The Peter Attia Drive - #97 - Peter Hotez, M.D., Ph.D.： COVID-19： transmissibility, vaccines, risk reduction, and treatment

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:15.480 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

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00:00:33.280 in-depth content. If you want to take your knowledge of the space to the next level,

00:00:36.840 at the end of this episode, I'll explain what those benefits are. Or if you want to learn more now,

00:00:41.740 head over to peteratiyahmd.com forward slash subscribe. Now, without further delay, here's

00:00:48.080 today's episode. My guest today is Dr. Peter Hotez. Dr. Hotez is a renowned vaccine scientist,

00:00:54.740 pediatrician, and an expert on the current coronavirus outbreak. His titles are almost

00:01:00.220 too numerous to get into at this point, but I'll make an attempt to do so. He's the dean

00:01:04.780 of the National School of Tropical Medicine and professor of pediatrics and molecular virology

00:01:09.420 and microbiology at the Baylor College of Medicine, where he's also the director of the Texas Children's

00:01:14.440 Center for Vaccine Development and the Texas Children's Hospital Endowed Chair of Tropical

00:01:18.820 Pediatrics. I learned of Peter a few months ago for unrelated reasons that pertained to

00:01:25.220 microbiology, vaccination, et cetera, and had wanted to interview him at the time and kind

00:01:31.160 of postponed it for a number of unrelated reasons. More recently, about three weeks ago, I saw him

00:01:36.320 talking about coronavirus, which was really around the time I started to think I had miscalculated.

00:01:42.180 This would have been mid-February, the second week of February, and I started to realize at that

00:01:47.320 point in time that this was going to be a much bigger deal than I had naively assumed in January.

00:01:52.640 I reached back out to him and said, Peter, let's get on a podcast when the time is right,

00:01:58.420 and assumed that that would mean when we had enough facts that it was worth talking about.

00:02:03.740 But what I did not really anticipate was the past seven days until they were upon us,

00:02:10.140 basically about a week ago. So if you're listening to this on the 14th of March, that would have been

00:02:15.620 about the 6th of March. A lot of things really changed in my mind. And I reached back out to

00:02:20.920 Peter and said, hey, we should probably talk at the end of next week, which gives you enough time

00:02:25.380 to manage the very important responsibilities that you have, but also allows us to sort of

00:02:30.880 fill in some pretty big gaps in knowledge. And we attempt to do that. And this podcast is actually

00:02:35.420 quite short by the standards of our podcast. It's about an hour long. And I think what we'll probably

00:02:39.580 do is shorter, more frequent podcasts at this point in time, because the information is changing

00:02:45.620 at a very rapid rate, such that anything we talk about on this podcast is likely to be

00:02:50.620 background information at best a week out. So we do talk about a number of things. We talk obviously

00:02:56.320 about the etiology of the virus, the difference between the virus, which is SARS-CoV-2 and the disease

00:03:03.560 state that it causes COVID-19. We talk about how it's spread. We talk about where it came from,

00:03:08.840 what we know about it, what we don't know about it, what some of the treatment options

00:03:12.040 may be, may not be, why a vaccine is probably not likely in the near term. We talk about something

00:03:17.780 called convalescent serum, which is something that looks kind of promising. And at this point,

00:03:21.740 anything promising, we want to put sort of all hands on deck with interpreting. So with that said,

00:03:26.660 let's just get to this interview with Peter and we'll be following this up with a number of other

00:03:31.840 interviews. Also, I should point out on pretty much every day, I'm putting updates up on Instagram,

00:03:37.500 where you can find me at peteratiamd.com is the website. And that'll point you to Instagram,

00:03:43.380 or you can just go to Instagram at peteratiamd. And that'll be kind of daily updates. But as I said,

00:03:47.960 expect to see podcasts at a slightly irregular cadence, just as a way that we can sort of

00:03:53.120 communicate with you. This podcast and all podcasts pertaining to the coronavirus will have show notes

00:03:59.100 available to all listeners. So these podcast show notes and the subsequent ones that pertain to

00:04:03.940 this subject matter will not be behind the paywall for subscribers. So this will be available to

00:04:08.820 everybody. We will attempt to provide show notes as quickly as we can. So hopefully that allows

00:04:14.780 everyone to access this information without any bottleneck. Without further delay, then please

00:04:19.260 enjoy my discussion today with Dr. Peter Hotels.

00:04:21.820 Peter, thank you so much for making time to speak with us. You're in unbelievably high demand. I saw

00:04:33.840 you on the news at 530 this morning, your time, and I don't think you've stopped since. And of course,

00:04:39.380 you've been nonstop for weeks now, and you've been very generous in making time to speak with me and my

00:04:45.260 team prior to today. So again, greatly appreciated on behalf of many people listening. Let's start with a

00:04:51.480 little bit of just the nomenclature. People are a little bit confused, I think, about the nomenclature

00:04:56.220 between COVID-19, SARS-CoV-2. Maybe explain which one's the virus, which one's the disease, and what

00:05:02.480 the history is here. Sure. COVID-19 is official designated name of the disease by the World Health

00:05:08.980 Organization. The causative agent is the SARS-CoV-2 virus, SARS-CoV-2. Just like there's AIDS and there's

00:05:18.020 HIV, there's the name of the disease, and the name of the virus. And the fact that it's called SARS-CoV-2,

00:05:24.620 as I often like to call it, has some meaning because there's a lot of similarity in the type of virus it

00:05:31.320 is compared to the original SARS, which I often call SARS-CoV-2, that originated out of southern China

00:05:38.120 in 2003 and caused a very serious pandemic, a deadly pandemic, that affected Toronto, Canada,

00:05:45.080 among other places. This is a somewhat different type of disease in terms of transmissibility and

00:05:50.840 fatality. We can talk about some of the differences between SARS-CoV-2. Maybe we should do that because

00:05:57.400 I think transmissibility and lethality are two things that are very important to understanding

00:06:02.480 this, and maybe touching on the distinction between SARS-CoV-2 will be helpful.

