccine and it largely helped eliminate Ebola from Democratic Republic of Congo in that during those hostilities last year and essentially saved,
00:28:24.000I think it's helped to stabilize the whole African continent.
00:28:55.000for a vaccine just to give people a sense of perspective.
00:28:59.000Peter, one of the things that I was reading about Wuhan is that there was an NPR article recently that was talking about people testing positive after they had tested negative, where they had tested negative and then a time period had gone by and then they had tested positive again.
00:29:15.000Are we learning, obviously we're learning about this as a new virus, but is it possible that this is something you can recatch in a short period of time, like within a few months?
00:29:25.000Or do you think that these people had false negatives?
00:29:30.000I think there's a high likelihood that they're not getting reinfected once they develop antibodies, but we don't know for sure.
00:29:37.000The problem with respiratory virus testing is this, and it turns out even before those three big pandemic coronavirus I was talking to you about, we've known about coronaviruses for even longer than that because kids get a lot of upper respiratory infections with these other type of coronaviruses that rarely cause We're good to go.
00:30:19.000And we have all these odd results, like kids with no symptoms at all are testing positive, and then kids with symptoms are testing positive and negative.
00:30:29.000And it turns out diagnosing respiratory virus pathogens is not easy.
00:30:34.000It takes a lot of time to do the quality control and really figure out all the testing.
00:30:39.000And the Gates Foundation has a A very significant respiratory virus pathogens program, which has been looking into this for a few years now, not necessarily for coronavirus, but for other respiratory viruses and other respiratory pathogens.
00:30:54.000It's not as straightforward to diagnose respiratory infections as it is, say, for things that are in the blood, because a lot of these respiratory viruses never get actually blood-borne.
00:31:07.000So you're sampling mucus from the nose or your washings from the mouth or the throat.
00:31:14.000There's probably inconsistency in the sampling.
00:31:18.000And I think that may have been partly responsible for the delays.
00:31:24.000The CDC trying to work it out and get it perfect, and it just took longer than perhaps they expected.
00:31:31.000Peter, is the possible silver lining to this cloud that this is a wake-up call for people to really take serious the funding of vaccines, the funding for pandemic research, to make sure that we never let something like this ever happen again?
00:31:50.000But then again, we said this after SARS in 2003. We said it after H1N1 in 2009. We said it after MERS in 2012. Right, but nothing's ever shut down the country like this.
00:32:02.000But the point is, after every pandemic, everyone says, oh, now we're going to put some infrastructure in place.
00:32:08.000And the truth is, things are better now than they were.
00:32:12.000So after SARS in 2003, they implemented this set of international health regulations, IHR 2005, and a lot of that was led by a friend and colleague of mine, David Heyman, who's now at the London School of Hygiene and Tropical Medicine and with Chatham House in London.
00:32:31.000I think he was Assistant Director General of the WHO then.
00:32:34.000And they put that in place and a global health security agenda.
00:32:38.000Now we have this thing called CEPI, this Coalition for Epidemic Preparedness Innovation.
00:32:42.000So there's no question things are a little better, substantially better than they were, but it's still not enough.
00:32:51.000The infrastructure in place we need to rapidly accelerate vaccines because a lot of the times and I get involved in this because I've been devoted my whole life to developing vaccines for diseases nobody else will make vaccines for because there's no financial return and we've been doing this for parasitic disease vaccines and that's what we spoke about last time but also we've had this coronavirus vaccine program and the problem is The big industry partners,
00:33:20.000the multinationals, sometimes they get involved in this, sometimes they don't.
00:33:24.000This leaves it to, you know, smaller biotechs, which are mainly focused on accelerating their unique technologies, or this handful of nonprofits like ours at Texas Children's and Baylor College of Medicine.
00:33:37.000We call our Texas Children's Center for Vaccine Development at Baylor.
00:33:42.000College of Medicine, and it's a fragmented infrastructure, and we're always scrambling for funds.
00:33:49.000I mean, even now, when we've got two vaccines, we're ready to move on.
00:33:53.000I'm still spending I don't know how many hours a day on teleconferences, you know, with potential donors trying to get this out at clinical trials.
00:34:05.000Peter, I think we'd both agree this is a very different situation than SARS or MERS or any of those other things in that the entire U.S. economy is totally shut down.
00:34:15.000If anything is going to be a wake-up call for industry, if anything is going to be a wake-up call for people with money, this is going to be it because this is devastating for everybody.
