March 16, 2020 - Rubin Report - Dave Rubin
16:07
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| So the symptoms are going to be just like any cold or flu that you get. | ||
| They're going to be cough, fever, sore throat, maybe a runny nose, maybe a little bit of GI symptoms, meaning nausea and vomiting, maybe some diarrhea. | ||
| And then shortness of breath is the one that we worry about in terms of pneumonia. | ||
| Those are the main symptoms and they overlap a lot with influenza. | ||
| Joining me today is an infectious disease expert working on pandemic policy, | ||
| focusing on emerging infections and preventing bioterror. | ||
| Dr. Amish Adalja, welcome to The Rubin Report. | ||
| Thanks for having me. | ||
| All right, thanks for doing this. | ||
| We're gonna try to do this in about 20, 25 minutes and just pack in as much information as possible. | ||
| So let's just start. | ||
| Coronavirus 101, what is this thing? | ||
| So coronaviruses are a large viral family. | ||
| They cause about 25% of our common colds. | ||
| And we knew about six of them. | ||
| Four of them are common cold viruses. | ||
| Two were more dangerous, SARS and MERS, which were emerging infectious diseases that | ||
| had a high mortality rate. | ||
| The other ones just caused common cold. | ||
| But after SARS and MERS, people got very interested in understanding, are there more severe coronaviruses? | ||
| And what happened was, in China, at the end of December, they noticed a cluster of individuals | ||
| who had an unexplained pneumonia. | ||
| And they discovered a new coronavirus. | ||
| And because of its linkage with SARS, because they're in the same family, people got very worried, and that's what sparked this whole initial response. | ||
| But they're just a viral family that causes upper respiratory tract infections for the most part, but in some individuals can cause pneumonia. | ||
| Okay, so can you explain how that's actually different than the common flu? | ||
| So the flu is a different virus. | ||
| It comes from a different viral family. | ||
| It's the influenza virus family. | ||
| And they share a lot of similarities with coronaviruses in terms of the fact that they cause similar symptoms, but they're very distinct viruses. | ||
| And influenza is one of our top infectious disease threats because it's caused pandemics through history. | ||
| One just about 100 years ago in 1918 filled about 50 to 100 million people. | ||
| So flu is always on the top of our list, but we hadn't really thought about coronavirus | ||
| as being able to cause pandemics until the SARS outbreak in 2003. | ||
| And while they are similar in their clinical presentation, meaning the symptoms that they cause, | ||
| they're a little bit different in their characteristics in the sense that there are no vaccines for coronaviruses, | ||
| there are no antivirals for coronaviruses. | ||
| And this coronavirus doesn't seem to be at a, it doesn't seem to be acting | ||
| like the common cold causing coronaviruses, meaning it's transmitting like them, | ||
| but it's killing at a higher rate, probably about 10 times the rate | ||
| of what we see during seasonal flu at the upper limit. | ||
| So that's why it's a little bit different. | ||
| It's more dangerous than the average flu that you get. | ||
| It's not one of those bird flu strains that kills 60% of people, but it is something that is more dangerous than the regular seasonal flu. | ||
| Okay, so two things there. | ||
| Can you talk specifically about the symptoms, because we're hearing some conflicting information on that, and then about the transmission part, because I think that's where people are most worried at the moment. | ||
| So the symptoms are going to be just like any cold or flu that you get. | ||
| They're going to be cough, fever, sore throat, maybe a runny nose, maybe a little bit of GI symptoms, meaning nausea and vomiting, maybe some diarrhea, and then shortness of breath is the one that we worry about in terms of pneumonia. | ||
| Those are the main symptoms, and they overlap a lot with influenza. | ||
| The contagiousness is that this is a disease that's pretty contagious compared to other coronaviruses like SARS and MERS, which were scary but not very contagious between people. | ||
| This is behaving more like the other coronaviruses that cause the common cold, meaning that it can be transmitted through coughs and sneezes and on some of the surfaces that people have touched if they have coughed or sneezed on their hands. | ||
| That's what's making this more scary than any of the other coronavirus outbreaks that we've dealt with in the past. | ||
| This is something that transmits very efficiently in the community. | ||
| And that's why this is spreading to many, many different countries. | ||
| And it's not really a containable virus because of how easy it spreads. | ||
| And the fact that many people have mild symptoms that are indistinguishable from the cold, and they're out there doing things. | ||
| That's part of the issue. | ||
| So is that really the number one problem, that there are probably many people that have this right | ||
| now and they simply don't know, | ||
| so then they're going to the supermarket, put their hand on, you know, | ||
| right by the cash register or something, or payment processor, | ||
| and then next thing you know, they're transmitting it. | ||