00:06:07.080 Yeah. So actually, we've had now three major pandemics caused by coronaviruses in the 21st

00:06:16.260 century. Up until then, when I was being trained in microbiology and infectious diseases, we knew

00:06:23.000 about coronaviruses, but they were considered of relatively minor importance. They were coronaviruses

00:06:29.320 that caused upper respiratory infections in kids, and rarely they would cause lower respiratory tract

00:06:35.240 infections. But we had our first really serious experience with a coronavirus in 2003 when SARS-1

00:06:43.400 caused a serious pandemic that disrupted the economy of China and Canada and elsewhere. Another second

00:06:50.760 coronavirus occurred in 2012 with Middle Eastern Respiratory Syndrome that emerged out of Saudi Arabia,

00:06:57.560 and that was around 2012. And now this is the third one, SARS-2. So the point is we've had a new

00:07:03.960 coronavirus pandemic every decade of this 21st century. So hopefully we're starting to realize

00:07:09.800 these are pretty serious actors here in terms of global health threats. And that has a lot of

00:07:16.680 relevance when we talk about ultimately developing vaccines and why we should prioritize coronaviruses

00:07:23.160 moving forward.

00:07:24.120 Peter, six days ago, I spoke with a colleague of yours who will remain nameless just because we didn't

00:07:29.880 speak on the record. And I asked him point blank, what is your level of concern today? And keep in

00:07:35.000 mind, this was a discussion on March 7th, six days ago. I said, what is your concern with SARS-CoV-2

00:07:41.480 relative to the coronaviruses responsible for MERS and SARS, which were very deadly viruses? And he said

00:07:47.320 something to the effect of, I am much more concerned with what I'm seeing today. Do you share that

00:07:53.400 sentiment? And do you think that that is an overreaction?

00:07:56.440 I think it is an appropriate reaction. And I would have shared that concern six days ago,

00:08:00.680 but for very quirky reasons. So you might say, well, everyone knows, or a lot of people know from

00:08:06.840 the, from all the public news that SARS-2 is not as deadly as SARS-1 or as MERS, but it's a cause of

00:08:14.680 serious mortality. We'll go into that a little bit more. And it's also highly transmissible.

00:08:20.040 So while it isn't necessarily the most lethal virus we've ever seen, nor is it the most transmissible,

00:08:26.440 it's high in both categories. And that combines in this very unique way. Let me explain that a little

00:08:32.760 bit better. So SARS-1, the original one was highly lethal. And if you had it, you were sick as hell and

00:08:38.440 you were going into the hospital in the ICU. And that meant that you didn't have a lot of people

00:08:44.600 walking around transmitting SARS-1. And that's one of the reasons it tended to burn out pretty quickly,

00:08:51.480 although it could cause serious nosocomial outbreaks in hospitals. And MERS-2 more or less

00:08:56.600 went by that same playbook. This one is fatal only for certain groups, a serious disease in certain

00:09:03.320 groups. And what that means is you have a lot of other, a large segment of the population walking

00:09:10.360 around shedding virus, including kids. So kids, for reasons that, and adolescents and young adults,

00:09:16.200 for reasons that we don't understand, are getting the infection, transmitting the virus,

00:09:21.800 but they're not getting very sick. And there's always the outlier that will,

00:09:25.400 but more often than not. So the problem is you have a lot of virus circulating and only certain groups

00:09:33.480 seem to be getting serious disease. And those tend to be individuals over the age of 70,

00:09:40.280 those who have underlying disability, including diabetes or hypertension or heart disease,

00:09:47.240 maybe those on immunosuppressive therapy, although we don't know as much about that.

00:09:51.560 Also quite interesting, healthcare workers. So a lot of healthcare workers are getting infected

00:09:56.120 because this is so highly transmissible and they're coming into contact with patients.

00:10:01.000 And for reasons that we don't understand, healthcare workers are getting a higher level

00:10:05.560 of serious disease than you would expect given their age groups. There's been a lot of medical

00:10:10.040 mysteries about this virus, why kids are not getting seriously ill, why adolescents, young adults not

00:10:15.240 getting seriously ill, but why healthcare workers are getting seriously ill. So we saw this

00:10:19.560 in Wuhan in China, where this virus emerged, at least a thousand healthcare workers became infected,

00:10:25.720 and about 15% of those developed serious illness or in the intensive care units. So they seem to get

00:10:32.680 much sicker than you would have expected. And whether that's due to a higher level of exposure or a higher

00:10:39.160 inoculum of virus, and whether that is reproducible in the US, we'll have to see. So those are the people

00:10:46.280 that seem to be the most vulnerable, the very old, those with underlying disability and healthcare

00:10:52.440 workers. And that also is a perfect mix because you're knocking out a lot of people out of the

00:10:58.360 healthcare workforce that have to self-quarantine or are getting sick. And we were seeing these tragic

00:11:05.400 situations play out in China or elsewhere where healthcare colleagues are taking care of healthcare

00:11:13.000 colleagues in the ICU. And that is also highly destabilizing.

00:11:17.480 Yeah. And it's also very non-linear because if you lose 10% or 15% in that situation of your healthcare

00:11:24.040 workforce between physicians, nurses, respiratory therapists, et cetera, the knockoff effect of that

00:11:29.240 is much more than a 15% hit to the ability to provide care. So...

00:11:33.080 That's right. And then the other population we're seeing at high risk, we're getting sick,

00:11:37.320 are the first responders. And the first responders are coming into contact with

00:11:41.960 very severely ill people, they're getting infected, and then they have to self-quarantine.

00:11:47.000 So we're seeing large numbers of first responders knocked out of the workforce. And then it's going to

00:11:52.280 reach a point, potentially, where we're going to have this perfect storm of not having enough healthcare

00:11:57.960 workers and first responders to help us. And so for all of these really odd features of the virus,

00:12:05.480 it starts adding up to become a very serious epidemic and highly destabilizing for any country

00:12:13.160 that has large numbers of people. And of course, we didn't help our case at all by the US being so

00:12:19.320 behind in diagnostic testing and allowing this virus to circulate for long periods of time.

00:12:25.320 As of today, Peter, do you know how many tests are available? I know that as of yesterday morning,

00:12:30.600 we were at about 75,000. How long until we hit a million, which in theory was promised as of yesterday?