00:35:03.000Doing teleconferences with Asia or Europe and going to bed with teleconferences with Asia trying to figure out how we're going to do our vaccine.
00:35:15.000We're making a unique vaccine that's a low-cost one that would be used not only in the US but globally.
00:35:21.000And then all the calls and everything else.
00:35:23.000And the one good thing is that I've stopped traveling.
00:35:50.000So it's, you know, we've got a group of scientists really dedicated, even though the labs are largely closed down at Baylor and Texas Children, we got special permission because they're working on the COVID vaccine.
00:36:00.000So they're coming in, this amazing dedicated group of scientists.
00:36:04.000And then I've been basically, you know, on teleconferences all the time.
00:36:09.000I I said to my wife, Ann, I said, I feel like I have to press star six just to talk to you.
00:36:20.000And I was going to the studio for a while, but now I'm just doing it from my Skype.
00:36:24.000So I have sort of this weird subterranean existence right now.
00:36:27.000I mean, the good news, you know, the people I feel so terrible for are those who, you know, now are not getting paychecks because of this crisis.
00:36:35.000And there's so many people suffering economic hardships.
00:36:40.000You know all the people who used to make my breakfast sandwich in the morning.
00:36:45.000They're presumably not getting a paycheck or all those things.
00:36:51.000The dry cleaners and all that kind of stuff.
00:36:53.000I feel so bad for them because I'm sure they don't have much of a safety net at all.
00:36:57.000No, there's never been a time where it's no one's fault, but half the country's out of work, at least.
00:37:05.000It's not like anybody did anything wrong.
00:37:09.000You could have showed up for work every day, worked hard, planned ahead, done all the things that you need to do to have a successful business, and all of a sudden the carpet gets pulled out from under you.
00:37:20.000We're hearing so many heartbreaking stories.
00:37:22.000I mean, the good news is, you know, the White House and Congress is the one thing they seem to be collaborating on is getting that stimulus package out there to people who need it.
00:37:34.000I hope there's some funds for those people.
00:37:39.000What's your take on Sweden and Sweden's, the way they're handling this, which is essentially they're giving people the freedom to go to restaurants and bars and they're shutting some things down but they're quite a bit more open than the rest of the world and subsequently they're experiencing a spike in cases.
00:37:59.000Yeah, I mean, the problem, again, is without a vaccine or other technologies, we have to go back to the 14th century.
00:38:08.000It was when ships would come into the harbor in Croatia and coming from Asia Minor, and they were fearful they were bringing plague, and they kept the ships for 40 days.
00:38:17.000That's where the word quarantine came from, and that's all we've got right now.
00:38:24.000Social distancing is probably our only hope, and there's a few pieces of evidence for that.
00:38:30.000I mean, it's real serious social distancing, not going to restaurants and things.
00:38:34.000My colleague, Mark Lipsitch, who's a brilliant epidemiologist at Harvard, has been doing a lot of analyses and modeling, and one of the things he's shown is that when he looks at the cities in China, for instance, where they did social distancing and other aggressive measures,
00:38:53.000And some of them were pretty aggressive that he couldn't even do in the United States.
00:38:57.000But he showed that the longer you allow transmission to go on before you intervene with social distancing and other things, the worse the surge and the worse the epidemic.
00:39:09.000And therefore, as we talked about in Italy, the worse the mortality.
00:39:12.000So, for instance, in Wuhan, Where he estimates, I forget the exact numbers, I think he found about six weeks of transmission going on before you intervene.
00:39:23.000It was a massive surge in hospital systems getting overwhelmed and a lot of healthcare workers getting sick.
00:39:28.000And I want to come back to that point after we finish this.
00:39:32.000As opposed to in southern China and other places in China where you intervened after a week.
00:39:38.000Then you got, you know, there was the difference between having 2,000 patients in your ICUs across the city versus 20. That's how the Dramatica difference.
00:39:47.000So that's a lesson we need to learn for the U.S. is it's the only thing we have and to really push hard on the social distancing.
00:39:56.000And I think it's especially important in the cities because it looks to me like what we're seeing so far in the U.S. is more of an urban slash suburban versus rural divide.
00:40:07.000We're seeing the big surges in ICU patients more in cities than rural areas.
00:40:12.000Although Dr. Fauci, I forget it was last night or the other night, said don't ignore the rural areas either because we don't know what's going to happen there.
00:40:19.000So social distancing is absolutely paramount.