| That's part of the issue. | ||
| We know that this virus emerged in China at least around mid-November, | ||
| which meant that it had been spreading probably for some time in the community. | ||
| And there was no restrictions or anything like that. | ||
| People were traveling all over. | ||
| So we know that this seeded many countries probably before we even knew it. | ||
| And we had a pretty severe flu season. | ||
| And because the symptoms are indistinguishable and most people have mild cases, they were probably mixed in and not even diagnosed. | ||
| And there likely are many undiagnosed chains of transmission in the United States that are starting to pop up now, like we saw in Washington state, for example. | ||
| And that's the issue is that we didn't know who had this disease. | ||
| So we couldn't tell them you need to isolate yourself and protect yourself from infecting others. | ||
| Nobody did any of that in the early stages of this outbreak. | ||
| And that's what we're left with now. | ||
| So on an international level, it seems that various countries are having various success and failures with this. | ||
| Can you talk a little bit about why Italy seems to be struggling so much with dealing with the outbreak? | ||
| Sure. | ||
| So Italy had an outbreak that started out and Basically, their approach was really to focus on the severe cases. | ||
| They started to test for mild cases, and they actually got criticized by their central government for finding mild cases because it was driving their case numbers up and it was making people stigmatize Italy. | ||
| Because during an outbreak, there's lots of stigmatization that occurs for irrational reasons, usually. | ||
| And that's what happened. | ||
| And Italy didn't really act quick enough on those mild cases and allowed those mild cases to spread. | ||
| And then You basically have the oldest population in the world in Italy and we know this disease is much more severe in those that are older and have other medical conditions and that really has created a crisis mode in that area of Italy where the cases are located in the Lombardy region and from what I understand they're not allowed to move those patients out of Lombardy so you've got a basically a fixed capacity of ICU beds and hospital beds there and a disease that's spreading very quickly in the population and that population is older so you've got these hospitals inundated and | ||
| Yeah, what about the rest of Europe? | ||
| It seems like the UK may be not doing enough at the moment, but it's a little hard to figure out who to trust at the moment. | ||
| So the UK has done something completely different. | ||
| They've actually tried to do something called herd immunity. | ||
| So they're trying to get many people exposed to this virus so that it builds up immunity and they can use that to cocoon their elderly and vulnerable populations. | ||
| But it's a very risky gamble because we don't know how you're going to keep the younger people compartment away from the older people compartment. | ||
| They're not there. | ||
| People have probably cross over. | ||
| You can't really seal those the elderly away from younger people. | ||
| So there's a lot of criticism going on right now of the UK's policy to do that. | ||
| And it's going to likely go. | ||
| It's going to result in more cases. | ||
| It's designed to do that. | ||
| But we don't really think that it's going to be able to save that. | ||
| That elderly population by exposing the younger population. | ||
| Right. | ||
| And what about the American response? | ||
| That's been kind of hit or miss. | ||
| There were some early good steps and then really bad steps. | ||
| I would single out the one thing that's the worst thing about this is the fact that this was a disease that we were kind of told is a Chinese disease and not going to be something that we have to think about other than with travelers. | ||
| When we knew that it was not that from the beginning, because like I said earlier, this had been spreading since November. | ||
| And we know that any of this, any of US notice of this basically came in January. | ||
| So it likely was already here. | ||
| And our testing was so restrictive that we could only test people if they'd been to China in the last 14 days and had severe, severe respiratory symptoms that were considered lower respiratory tract. | ||
| They couldn't do somebody that just had a sore throat. | ||
| For example, the mild cases were not able to be tested. | ||
| And we had this major bottleneck in testing because it was all initially being done by the CDC. | ||
| And then the state health labs, but there was a problem sending that kid out and there was a little bit of regulatory issues that had to be worked out before hospitals could make their own tests and big lab companies can make their own tests. | ||
| All of that put us really behind and all of that lead time we might've had from the time this appeared in China and became recognized as a problem in China to when we got to where we are today was basically wasted because we had no idea of who had the disease, how to target our interventions or anything like that. | ||
| So I think most people assume or at the very least hope that their governments are doing the right thing. | ||