00:12:36.680 Who knows? The promises keep coming. And this also has a lot of serious consequences because

00:12:43.240 my colleague, Mark Lipsitch, has done some nice studies with his doctoral student, Ruan Li,

00:12:50.920 in China showing that the cities that get hit hard in terms of depletion of healthcare workforce and

00:12:58.520 run on hospital beds and ventilators are those that allow transmission to go on for long periods of

00:13:06.040 time without intervening. So whether or not you're a city that is totally overrun in terms of having

00:13:14.760 patients on ventilators and hospital beds and depletion of healthcare staff is very much depends

00:13:20.920 on how quickly you picked up transmission. So in Wuhan, where transmission went on for six weeks,

00:13:26.760 without people intervening, it was a catastrophe. So it was, and we all heard the stories of what went

00:13:32.920 on in Wuhan and creating 10 cities of hospitals as opposed to Guangdong, where they picked it up after a

00:13:40.200 week and there were 20 people in the ICU. So it's night and day. And in the U.S., now we probably

00:13:46.120 think transmission likely began in the middle of February if our first known indigenous case occurred,

00:13:52.440 I think it was around February 26th. So back date around five or six days, the average incubation period,

00:13:59.480 we're getting up there now three, four weeks where transmission has been going on undetected because

00:14:04.360 we haven't had the testing available. And that's what I'm worried about is in two weeks from now,

00:14:10.200 all of a sudden we're going to see hospitals inundated with large numbers of sick people.

00:14:15.320 We don't know for sure, this is a new virus, but that is the consequence of the failure

00:14:21.480 that our government has had in terms of getting testing available.

00:14:25.240 And Peter, that's a really important point that I just don't think can be overstated,

00:14:29.240 which is coming back to this point of the importance of social distancing now to buy time.

00:14:35.400 Because if we could do anything at this point, there is no stopping this. The opportunity to prevent

00:14:42.520 this virus from entering this country or reaching a sufficient number of the population seems pretty

00:14:49.320 slim at this point. It's a question of if 100,000 people are going to be infected and it happens over

00:14:54.760 a year versus a month, that has enormous consequences. Do you think there is still an opportunity to shift

00:15:00.760 that curve? If we can get a big order of magnitude level of testing in the next week and we can see

00:15:07.240 which communities have significant levels of transmission, potentially we could intervene.

00:15:12.920 So yeah, we still have to try, but boy, it would have been nice to have that three or four weeks ago

00:15:18.120 when there was maybe just a handful of communities that had transmission. We could have focused all of

00:15:23.400 our energy on that. And so we did lose an opportunity, I think, to prevent this from becoming a large

00:15:30.600 epidemic. And I get asked about this a lot. For instance, I got Alison Camerata on CNN asked me this

00:15:37.240 morning, whose fault is this? And I think my response to her was a bit surprising. I said, look,

00:15:43.560 now's not the time to start assigning fault. There's going to be time for that later and

00:15:49.640 we can have a federal investigation of where the breakdowns occurred. But I think right now,

00:15:56.280 we've got to focus on what the task at hand is. And I introduced this new concept this morning,

00:16:02.200 both on CNN and on Fox News. And I did it after calling my friend and colleague, Arturo Casa Duval,

00:16:10.360 who's a professor at Johns Hopkins, who's been pushing this idea for a few weeks that there is a

00:16:17.480 low-cost intervention that we could apply right now. And that is identifying patients who've been

00:16:23.720 infected, recovered, and looking at their convalescent serus. In other words, people develop

00:16:30.120 antibodies, an antibody response to varying degrees, collecting that serum, isolating antibody,

00:16:37.400 and then using that as a treatment. Because that's all we're going to have right now. I already think

00:16:42.840 the window is passed when we're going to start having significant numbers of people sick from

00:16:48.600 this virus in hospitals and intensive care units. And this is the one thing we can offer them given

00:16:55.640 the fact that we're not likely to have any effective antiviral drugs for a while. And it could be very

00:17:01.400 effective based on what we learned historically from things like the 1918 flu pandemic, the Spanish flu,

00:17:08.920 or even from experiences that we've heard about from SARS and MERS or even this virus in Wuhan,

00:17:15.000 both as a treatment, which would require large amounts of antibody, but also as prophylaxis.

00:17:21.160 So you can give a small amount and keep healthcare workers and first responders on the job because

00:17:28.280 it's preventing them from potentially from getting sick. Peter, when it comes to convalescent serum,

00:17:34.280 I want to make sure I understand something, which is from a technical standpoint, this is easy.

00:17:38.200 Obviously, from a theoretical standpoint, it makes sense. This is, as you point out, not a new trick.

00:17:43.800 However, when we start to think about bottlenecks in the supply chain, it does require apheresis,

00:17:48.520 correct? Yeah, it looks that way. And so we really need the help of blood banks and any,

00:17:54.120 I don't know if you do this only in academic health centers or whether every community hospital

00:17:59.400 would have this capability. And we would need some guidance from the drug administration,

00:18:05.320 from CBER, the Center for Biologics Evaluation Research. So this is kind of a 30,000-foot aerial

00:18:11.320 view of the problem. Speaking to Arturo, he thinks putting together a federal task force to really

00:18:17.720 look into this and to help with standardizing it and figuring out what we can do. But it has,

00:18:24.120 if we have, wind up having a situation similar to Italy in the United States or even part of the United

00:18:31.480 States, having this at our disposal is going to be really important because otherwise we've got

00:18:37.320 nothing. Otherwise, we go back to the 14th century in terms of using quarantine methods and that kind

00:18:43.400 of thing. And we see what happens when we have to do that. It's not a good look for our country.

00:18:48.600 Peter, do we have a sense of how many individuals could be helped by the serum of one convalesced

00:18:54.600 patient? How scalable is it? The kinds of numbers people are throwing out are 300 mils,

00:19:00.360 300 to 600 mils for someone who's potentially seriously ill. So that looks like a one-to-one

00:19:06.760 donor per patient. But for the prophylaxis, if we're talking 5 mLs, a single donor could potentially

00:19:14.120 prophylax dozens or maybe even 100 individuals. And who knows how often those numbers really are. But

00:19:21.560 given the fact that it's relatively low technology, doesn't need to bring in a lot of specialized

00:19:29.160 equipment, I don't think. I think it's something we need to look into. And Arturo gave me the

00:19:34.520 permission to sound the alarm on CNN and Fox News. And we'll see how it resonates in the coming days

00:19:41.720 and weeks and see if it catches fire. What about remdesivir, which seems like one of the more promising

00:19:47.960 things that could be repurposed? Do you buy that argument that this drug, which has been developed

00:19:52.680 by Gilead for Ebola is potentially, I mean, it's being used now on compassionate exemption. Do we have

00:19:58.760 a sense of its efficacy? Or is it too soon? I haven't seen those numbers. And so it will require

00:20:04.040 a clinical trial. And whether you use combination therapy, certainly antivirals will go a lot faster