00:40:23.000And unfortunately what's happening, because things got so fucked up with the testing, that we've often found out that transmission is going out for several weeks, only when a lot of ICU patients started hitting the door.
00:40:38.000So this is what happened in New Orleans, this is probably happening in Detroit.
00:40:42.000The mayor of Atlanta just said, you know, all of a sudden we've had all of these people show up in the ICU. So that's another lesson learned.
00:40:51.000We really, not only doing the diagnostic testing, but the social distancing is really important.
00:40:57.000And I've been on calls with the leadership of people in Houston because, you know, you're right, it's hurting the economy in so many ways.
00:41:07.000But, you know, if you want to prevent Houston from replicating the New Orleans experience, I've been saying to the mayor and everyone else in Houston, this is unfortunately what we're going to have to do.
00:41:36.000They do all these amazing things to look at the not only epidemic diseases, but also chronic non-communicable diseases, diabetes and heart disease and mental health issues.
00:41:48.000But they've been all hands on deck at this COVID epidemic and they've just put it out on their website.
00:41:53.000It's healthdata.org and you can go to the COVID-19 site and what they're showing is that they anticipate the peak of this epidemic in the US is going to hit about the middle of April so we're not even at the peak yet and so we're another two weeks of this is going to continue to go up and in some places like in Texas it's going to be delayed it's probably going to be around around May 2nd and I think California was was around there as well so Their numbers
00:42:24.000say it's going to be the next two months that are going to be the crunch time when it's going to start really going up.
00:42:30.000And then as we move into later in May, it'll start to go down and maybe really bottom out by June.
00:43:07.000I mean, let's take economics out of it.
00:43:11.000What would you think, if there was no concern whatsoever about economic loss and the damage to the economy, what would you recommend in terms of, just purely from a medical perspective?
00:43:24.000Well, the problem is from a medical and public health perspective, we don't really know where this virus is heading.
00:43:30.000I forget what Dr. Fauci said, the virus makes the decisions, we don't make the decisions.
00:43:35.000Although not entirely true, because we can enact intervention.
00:43:41.000So hopefully by the summer, this is not going to be a huge problem, but we don't know.
00:44:07.000Why would it go away and then come back in the fall?
00:44:11.000Well, there's a few things that are happening.
00:44:12.000One, all the social distancing potentially could interrupt the transmission.
00:44:17.000We use this number called the reproductive number, which describes the number of people that get infected if a single individual has it.
00:44:25.000So the number right now is between two and four, depending on whose numbers you look at.
00:44:29.000The idea is you bring that below one by the social distancing.
00:44:33.000There's also the question of whether there's seasonality to this virus.
00:44:38.000Again, this guy Mark Lipsitch has done some studies to show that the virus infection doesn't seem to be as severe in areas that have higher temperatures and greater humidity.
00:44:51.000It's a bit of a soft call, but maybe there's going to be some seasonality to this as well.
00:44:58.000And so let's use an example of another seasonal virus, influenza, which peaks, of course, in the winter and then goes down.
00:45:06.000In the summer months, it never really disappears, but it goes down.
00:45:11.000But then in the southern hemisphere, it's the opposite.
00:45:14.000So in the southern hemisphere, peak flu season is our summer, their winter in places like Australia.
00:45:20.000And then in the tropics, it's about the same all year round.
00:45:23.000So we don't really understand seasonality.
00:45:25.000Potentially, the virus could start showing a pattern like that.
00:45:30.000And then the question is, does it come back year after year after year like flu does?
00:45:38.000These are all scenarios that are being looked at.
00:45:40.000So for instance, our vaccine, if it's used and goes through all the clinical testing hurdles, probably is not going to be used for this 2020 epidemic.
00:45:50.000If it's used at all, it's going to be used in the out years if this virus starts to come back on a regular basis.
00:45:58.000Is there any other way to handle this in terms of quarantining or social distancing?
00:46:08.000Would it be possible to quarantine the people that are at most risk instead of the general population?
00:46:16.000Well, again, the problem gets to the fact that, you know, again, there's this idea that this is only among older Americans and people over the age of 70, diabetes, hypertension.
00:46:31.000But now, as the Center for Disease Control has been reporting, we've had this big flux of Young adults getting very sick and in the ICU. So at what point do you say pretty much everybody potentially is at risk?