| But can you take this now down to the personal level and the community level, you know, from as simple as washing hands to just other techniques people should be doing in their daily lives right now? | ||
| So the first message is wash your hands a lot, touch your face less. | ||
| That's the thing that everybody can do. | ||
| Now, because we're in a pandemic state, we have to think about social distancing. | ||
| And that's going to be a little bit different for every person, depending on what's essential to them and what's not essential. | ||
| Starting with people who are older or who have medical problems, they need to start thinking about their interactions with other people and trying to limit their risk, because that's what we're really worried about here. | ||
| This is all designed to help them, because if they end up getting sick in large numbers, we will crash our whole US healthcare system because we don't have the capacity to deal with that many sick people, such as what's going on in Italy. | ||
| Other individuals who are lower risk, you have to think about what you're doing, how you can minimize your time, minimize your contacts without completely destroying your quality of life. | ||
| You might, there's, you know, there's some variation on what people can and can't do. | ||
| Right now we're seeing governors close bars and restaurants. | ||
| And I think that's something that you're going to see more of because there's too much social interaction going on in those types of places. | ||
| And they end up being a nexus for the spread of the virus. | ||
| But I do think that just being common common sense, you know, if you're going to the gym, go at times where there's not that not peak hours. | ||
| maybe order out instead of, order takeout instead of sitting in a restaurant. Maybe, | ||
| and mass gatherings are basically being banned everywhere because of their, their risk. So | ||
| that's not an issue to think about anymore. But it's, it's that type of thing that you're going | ||
| to have to do at least for a period of two weeks, maybe longer to see if we can actually blunt the | ||
| response, blunt the curve basically, or flatten it out because we don't want to exceed hospital | ||
| capacity. So the, the idea is let's slow the number of, the rate of infection so that they're | ||
| coming at a slower clip to the hospital so that they don't get overwhelmed because we're really | ||
| really nervous about that. | ||
| That's the biggest linchpin in our response. | ||
| So I know that you talked about the differences that Italy has just in terms of the demographics and population, but I hear a lot of people saying, oh, we're just two weeks behind Italy. | ||
| Do you think that that's a fair estimation? | ||
| If you look at the numbers, we have a case count around what Italy had two weeks before. | ||
| So I think it is something that people are saying with some evidence behind it. | ||
| I think we're going to start to know if we're going to follow this Italian type of model or we're going to have more of a South Korean outbreak. | ||
| But it's increasingly looking like it might be a little bit of a hybrid between them because we were not as quick with testing mild cases and isolating them as South Korea was. | ||
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Yeah. | |
| Can you talk about flattening the curve? | ||
| That seems to be the phrase that everybody's talking about. | ||
| We're seeing a lot of images on Twitter. | ||
| Sure, sure. | ||
| So what we're talking about here is the epidemic curve. | ||
| So think of it like a bell curve. | ||
| You have a peak in cases and then they go, they peak and they come down. | ||
| What we're trying, and we have a line here where hospital capacity is. | ||
| You want to keep your curve below hospital capacity, even if it means you have the same amount of cases, but you flatten it out so you never exceed hospital capacity. | ||
| So that's what we're trying to do. | ||
| We know that we can't contain this virus, but can we slow the accumulation of cases to a rate that's manageable by hospitals? | ||
| That's what flattening the curve is. | ||
| So you don't have this big peak, you kind of have a rolling peak that's not as, not as A huge of a spike. | ||
| And that's kind of the strategy being pursued by many different countries now in order to preserve our hospitals. | ||
| Where are guys like you turning for sensible information? | ||
| I see online, that seems to be the number one thing just for the average person is we live in a strange time where people don't trust our institutions the way they used to. | ||
| You know, there's always a lot of noise on social media. | ||
| I mean, where are you getting actual information? | ||
| Where should we point people to besides, you know, interviews like this and things like that? | ||
| Well, so obviously, if you're an infectious disease person, you kind of have your own sources that might not be suitable for people in the general public, but there are good sources. | ||
| The CDC is actually a very good site. | ||
| There's a lot of stuff on there that you can use that's actually vetted, and there's guidance and lots of different types of, all types of different scenarios that you could imagine. | ||
| I think I would also make sure that people are looking at their local and state health department websites because if something happens to them, it's going to be local. | ||