00:20:10.200 than vaccines. And we've developed a recombinant protein vaccine, but it's, you know, we'll see how

00:20:15.560 quickly that can come up to speed in terms of clinical development. You've said in the past,

00:20:21.800 a vaccine is really not something we're going to have in the next 12 months. And it might even be

00:20:26.360 longer than that. Can you just explain to folks two issues? One, the technical challenges of

00:20:31.640 vaccinating against this coronavirus per se versus say an influenza and the lessons we've learned from say

00:20:37.960 RSV viruses. And then secondly, the logistics of getting a vaccine tested, vetted from a safety and

00:20:46.680 efficacy standpoint to be used on asymptomatic people. Those seem to be two separate issues

00:20:51.720 that are both stacked against us. Well, yeah. I mean, vaccines are about the highest bar there is

00:20:56.680 in terms of testing because you're essentially, typically you're immunizing well individuals

00:21:02.440 or healthy individuals. So you have to be pristine in terms of its safety. And historically, it's been

00:21:09.640 very difficult to compress those timelines to something quick. So it's not unusual for a clinical

00:21:15.720 development plan for a vaccine to last a year, two years, sometimes three years to go through

00:21:22.040 the series of phase one trials for safety and then graded trials for phase two to show that those

00:21:29.640 are expanded safety studies, maybe getting a hint of efficacy, and then the phase three pivotal study

00:21:35.720 for licensure in an area of transmission. So even under ideal circumstances, that will take time. Now,

00:21:42.280 I think there are opportunities to streamline this. So my colleague, Rino Rapioli, who's one of the real

00:21:49.640 thought leaders in vaccines, he's at GlaxoSmithKline, has drawn up a lot of interesting roadmaps for doing

00:21:57.160 more things in parallel rather than serially and accelerating those timelines. And I think that

00:22:03.800 there's a lot of interest in applying that for this vaccine. But I've made the statement that I'm

00:22:09.320 not sure this is the one you want to do it with, even though there's so much urgency. And the reason I

00:22:13.960 say that is coronavirus vaccines have, at least in laboratory animals, shown that they could create a

00:22:22.360 problem known as immune enhancement, where the vaccine could actually make things worse. This is a

00:22:28.760 phenomenon that was found originally with the respiratory syncytial virus vaccine, the RSV vaccine,

00:22:36.280 that was a killed virus vaccine, a formal and inactivated vaccine that was tested by the National

00:22:42.360 Institutes of Health at Children's Hospital in Washington in the 1960s, where vaccine recipients

00:22:49.400 actually did worse than the non-vaccine recipients after they were exposed to the natural virus

00:22:55.960 living in the community. And the mechanism is not still entirely clear, but those who were vaccinated

00:23:02.520 had more hospitalizations than there were even two deaths. And there was the added layer of complexity

00:23:08.520 that this study, when you look at the paper, I only realized this recently, was done among almost all

00:23:13.320 African-American kids as well when it was done in Washington, D.C. And there were potentially two

00:23:18.840 deaths. So this squashed enthusiasm for RSV vaccines, appropriately so, for a long time.

00:23:25.640 And the question is, was this unique to respiratory syncytial virus or is there others that do it? Well,

00:23:32.120 after SARS in 2003, there was an initial effort to again develop killed virus vaccines to test in animals.

00:23:39.880 And unfortunately, after virus challenge, those animals also exhibited a lung pathology that bore

00:23:47.240 some resemblance to what we saw in the kids with RSV in the 1960s. And we said, oh no, this is,

00:23:55.960 are we going to be faced with this again? And so the thinking was, well, okay, maybe that was unique

00:24:01.080 to a killed virus vaccine. Let's do this with the whole spike protein. So if you look at a cartoon of what

00:24:07.320 coronavirus looks like, you always see these little spikes all around it, that's the part that docs

00:24:12.520 with the receptor. So a recombinant protein vaccine was made with the whole spike protein. Sure enough,

00:24:18.760 we also saw immune enhancement, although it was more in the liver than in the lungs. But the thinking was,

00:24:24.920 can we get around this? Is it going to be impossible to develop coronavirus vaccines? Well then,

00:24:30.520 our colleagues at the New York blood center, Shibu Jiang and Lanyin Du found that if they only use the

00:24:36.600 receptor binding domain, the smallest part of the S protein that docs with the receptor, the

00:24:42.360 acetylcholinase 2 receptor in the lungs, they seem to get protection in laboratory animals without all

00:24:49.080 the immune enhancement. That was pretty exciting. And that's the concept that we partnered together to

00:24:54.680 write a grant to the NIH together with the Galveston National Laboratory where they had the virus for

00:25:01.080 potentially doing preclinical studies and Walter Reed. And we wound up making a vaccine, manufacturing it

00:25:08.120 that showed pretty good levels of high levels of efficacy and seemed to get around the problem

00:25:13.080 of immune enhancement. And that's why we got so excited at the prospect of maybe we could develop this

00:25:20.680 receptor binding domain as a vaccine. And we did. And we got funded by the NIH. It took us several

00:25:26.200 years to do it to show all of the safety, none of the immune enhancement and the efficacy had it

00:25:33.320 manufactured. But after then, by then nobody was really interested in coronavirus vaccines anymore.

00:25:39.720 And we couldn't attract any investment in moving into clinical trials. We kept it on stability studies,

00:25:46.520 but that project more or less was done until a few weeks ago when this new coronavirus emerged.

00:25:54.120 And we began looking, the Chinese were really good about putting up their data. Everyone says how 1.00

00:25:59.640 non-transparent they were, but I disagree. They were very transparent. They were putting up all their data

00:26:05.560 on these preprint servers like BioArchive, MedArchive. And we were able to see

00:26:09.960 that the SARS-2 coronavirus bore a lot of resemblance to SARS-1. It was about 80% similar in terms of its

00:26:18.520 genetic code bound to the same receptor. We realized, oh my God, we might actually have a

00:26:24.840 vaccine that we could repurpose for this epidemic. In the meantime, we also started trying to make the

00:26:30.360 new one as well, the receptor binding domain for the new one, but this was already manufactured. And

00:26:35.240 now we've been in this hunt to try to identify prospective donors to see if we can now move

00:26:41.880 this into clinical trials. That's been a few weeks now. And I'm, you know, it's sad to report we've

00:26:46.680 still not been able to raise the money to move it into clinical trials, which is really tragic. It's

00:26:52.120 already manufactured. We can move as fast as anybody, but this really goes to show you the problem of

00:26:57.960 dealing with vaccines, either for neglected diseases that I've devoted my whole life to.