00:46:44.000Then among the children, even though the children generally are children and adolescents seem to do pretty well with this virus, now we realize from studies coming out of China that was published in the journal called Pediatrics, put out by the American Academy of Pediatrics,
00:47:00.000about 10% of infants are getting very sick with this virus.
00:47:07.000Okay, older people, those underlying diabetes, hypertension, and younger adults, and 40- and 50-year-olds as well.
00:47:15.000And we're hearing all these stories on CNN and elsewhere about, you know, valued colleagues, you know, in their 50s and that kind of thing, getting really sick or even dying.
00:47:26.000And then infants, after a while, it's just, you can't slice it that fine.
00:47:37.000One of the things that's come up about this is people are now aware, people like myself, are aware of the number of people that die every year in the United States from the flu, which is staggering.
00:47:49.000It's a lot more than I ever thought before.
00:48:00.000And it varies year to year, different variants of the flu.
00:48:04.000So it usually goes between 12 and 50,000 people die every year of influenza.
00:48:09.000And the vast majority of those, by the way, are not vaccinated.
00:48:13.000So even in years where there's not a good match between the flu vaccine and the flu, it could still reduce your likelihood of hospitalization and death.
00:48:22.000So that's an important message to get out.
00:48:24.000The numbers here, unfortunately, are looking worse.
00:48:39.000So if you imagine a virus that has all of these different pieces to it and all the antibodies each reacting to a different piece of the virus, in a perfect match, all of the antibodies target the virus.
00:48:55.000In a less than perfect match, only some of the antibodies target.
00:49:34.000So if the minimum is 12,000 from flu, the minimum that's going to die from COVID-19 is around 50,000.
00:49:41.000And at the high end, times 10 could be between 500,000.
00:49:45.000So that's where you're hearing those numbers from the White House press conference saying maybe 100,000 to 200,000 Americans could die.
00:49:53.000I think it's probably, I like the Institute for Health Metrics numbers that just came out.
00:50:00.000They say 84,000 Americans will die in that peak season going from April, May, and June.
00:50:09.000But we don't know what will happen again in the out year.
00:50:12.000So the point is a lot of Americans are going to die.
00:50:15.000I'm hoping it doesn't get as high as 200,000.
00:50:18.000And again, the modelers are really looking at this.
00:50:21.000Those numbers that I gave you, that estimate was a sort of simplistic version.
00:50:25.000There's much more sophisticated models.
00:50:27.000But again, they're models based on assumptions.
00:50:30.000And with the new virus pathogen, it's hard to get all the assumptions right.
00:50:34.000But the point is, many more people will die of this virus than even in a bad flu season.
00:50:39.000I think people are concerned that this is kind of setting a precedent and that this is going to be something that we have to do in the future.
00:50:46.000Is there a way to prevent something like this, a full shutdown of the country, to happen in the future?
00:50:53.000Well, the way is, you know, we've got this incredible scientific infrastructure in America, right?
00:50:59.000The best research universities and institutes in the world.
00:51:03.000And I work at two of them, Baylor College of Medicine and Texas Children's Hospital.
00:51:08.000And now I'm doing a few things with Texas A&M University and Baylor University as well, and Rice.
00:51:20.000This is why we have an NIH with a budget of $36 billion annually.
00:51:28.000We need to have a pipeline of technologies getting ready for this epidemic.
00:51:35.000If we had all the funding we needed for our coronavirus vaccine program, we would have had several coronavirus vaccines and Clinical trials, and potentially we could have combined them in a way to be ready to go now.
00:51:49.000So figuring out a way to support organizations that are looking at vaccines and other countermeasures, not in terms of products they can sell, but that are going to help the health security of the country,
00:52:08.000So one of the books that I wrote is called Blue Marble Health, and it finds...
00:52:13.000This unusual, and we spoke a little bit about this last time, the unusual number of illnesses from emerging infections like this one and poverty-related and neglected diseases actually in the G20 countries.
00:52:28.000The G20 economies, the 20 wealthiest economies, especially the poor living in those, actually account for most of these diseases.
00:52:36.000And the problem is the G20 economies are not stepping up It seems one of the critical aspects of getting through this is having a strong immune system.
00:53:04.000What emphasis, if any, are you guys putting on developing techniques or at least educating people on how to strengthen their immune system and how to keep their body healthy?
00:53:18.000Certainly keeping the body healthy is key, right?