| You need to know what's going on locally and what the plant plans are there as well. | ||
| And then I would say for science stuff, I recommend stat news. | ||
| The most stat news is owned by the Boston Globe. | ||
| It's probably the best scientific reporting. | ||
| in the world, that's where I look at that every day. | ||
| And there's another group called CIDRAP, C-I-D-R-A-P, which is at the University of Minnesota. | ||
| That's the Center for Infectious Disease Research and Policy. | ||
| They also put out very good news articles that are easily digestible by the public | ||
| and have a lot of really great factual information there. | ||
| Yeah, I know this is gonna be a sort of vague question, but if you're just the average person and you're at home | ||
| and you're doing these things and you're social distancing and you're trying not to be out there too much, | ||
| I mean, what level of concern should we all really be feeling about this right now? | ||
| So this is a hard question because there's a nuanced answer to it. | ||
| If I'm talking to a patient that I've just diagnosed with this, I'm going to tell them, Don't worry, you're going to be okay. | ||
| You're not going to die. | ||
| This is something that has a very low mortality rate in most individuals, and it's going to be like a severe cold. | ||
| But it's a very different thing when you're talking to a hospital CEO or you're talking to a mayor or a governor, because the sheer number of people that are going to get infected, because there's no immunity to this, is going to be so high that even that small percentage that needs hospital care could overwhelm our hospital system. | ||
| So it's a totally different conversation you're having. | ||
| And I think that's why people are understandably mixed up because they're hearing both of those things. | ||
| And they're both true. | ||
| They're just different contexts. | ||
| And you have to really have that kind of nuanced communication because people then say that you're exaggerating the risk, but we're not exaggerating the risk. | ||
| The risk to the individual is not very low, but the risk to a hospital or to a city or to a town is really high because of the sheer number of people that will be infected. | ||
| So I think when some people hear, oh, there's no immunity or there's no cure, they sort of don't see an end. | ||
| Like, how does this actually burn out? | ||
| So can you explain a little bit about how something that can't be cured at the moment can actually end? | ||
| So what may happen is that we'll see a pretty strong first wave. | ||
| We might get a little bit of a respite in the summertime. | ||
| It's unclear if we will or not. | ||
| Some coronaviruses do decrease their transmission. | ||
| We don't know for sure about this one, but there is some suggestion that we might see a little bit of decrease in transmission over the summer, but it will likely be back in the fall. | ||
| I think this first wave will be bad, and then we'll have enough people immunized by getting infected that this won't be that much of a problem. | ||
| It will be something that we have with us, and it might cause severe disease. | ||
| But until we have a vaccine, this is going to be with us in the population. | ||
| Yeah, all right. | ||
| Well, I'm trying not to overload people with too much at once. | ||
| Is there anything else that we should get out in this initial call? | ||
| I hope as long as this continues that you'll be able to find a little time for us. | ||
| But is there anything else that you really want to get across to people at the moment? | ||
| Sure, sure. | ||
| One thing is, you know, this is an emerging infectious disease outbreak, so information is evolving. | ||
| So when you see something change or some guidance change, you should expect that because we're learning on the fly. | ||
| This is real-time. | ||
| So we're, everybody in the infectious disease field is trying their hardest to try and deal with this. | ||
| It's become the top priority of almost every infectious disease doctor in this country to try and keep everybody safe and understand this outbreak. | ||
| So I just think that sometimes people get a little, they get very fixated on certain numbers and when the numbers change, they think somebody has, you know, somebody's pulling something over their eyes. | ||
| It's not that, it's just that this is so fluid that we don't know what's going on. | ||
| Even between this call, when I started this call with you and now I'm sure something has happened that's changed one of my answers. | ||
| So it's important to know that we're doing this all on the fly and trying to use the best of our minds to come to a solution here. | ||
| All right, well, listen, I really appreciate you taking the time. | ||
| I know you have another hit on CNN in just a moment, and we'll link also to your interview with Sam Harris, which was really extended. | ||
| I wanted to give people sort of as much as we could in a short amount of time, because what I can do is hopefully give a little information to people and not have everybody feel kind of crazy. | ||
| So I appreciate it, and as things develop, we'll reach out to you, and I'll keep trying to amplify your voice on Twitter and the rest of it. | ||
| So thanks for taking the time, really appreciate it. |
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