00:27:02.440 We've made vaccines for schistosomiasis and hookworm and Chagas disease and moving them

00:27:08.600 into the clinic through our National School of Tropical Medicine at Baylor College of Medicine

00:27:14.600 and Texas Children's Hospital Center for Vaccine Development taking on this coronavirus. But you'd

00:27:19.720 think that people would be pretty eager to support us to move this forward, but so far it hasn't happened.

00:27:25.480 Should that change? I assume people can pretty easily get a hold of you if there's

00:27:29.800 interest in this. What's the easiest way for people to get a hold of you at this point in time?

00:27:34.040 I assume just through the university? Yeah, just send me an email. My email is

00:27:38.200 pretty public. It's just HOTEZ last name at BCM stands for Baylor College of Medicine.edu.

00:27:45.240 And we can do this through either the college or Texas Children's Hospital and be fantastic.

00:27:51.000 What do we know about the ACE2 receptor and its role here? Certainly a few weeks ago,

00:27:59.320 I remember seeing a paper that discussed this in the context of the first SARS outbreak. This was a

00:28:05.640 2005 paper and that got us very interested in looking at angiotensin receptor blockers and things like

00:28:11.400 that. But is the following still our understanding, which is that the virus gains access to these cells in

00:28:18.120 the lung, the type 2 pneumocytes that make surfactant? Probably through this ACE2 receptor,

00:28:23.240 though there may be a co-receptor, once the pneumocyte is infected, it reduces its capacity to

00:28:29.880 produce surfactant, which is one of the more telling pieces of the pathology. Is that still largely

00:28:35.880 accurate to our understanding? Well, I think there's a couple of things. I think first of all,

00:28:39.400 the receptor is not only in the lungs, it's also found in the intestinal tract, and you can see

00:28:43.880 intestinal pathology with this. And that may even be... And even myocardial, potentially.

00:28:49.000 And it's in endothelial cells as well. And that may partly explain some of the diverse pathology

00:28:55.720 that we're seeing. So for instance, patients who are very ill with this, if you look at the

00:29:01.400 MedArchive reports coming out of China and elsewhere, a lot of them are getting acute myocardial injury.

00:29:07.080 And we don't really know if that's from myocarditis or whether just getting myocardial infarction is a

00:29:13.080 consequence of the infection. But I think that's probably a major mode of death for a lot of these

00:29:18.600 patients. And it's very confusing because there's a lot of things going on at once. You have

00:29:25.080 acute myocardial injury, but you're also seeing acute respiratory distress syndrome, ARDS.

00:29:30.760 So therefore, is the heart injury due to the ARDS and shock, or is it occurring in parallel? And then

00:29:37.480 what's the basis for the ARDS? Is it overwhelming virus invasion in the lungs, or is there a huge

00:29:45.960 inflammatory component to this? And there's differing opinions on that. And that also has implications

00:29:52.360 for treatment. Then the intestinal pathology as well. And we've seen patients, at least 10% of the

00:29:58.520 patients reported in some hospitals in Wuhan, they presented with GI symptoms and were erroneously

00:30:05.640 admitted to the surgical suite. And those are the ones that wound up actually infecting large numbers

00:30:11.480 of healthcare workers because nobody suspected this was SARS-2. So that's confusing as well. And you can

00:30:18.600 imagine how well the confusion that would create for monitoring and figuring out who should get tested.

00:30:24.920 So my colleague, Paul Offit, is of the opinion that he thinks the GI route is actually a major

00:30:32.440 mode of transmission, is noted and speculated. Well, at least he's talked to me on the phone about

00:30:39.320 whether the fact that cruise ships are so widely affected, he says it reminds him a little bit of

00:30:45.720 norovirus when it affects large numbers of cruise ships. So is it getting into the food? So we don't

00:30:51.480 really know the modes of transmission of this. We know droplet contact is going to be important.

00:30:56.120 People are coughing micro droplets onto surfaces and then people come into contact with them with

00:31:01.960 their hands and auto-inoculate themselves in the mucous membranes of their eyes and mouth or

00:31:07.880 whether they're coughing directly onto people's faces. But the other modes of transmission are also

00:31:13.240 interesting. Is there a lot of fecal oral transmission? I don't think we know that.

00:31:16.840 Is there a true airborne transmission where the virus can travel on microparticles long distances?

00:31:23.640 It turns out not many respiratory viruses do that. We know measles does, chicken pox does.

00:31:29.640 So we're still in this deep learning curve about this virus.

00:31:33.000 Which again brings us back to this point of can you buy time? Because time presumably brings clarity,

00:31:39.800 reduces uncertainty. Did you see the paper today that just came out from the New England Journal of

00:31:43.960 Medicine that looked at the fomite transmission? No, I didn't see that. What did it find?

00:31:48.760 Well, here, I'm going to pull it up. The telling figure in this sort of looks at four different

00:31:53.720 surfaces, actually several plastic, steel, cardboard, copper surfaces, and it looks at the median and

00:32:01.080 half-life survival on these surfaces. And not surprisingly, I think, based on what you just said,

00:32:07.560 Peter, there's pretty reasonable survival. So until you reach a level that they think is

00:32:13.000 not compatible with transmission, takes about 72 hours on plastic, takes 48 hours on cardboard,

00:32:20.120 takes about 24 hours on steel, and takes about eight hours to 24 hours on copper.

00:32:28.920 So a couple points I'd make there from a public service announcement. I've seen a lot of talk on

00:32:33.720 Twitter of all you need to do is have copper on your door and nothing gets in. Well, apparently not.

00:32:38.920 And we have evidence that at least a day of survivability on these fomites. And again,

00:32:46.760 I think that speaks to the R-naught being as high as it is. And maybe this is a reasonable time to 0.99

00:32:52.840 explain exactly what R-naught is and what we think our best estimates are of it and why it probably

00:32:58.040 feeds into what you've been saying about the concern over the transmissibility.