00:53:21.000One of the populations that this virus is devastating are those with Hypertension and underlying heart disease and actually we're learning this virus itself not only causes lung disease but heart disease as well so we could talk about that but you know keeping your you know keeping yourself healthy could make the difference between life or life or death but even in a healthy individual with a new virus pathogen and you've never seen before It takes time to train the immune
00:53:52.000system and then it's too late because the virus has already done incredible damage to your lungs.
00:54:15.000There's some genetic predisposition to it.
00:54:18.000But if you can keep your body healthy, that will definitely stack the deck in your favor.
00:54:22.000I was reading something about regular sauna use and viral infections and the diminished impact of viral infections on people who regularly use a sauna because of heat shock proteins and cytokines.
00:54:34.000Are you aware of anything that goes along those lines?
00:54:39.000Now, as far as yourself, I joked around about the fast food stuff, because we joked around about that last time you were here, but have you altered your approach to food because of this and diet?
00:54:53.000Well, I have, partly because I've been so upset and so anxious to eat.
00:54:59.000It's just been on teleconferences, and my wife will actually...
00:55:03.000We set up a little study here in our bedroom, and It's not much, but my wife will just bring me a plate of food and I'll just eat it and then whatever.
00:55:14.000I've been trying to eat a healthier diet and be more careful.
00:55:20.000My wife spends a lot of time trying to take care of me, but right now I've just been so upset about what I'm seeing, not only with people suffering in the hospital, but people economically put out of work.
00:55:33.000I'm so worried about All of these healthcare providers who are getting sick that, you know, I just don't even want to eat.
00:56:21.000And a lot of them are my former students, my medical students.
00:56:27.000And I remember, in medicine you have something called Match Day, where if you're a fourth year medical student, you open this envelope and figure out and you learn where you're going to do your residency, whether it's in internal medicine or surgery or...
00:56:41.000Ear, nose, and throat, or neurosurgery, or whatever.
00:56:44.000And, you know, a lot of the medical students would come and see me.
00:56:48.000Dr. Hotez, hey, where should I go to do residency?
00:56:50.000And a lot of them, I would say, you know, it's great spending some time in New York.
00:56:54.000You know, I did my MD and my PhD in New York.
00:56:58.000It's a great city, great medical centers, Mount Sinai, and Columbia, and Cornell, and NYU, and Einstein.
00:57:05.000It's fantastic to live in the city, and I'm really, what the hell did I send them into?
00:57:10.000They're there with inadequate protective equipment, scared as hell of getting sick or worse and being overwhelmed by patients.
00:57:22.000I think I said on, I forget what CNN or MSNBC or whatever, I feel like I sent them to hell, and feeling a lot of guilt for being so enthusiastic about Having them go to the hospitals in New York.
00:57:34.000Of course, you can never know what was going to happen, but that's been bothering me as well.
00:57:42.000This has been a very emotional time for me.
00:57:44.000The lack of sleep also has a big impact on the immune system.
00:57:49.000Oh yeah, it really sets up your immune system, no doubt about it.
00:57:53.000Now with you, is it simply just because of anxiety?
00:57:56.000Is it a lack of time to sleep properly?
00:58:00.000And have you looked into any sort of meditative practices or anything that can calm the mind and allow you to perhaps get a little bit more sleep, which would significantly probably improve your immune system?
00:58:11.000Well, one of the reasons is a practical matter because I've been doing some evening TV interviews and they're great opportunities because they reach such large audiences.
00:58:23.000I mean, I've been on everything from Chris Hayes to Tucker Carlson to Hannity and, you know, how many people do that, right?
00:58:31.000Going through the extremes on the political spectrum, but it's been a great opportunity.
00:58:36.000But I, you know, deliberately try to be on all those networks to show that I don't give a shit about the politics.
00:58:40.000This is about, you know, saving people's lives, and they've been great.
00:58:44.000So I don't want to lose that opportunity.
00:58:46.000But then I'm getting up, you know, early in the morning, either for teleconferences or, you know, do CNN New Day or American Newsroom with, you know, Sandra Smith and I'll never get a chance to talk to the country like that,
00:59:04.000although I do a little bit with Ebola and then with Zika.
00:59:11.000And it's also really important for Americans.
00:59:13.000To hear about scientists, because working scientists tend to be invisible in this country, and I have a paper I just put out in the Public Library of Science, and PLOS Biology, about how the fact that scientists are invisible and are enabling for anti-science movements to rise,
00:59:30.000and I blame part of it on our scientific profession that we're too quiet, so here I have this chance, so I'm trying to take advantage of that, but then I'm in teleconference after teleconference all day, you know, trying to get this vaccine vaccine So you can't even take a nap sometimes,
01:00:11.000Talk about that and what, if anything, can be done to try to heal those people post-infection.