00:33:02.040 I think all of this put together presents a picture of why this virus is so highly transmissible. You

00:33:10.840 have the fact that this virus can live on surfaces. So the droplet contact motor transmission is

00:33:19.480 significant because it depends on the virus being able to survive on fomites and surfaces. And the fact

00:33:26.840 that this virus will often land on people's face and they can auto-inoculate themselves,

00:33:32.120 that's the mode of transmission, maybe fecal-oral and maybe airborne transmission as well. And so

00:33:37.400 what does that all add up to? It all adds up to the fact that when people have looked at it,

00:33:43.240 it's a pretty high what we call reproductive number, or what the Brits call R-naught, what we call R-sub-zero,

00:33:50.040 which refers to roughly the working definition is the number of people that will get infected

00:33:57.640 if a single individual has this virus. So the number that I carry around in my head is between

00:34:05.240 2.24 and 3.58, roughly between two and four people infected for every single individual.

00:34:13.160 And some people will shift those numbers around more or less. And I think that level of transmission

00:34:19.000 varies depending on location and a number of other factors, but it's pretty high. If you look at

00:34:26.760 seasonal flu, for instance, which is around 1.2, 1.3, so this would be two or three times more

00:34:33.640 transmissible than seasonal flu. Clearly not as transmissible as measles, which is up to 12 to 18,

00:34:39.880 but still quite high. So as I mentioned before, every new emerging pathogen has its own little shop of

00:34:47.240 horrors. In the case of this one, it's pretty highly transmissible. And there are a lot of people in

00:34:54.440 this case who are running around who are not sick that are spreading this virus around and infecting

00:35:01.240 a subgroup of individuals who happen to get very ill and with very high mortality rates. So the case

00:35:07.720 fatality rate of this virus is between 0.6 and 3.4%, which may not sound all that high, but that's

00:35:17.640 easily between 4 and 20 times higher than influenza. And that, given the fact that there is a group

00:35:24.120 walking around with this, means you're going to have a lot of people in hospital in intensive care

00:35:29.480 units, and especially among older populations where that mortality rate is between 10 and 20%.

00:35:35.240 And that's what's so devastating is the fact that when this virus goes into areas where large numbers

00:35:43.480 of older people congregate, especially older people with underlying disability can have some

00:35:49.480 devastating effects. And the Chinese told us this was going to happen. They told us about what happens 1.00

00:35:55.240 when this virus goes into a nursing home or affects older people and large numbers of deaths of those

00:36:01.640 individuals over the age of 70. And I don't know if it was because we didn't believe them or we just

00:36:07.320 had to learn it on our own. But when we had our first community transmission in Kirkland, Washington,

00:36:14.360 we saw how this virus raced through that nursing home and killed 13 people in a nursing home of about

00:36:21.960 100 individuals. So 13%, which is exactly right in that area of 10 to 20% that the Chinese told us about. 0.57

00:36:29.640 And then I became very concerned, not only from the lack of government response from

00:36:35.080 the debacle with the testing, but also that there was not a lot of guidance being issued around nursing

00:36:41.640 homes or assisted living facilities. And I had the opportunity to testify to Congress about our vaccine

00:36:49.480 to the House science space and technology committee. But I hear I had the attention of Congress and it was being filmed on C-SPAN

00:36:58.600 to or C-SPAN. And I said, look, this is my chance to really sound the alarm on what's not happening to protect our old

00:37:06.760 people. And as I was saying it, I knew it was being very provocative and I was being deliberately provocative.

00:37:11.480 And I knew it was going to be on the evening news and be on the news the next day, but I felt I had to say something.

00:37:19.960 And that's when I used that expression, this is the angel of death for older people. And indeed that had that effect, 1.00

00:37:27.560 but it was a wake up call to people. And now we're starting to see nursing homes across the country take those extra measures to

00:37:35.320 carefully screen people going in and out of nursing homes to review all of their preparedness plans.

00:37:42.520 And now the health and human services secretary is mobilizing inspectors around infection control.

00:37:49.400 And that's an example of where I, over the years, I've always had this interesting career that balances being a working

00:37:57.560 scientist and MD-PhD vaccine scientist developing vaccines and for neglected disease interventions with

00:38:05.160 that advocacy in places where I've seen gaps. So I saw a gap in getting people to care about these

00:38:12.920 poverty related and neglected diseases in the early 2000s and helped raise awareness that's now led to

00:38:19.160 treatment of more than a billion people annually for neglected tropical diseases, raising awareness about

00:38:25.800 diseases of the poor in places like the United States. And now we've been working with Senator Booker,

00:38:31.080 Cory Booker around this issue, getting people to counter the anti-vaccine movement. So I'm a parent of an

00:38:39.000 adult daughter with autism and wrote this book called Vaccines Did Not Cause Rachel's Autism to kind of

00:38:45.720 counter the false narrative and the misinformation from the anti-vaccine movement. And here was another

00:38:51.480 example of using my voice to really help people who didn't have a voice otherwise.

00:38:57.160 Peter, what geographies in the United States are you most concerned about? And then I guess I also ask you that

00:39:04.120 question at a global level, but we'll start maybe in the United States.

00:39:07.000 Well, I mean, right now, it's all bets are off. I think any urban area of the U.S. now is vulnerable. And we've seen

00:39:16.200 this now take off in Seattle. We've seen this take off in New Rochelle in Westchester County. We're starting to see some

00:39:25.160 uptick in New York City. And there's nothing really unique about those cities other than there are

00:39:31.000 congregations of a big urban population. So on that basis, I have to believe any large urban center is

00:39:38.120 vulnerable. And it could be any place is vulnerable. It's just that urban areas tend to have more

00:39:44.200 physicians and so more health care, better public health infrastructure. So maybe it's just being picked

00:39:50.360 up there for. So I said last week, this is going to be a difficult week for America because the testing is going to

00:39:57.160 start to gear up. And now that it's in the hands of Quest Diagnostics and LabCorp and Roche, we're going to get a much

00:40:04.840 more full picture of the extent of this virus in the United States and North America. And I think we're starting to see that

00:40:12.040 the numbers are going up 1,600. Who knows what it'll look like by next week? Is it going to be 10 times

00:40:17.640 that number? I think that's quite possible or even more. And with that, we'll undoubtedly be picking up new

00:40:24.360 foci of infection. That's a pretty frightening thought to have a log increase in a week. But when you look at

00:40:30.480 other countries that have not done well, that's exactly what we have seen, isn't it? Well, the question is whether

00:40:36.460 that's a true log increase or whether we've had that transmission all along. It's just that now we're

00:40:41.540 cherry-picking communities to detect it, or maybe both going on simultaneously. But I suspect we're

00:40:49.480 going to see those numbers steeply rise again. And so this gets back to what I was talking about with

00:40:57.020 Mark Lipsitch's paper, where he says the more sustained community transmission goes on, the health

00:41:04.540 burden's going to be in terms of hospital beds and ICU beds and the demands on healthcare staff.

00:41:10.780 I think as we pick up these new levels of transmission in places that's been going on for

00:41:16.040 a while, next week, so the horror this week was we realized we're seeing a lot more cases and maybe new

00:41:22.220 areas of community transmission. I would say the same for next week with the added piece. Now we're

00:41:27.680 going to start to see hospital beds fill up. And that's why I'm really pushing now for blood banks

00:41:34.080 to implement this new antibody therapy, because I think the need's really going to be there. And if

00:41:40.020 you don't offer people any hope of anything, I think that's where panic starts to spread, where you

00:41:46.200 start seeing panic, not only among the population, but among the healthcare workers. And we've got to be

00:41:53.020 able to stop that. So I think just like this week was challenging because we're starting to see an

00:41:57.740 increase, I think in the next two weeks may be the critical period when we may start to see

00:42:02.640 this start to reach a peak. Peter, do we have a sense of what the excess capacity is in the ICU

00:42:10.520 and where the, where's the bottleneck going to be in the supply chain? Is it the number of ventilators,

00:42:15.760 the number of ICU beds or beds that could be repurposed for ICU? Is it going to be the number

00:42:19.940 of anesthesiologists, respiratory therapists, nurses? There are so many things here.

00:42:23.860 Yeah, I think, I think only now we're really starting to look at this. And if you've ever listened

00:42:28.260 to Zeke Emanuel, he's been commenting a lot about this. We don't have a great capacity. Hospitals

00:42:35.760 for cost-saving measures and everything else have operated at slim margins. So it's not like we have

00:42:42.640 a lot of excess capacity laying around. And does this mean we're going to have to build

00:42:48.140 tent city hospitals? Will we have to bring in the National Guard? I think all of that, you know,

00:42:54.240 it's a big unknown. I mean, the only good thing that we have going for us is we did make that

00:43:01.540 sacrifice of shutting down things we love, like the National Basketball Association, the NBA and

00:43:07.820 the rodeo and that sort of thing. And that's a good thing about America. We did this to protect

00:43:12.780 our most vulnerable or older citizens, a lot of them veterans of foreign wars. And

00:43:18.300 I think that that's important. And maybe if there is a seasonality to this virus, maybe we're just

00:43:25.760 hitting it right in terms of moving into warmer weather, but we have no evidence for that.

00:43:30.580 That certainly was not the case with the first SARS, right? I mean, it didn't seem to stop when

00:43:34.900 the summer came, did it? Well, you know, if you look at the curves, the peaks that I saw looked like

00:43:39.860 more around the springtime, but who knows? I mean, we certainly can't count on it. You know,

00:43:45.480 there's some people who feel that it may start to go down in the summer, but not disappear entirely

00:43:50.180 and then come back in the fall. So we just don't know. As I've also been saying is confronting a

00:43:56.380 new serious virus pathogen is one of the hardest things our country faces, has faced the last 20

00:44:02.700 years. And it always starts out pretty bumpy and pretty rocky, I think in part because it takes the

00:44:08.600 CDC a while to figure out how the federal government and the CDC, how to work with state and local

00:44:13.600 health authorities. This one has been rockier than most because of the inability to do the testing

00:44:20.020 and other factors. But the problem is unlike Ebola, which was never going to be transmitted

00:44:25.840 widely across the country because that very low reproductive number, unless you're taking care of 1.00

00:44:30.880 a dead or dying Ebola patient, you're not going to get Ebola. This one is pretty transmissible. So

00:44:36.100 our margin for error is much smaller as the studies in China have pointed out. So we could be in for

00:44:44.420 some very serious times. Mark Lipsitch has stated that he believes we could be entering kind of a new

00:44:51.660 world where two years from now, half the world's population or thereabouts has been infected by this

00:44:58.480 virus. And even if you use the absolute lowest estimate of mortality that's being provided,

00:45:04.760 which is 0.5% or 1 in 200 people dying, the impact of what I just reiterated as his estimate is

00:45:13.340 staggering. Do you share that view or do you at least think that that is a plausible scenario?

00:45:19.500 Yeah, it's absolutely plausible. And Mark's an outstanding epidemiologist. And a lot of these estimates are

00:45:25.400 based on models. I would say the only thing about models, and I'm not a modeler, but I've collaborated

00:45:31.180 with modelers to look at projections of our different vaccines and to give us a sense of what level of

00:45:38.640 protection we would need to have a significant impact on a population and how wide a coverage

00:45:46.600 we would need. And one of the things that always impresses me working with modelers is that a modest

00:45:52.660 change in assumptions of what goes into the model can often have huge differences. So the only

00:45:59.040 comfort I take in that is to say, well, maybe if those models are like the ones I've worked with,

00:46:06.000 a few tweaks to the model can result in two or three log reductions in deaths and cases and that

00:46:13.360 sort of thing. So models are useful exercises to help you think through problems, but how predictive

00:46:21.040 they are is only as good as the assumptions with the new virus agent, where we don't even know all the

00:46:26.100 modes of transmission and everything else, don't fully understand reproductive number, that might 1.00

00:46:31.720 help us. Yeah. As a physicist, a very famous physicist once said, all models are wrong, some are useful.

00:46:38.040 So hopefully that model is woefully wrong. But I think part of that is, as you said, it's a little

00:46:45.080 bit in our hands how wrong that model is going to be, isn't it? I mean, it's still, we still have some say

00:46:50.880 over our response to this, both in terms at the federal level, but also at the local and state

00:46:56.860 level. And then at the individual level, we can all take steps to reduce our risk and buy more time.

00:47:02.900 How are you thinking about this? I don't want to say personally, because you're in a very unique

00:47:07.880 position where you have to be out there talking about this. You don't have the luxury of maybe being

00:47:13.760 a little bit more sequestered, but are there a certain subset of people that at this point,

00:47:19.140 Peter, you would say absolutely need to be self-quarantined, either the symptomatic folks, 0.99

00:47:24.740 obviously who run the risk of infecting others if they can't be tested, but also people who are

00:47:28.720 showing no signs or symptoms, but who are at high enough risk. How are you helping people create their

00:47:34.900 own sort of framework around that very difficult decision? Well, certainly older individuals where

00:47:41.680 they're clustering together, we've seen the devastation. So we can't repeat the debacle

00:47:47.360 that we had in that nursing home. And so it's all hands on deck with protecting those individuals.