01:00:17.000Well, so what happens is the virus gains entry into The deep passages of the lungs, you know, all the airway spaces.
01:00:27.000And then it has, if you ever see a cartoon, a schematic drawing of a coronavirus, it looks like a little ball with spikes sticking out of it.
01:00:35.000And those spikes are called the S protein.
01:00:38.000And actually, the vaccine that we're making interferes with the binding of a part of that S protein called the receptor binding node made for binding into the receptor.
01:00:47.000So it uses those spikes, the tip of the spikes, to get entry, to bind to the receptors in the lung, which is actually an enzyme called an acetylcholinesterase, and it gets into the lung cells.
01:00:59.000So the first thing that happens is a large amount of virus is getting into the lungs, and that triggers what's called the innate immune system, meaning your natural first-line body of defense.
01:01:11.000And it signals something called toll-like receptors, which cause a lot of inflammation.
01:01:17.000And so you're seeing a big inflammatory response to the virus.
01:01:22.000So the two components are a lot of virus causing direct damage, and then all the inflammatory response.
01:01:30.000And that's one of the reasons why, you know, when I heard about hydroxychloroquine, I had some enthusiasm, because it can maybe suppress the inflammatory component, whether it clinically has The ability to make a difference.
01:01:43.000So you've got those two things going on.
01:01:46.000The other thing that's happening, and that's causing severe lung disease, and there's all that inflammation, and it causes a condition known as ARDS, Acute Respiratory Distress Syndrome, where there's so much inflammation and scarring that it becomes difficult to oxygenate the lungs,
01:02:03.000and people go into shock because of this ARDS syndrome.
01:02:07.000So that's why a lot of people are dying.
01:02:09.000The other thing that happens, though, and we don't really understand the mechanism, is there's been a lot of reports.
01:02:15.000And by the way, anybody can download this.
01:02:17.000There's this fantastic preprint server called BioArchive and MedArchive.
01:02:22.000It's put up by Cold Spring Harbor Laboratories, and I check it every morning.
01:02:26.000It's called B-I-O-R-X-I-V-X. And MedArchive is M-E-D-R-X-I-V. It's put up by Cold Spring Harbor Laboratories.
01:02:34.000So scientists have been great about sharing information.
01:02:37.000They're putting all their stuff up on these preprint servers.
01:02:40.000They're not peer-reviewed yet, but just so we can get information into the hands of the scientists and anybody can look at them.
01:02:46.000But one of the other things we're seeing with that is a lot of heart injury, whether people are having heart attacks because they're intubated in the ICU and under stress and they're in shock so they're not perfusing the heart, Or, and we know that the old SARS virus,
01:03:03.000SARS-1, had the ability to go into the heart tissue and cause what's called myocarditis, actual infection of the heart.
01:03:10.000So it's really the heart and lungs that are getting knocked out.
01:03:14.000There's also some evidence that the virus can go into the intestinal tract as well, and so that could actually be a potential route of transmission, meaning fecal-oral transmission as well.
01:03:26.000So this is why People are getting so hammered is this direct damage from the virus and the inflammatory component to the heart and the lung.
01:03:35.000Is there any understanding of what, if anything, can be done to try to heal these people post-infection, particularly like damage to the lungs?
01:03:44.000Yeah, I think there's a question of whether steroids actually help or hurt.
01:03:49.000Steroids are always a mixed bag because steroids can suppress inflammation and help the inflammatory component.
01:03:56.000But they also suppress the immune response to the virus.
01:04:00.000So you can have an increased number of virus particles potentially.
01:04:05.000So people are definitely looking into steroids, other anti-inflammatory drugs.
01:04:11.000But those who survive this, and fortunately most do, you'll find that they'll probably tell you they've been hacking and coughing.
01:04:21.000For a long time afterwards, and a lot of that is, and we see this with flu as well, and other viral pneumonias, it's not because they're still infected with the virus, it's all that scarring.
01:04:31.000It takes the body a long time to remodel all the scar tissue before the coughing stops, so we can anticipate that happening as well.
01:04:41.000Do we think it's possible to fully recover from this for people that do experience these lung scarring issues?