00:47:53.340 Then you can say, okay, Peter, well, tell us what that means. Does that mean thinking of my 90 year

00:47:58.560 old mother in the Hebrew home in Brooklyn, outside of Brookline, Massachusetts, do we now tell her that

00:48:05.340 she has to stay in her room and can't go down to the cafeteria and sit with her friends? Is that what 0.96

00:48:10.800 you're telling us? And so these are going to be really tough decisions. We know how important

00:48:16.960 socialization is for older people, for anybody, right? But for older people in nursing facilities,

00:48:22.540 that's really heartbreaking. And so Dr. Hotez, is he telling us that the grandkids can't visit,

00:48:29.960 can't visit. So these are really tough decisions for us. Because at what point do you say,

00:48:36.120 we know older populations are so fragile in terms of suffering serious mental decline? And do you want 1.00

00:48:43.760 to do that just to protect them from this virus? And this is where I say, well, I'm a vaccine

00:48:50.260 scientist, pretty good at understanding infectious disease epidemiology, because I've had to really

00:48:59.020 understand how to make the best vaccine. But there's a certain point where the decisions become

00:49:04.500 so tricky that I have to say, no, I'm starting to exceed the limits of my comfort zone. And here's

00:49:11.380 where we start needing some federal guidance, state and federal guidance, people to really think about

00:49:16.480 this very deeply and bringing experts together that understand that. And I don't see that happening,

00:49:22.300 unfortunately. What I'd like to see are key task force created around, not in general, as has been done,

00:49:29.920 the president's created on sort of an overarching task force for this. But there are so many

00:49:35.520 specialized pieces to this that we have to focus on, like creating an antibody based technology,

00:49:42.480 bring those experts together, bring experts together around what nursing homes are like and

00:49:47.900 how they're structured, which would include experts in the mental health of older people,

00:49:53.580 those experts in diabetes and hypertension to understand what's going on. And I think

00:49:58.120 that's going to be really critical as well. Peter, what are you personally going to be paying

00:50:04.580 closest attention to in the next seven days besides the potential for using convalescent serum,

00:50:12.320 both from the sort of clinical trial standpoint and or utilization standpoint? And in terms of data

00:50:18.780 that are going to say, hey, are we heading towards the Italian path or are we heading towards sort of the

00:50:25.580 Singapore path? What data are you monitoring closely?

00:50:29.800 Well, certainly incidents and prevalence data is going to be really important because right now

00:50:34.860 there's none, right? We've done so little testing. So as we ramp up and also starting to see which new

00:50:42.320 communities are becoming infected, I think that's going to be absolutely critical. And seeing if the

00:50:48.560 situation that we've seen in the Pacific Northwest and New Rochelle is being replicated elsewhere,

00:50:54.400 or the demographics taking on a different characteristic, those are some of the big

00:51:00.520 things that I'll be looking for. And then also there are some vaccine trials that have started

00:51:05.240 in the Washington area. Interest in following those because my understanding is the one in Seattle

00:51:11.540 began with one of the vaccine trial evaluation units at the University of Washington, and it was

00:51:17.820 initiated at a time where there wasn't transmission of this virus. Now there is.

00:51:21.460 So you're doing something that is going to be very interesting, but also a little bit scary because

00:51:29.300 if there is immune enhancement, now we're going to start to see it among those volunteers who are

00:51:34.960 getting immunized. Peter, I want to be respectful of your time, and I promised you we would only take

00:51:39.640 an hour. We've now gone a little over an hour. So I want to let you go with the ask that either we can

00:51:46.300 speak again, either formally or informally, because again, I think it's probably less important to

00:51:50.560 spend hours at any one point in time and maybe more important to... And this is what I've been

00:51:55.720 saying, you know, on CNN and Fox and MSNBC, and it's not easy going from one network to the other,

00:52:01.760 right? Especially those networks. Yeah. Well, you know, one, you have to say something nice about

00:52:06.780 the president. The other one, you're not allowed to say anything nice about the president. It's also

00:52:10.580 polarizing threading that needle. It's interesting. But one of the things I always say is this is where

00:52:17.200 we are right now, and this virus is racing so quickly that new pathogens in general set you up 0.97

00:52:24.100 to look stupid because, you know, when you're trying to learn something about a new pathogen, but this 0.96

00:52:29.040 one especially because it's so fast-moving and transmissible, I would cringe if I were to look at my 0.99

00:52:35.020 interviews from two or three weeks ago in terms of the things I said, I think. And probably a month

00:52:41.780 from now, I would say, oh my God, I can't believe I said that at what we're talking about now. So I

00:52:47.000 think absolutely that's important to update this and to say, to take a step back and look to see what

00:52:52.240 have we learned in the last week? And because we're trying to make our best guesses, best estimates on

00:52:58.280 what we're seeing now. But this is, as I say, it's moving so quickly. We have to continually

00:53:04.040 reevaluate that. And that's why I'd like to see the White House out there every day because this

00:53:10.120 thing is moving so quickly. Yeah. Well, look, for those listening to this, probably on a Saturday,

00:53:15.040 it's now Friday night in real time, March 13th. Peter, let's let you get back to work. Let's touch base

00:53:22.100 next week and continue to look at the data and in real time, try to come up with the best

00:53:28.100 assessments of what we can. Thank you very much, Peter. Thanks for having me. Thanks for all your

00:53:32.300 great work. One of the things that I do when I give talks about confronting anti-science, and I do that

00:53:38.740 a lot standing up to the anti-vaccine movement, I say part of this is our fault because as physicians

00:53:44.660 and scientists, we're too inward looking. We've somehow decided that engaging public audiences is not

00:53:51.380 important. And so the kinds of things you're doing is really critical to break that. I think the best

00:53:58.700 weapon against ignorance and false information is the kinds of things that you're doing. So I just

00:54:04.180 want to congratulate you on what you're doing and there's nothing more important. Thank you, Peter.

00:54:08.520 We're greatly appreciated. And I hope you get some rest tonight and we'll be back in touch next week.

00:54:12.680 Thanks. Me too. I hope we get some rest. Thank you for listening to this week's episode of The Drive.

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The Peter Attia Drive - March 14, 2020

#97 - Peter Hotez, M.D., Ph.D.： COVID-19： transmissibility, vaccines, risk reduction, and treatment

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