01:04:47.000Yeah, I think so, especially for younger people.
01:04:50.000For older people, you know, they may have some permanent pulmonary deficits, but we don't know.
01:04:55.000It's still too early in this epidemic to know.
01:04:59.000Is that a big part of what's going on, is that it's just really too early for so many of these things?
01:05:04.000The treatments, the cures, dealing with the immune systems, finding out which people are genetically more predisposed to the virus?
01:05:13.000Typically, it can take years and years to figure all of this out.
01:05:19.000Everybody's working overtime trying to Trying to make a contribution, figure this out.
01:05:25.000The great news is the data sharing among scientists has just been amazing.
01:05:31.000Everyone's putting aside their eco, putting all their stuff up on BioArchive, MetArchive, and the major journals are doing incredible things also, expediting publication of paper.
01:05:45.000So, you know, the flagship journals like New England Journal of Medicine, Lancet, JAMA. If you look at the good stories that are happening around this,
01:06:06.000definitely the data sharing, the journals not conducting business as usual, recognizing that the stuff that they're publishing could be life-saving and responding to a public health crisis.
01:06:21.000I think that's been a nice part of the story.
01:06:24.000I'm hoping so much of what comes out of this is a wake-up call.
01:06:28.000So much of the newfound understanding and appreciation for the science behind dealing with these diseases, appreciation of healthcare workers and first responders.
01:06:38.000I mean, if there's any bright lining to this, that's what I'm really hoping for, is that people wake up and recognize the good work that people like you have been doing.
01:06:50.000We live in strange times and these things can happen again and we need to be prepared and we need to put a lot of emphasis and effort and thought to that as a whole, as a whole society.
01:07:02.000I think, you know, maybe this will help us reassess some of our values and, you know, appreciate some of the things that the healthcare professions especially are doing and, you know, you're seeing people volunteer, you know, they're going right, you know, right into the belly of the beast.
01:07:42.000Well, we just, we didn't get ready for the surgeon time.
01:07:46.000I think I'm sort of holding back, trying to throw stones at this agency or this person or this group, because we don't really know what happened.
01:08:00.000I think it's going to be really important that Congress, after this, conduct an investigation, not from the standpoint of prosecuting people or calling them out, but just say, hey, what the hell went wrong here?
01:08:16.000I mean, the problems with the testing and not having all the protective equipment.
01:08:20.000Now we're getting geared up and mobilizing industry, but what could we have done better, especially in that window period when things were collapsing in Wuhan and the other cities in central China, when we knew this was going to be bad and we knew this could become one of the great pandemic threats.
01:08:40.000How could we have better used those six weeks In order to get ready, and what didn't we do?
01:08:47.000And now's not the time to do it, because the last thing you want to do is start distracting people and worrying about congressional hearings and that sort of thing.
01:09:02.000It has to be done in the right spirit, not, again, we have to figure out a way to stop these partisan lines and say, you know, as a country, we've got to figure out the work together.
01:09:13.000I know that sounds Pollyannish, but, you know, when I was...
01:09:16.000Before I moved to Texas a decade ago, I was Chair of Microbiology at George Washington University for 10 years, and I worked with Congress a lot to get legislation passed around neglected tropical diseases, and it was a different Washington then.
01:09:31.000I mean, I would go to Sam Brownback's prayer breakfast, Sam Brownback's governor of Kansas before he was a senator from Kansas, very conservative, Republican senator.
01:09:42.000Walk across the hall and go talk to Senator Leahy's people from Vermont or Sherrod Brown's people.
01:10:02.000So I hope the other thing that we get out of this is figuring out a way that Republicans start talking to Democrats again and Democrats Talk to Republicans again and figure that out as well.
01:10:16.000Well, Peter, I appreciate your time and I know you're incredibly busy.
01:10:20.000Is there anything else that you need to say or you think should be said about this before we wrap this up?
01:10:26.000I can't tell you how important it is to use your voice to amplify you know a straightforward discussion about about this epidemic I think you know you're and just by doing that you're making a huge contribution because you have incredible bandwidth and and extraordinary audience I mean at the last I can't tell you the last time I did did talked about your I was on your show I think it was last year around this time actually um You know,
01:10:54.000the response I got about neglected diseases of poverty in the U.S. and vaccines, and you have so much, he's such a powerful show and powerful guy, and, you know, being able to use this time to talk about COVID-19 and what SARS is and why And how we deal with pandemic threats,