An Interview with Amesh Adalja
RWT: This is Salon of the Refused, I’m Rob Tracinski. My guest today is Amesh Adalja, and he’s a senior scholar at the Johns Hopkins Center for Health Security, and I’m talking to him about the coronavirus pandemic.
Now, the first big question, the sort of overarching question people want to know is: Are people panicking about this?
Amesh Adalja: That’s a hard question to ask, because there are definitely people that are panicking, and they are hoarding certain materials in their house, they are buying masks that they don’t need, they’re wearing gloves when they probably don’t work for the general public, but there is—that’s one end of it—but there is a difference between panicking and being proactively ready for a pandemic, and trying to take steps to minimize your risk and the risk to those that you care about.
And I think that’s sometimes hard to do from a media perspective or even as an infectious disease doctor try to talk to people about what to do without panicking them, but with getting them proactively ready for something that will likely be severe and disruptive—but won’t necessarily kill them but may kill people that they know and kill people that are high-risk and really put the US healthcare system into a surge mode where we may end up having a capacity problem.
RWT: Right. The surge mode is, I think, the important thing. So let’s talk a little bit about what the magnitude of the risk is, get some idea of what’s going on here. And the big question I think is how this is different from the seasonal flu, in terms of—how contagious is it?—how many people are going to get it?—and especially the mortality rate.
Adalja: Okay, so starting with—this is a novel coronavirus. We have other coronaviruses but this is a new one that was discovered that can infect humans. And because of that fact, there is not much cross-immunity to it. That means that most individuals who are exposed to it are going to get infected. And we know back from 2009 H1N1, when a novel flu virus was discovered, that about 20% of the world’s population got infected.
So we can take that as kind of the lower limit. So this is going to be—you know, 30 to 50 percent of people are going to be infected over a period of about a year or so, is what I think is the most likely scenario.
RWT: That’s as opposed to something that’s a variation on an existing virus that’s been around, so a lot of people have some degree of immunity to it.
Adalja: Exactly, This doesn’t have—we don’t have population immunity or herd immunity to this, and that’s why you’re seeing high (what we call) “attack rate,” that this can infect a lot of people. It doesn’t mean a lot of people are going—the majority cases are going to, again, be mild—but that’s a lot of people getting infected. And even if the majority are mild, the ones that are not mild, that need hospitalization, that need ICU [Intensive Care Unit] care—that what we’re worried about, burdening our hospitals. And that’s what we’re really preparing for. That’s what all of this is about is that group of people, not the ones that just have mild symptoms—although those with mild symptoms can then transmit it to their grandparents or their friends—and that’s what this is all about, this idea of “bending the curve.”
You asked about the mortality, and that’s kind of been a controversial subject because we don’t quite know exactly where to put this, because there’s something called the Case Fatality Ratio (CFR), and we’re trying to understand what percentage of people who get infected die from this. And that’s a number that you can only say with accuracy when you have full capture of what this disease’s spectrum of illness is. And when our testing in the United States and all over the world is skewed towards people who are hospitalized or are coming to a healthcare facility, you’re getting a lower denominator because you’re not testing the mild cases, the people who may just have a runny nose. So you can see why differences in the CFR are based on that. So for example, in Hubei Province in China, the CFR might be three to four percent, but outside of Hubei province, it drops to lower than one percent in some places, and in places like South Korea, where they’ve done extensive testing, the CFR is around 0.85 or so percent. So it’s very different based on that testing.
But we do know, even if you take a lower bound of 0.85%, or anything in that—0.6, 0.7, even if we figure out it’s lower than 0.85, that’s still about eight times worse than the worst seasonal flus that we have.
RWT: Right. The seasonal flu is about 0.1%. And you mentioned the issue that it’s a novel virus, and that really important. That means it’s totally new, and it means you don’t have a lot of information about it.
RWT: And you’re sort of figuring out what it is. But it’s looking like—with the regular flu, they have great estimates, a lot of experience making estimates about how many people actually get infected versus how many people, then, for whom it’s fatal. Whereas here, you don’t have that information, but it’s looking like it’s significantly—like, on the order of one order of magnitude higher than the seasonal flu.
Adalja: Right. And remember, during a severe seasonal flu outbreak, for example 2017 to 2018, our hospitals are really stretched, where you’re triaging people in the parking lot. And that’s important to remember. So we’re not equipped in our hospital systems to be able to deal with this type of an influx of patients, and that’s what people are really worried about. If we have anything approaching what we’re hearing about in the northern part of Italy, it could be disastrous. And it’s unclear what’s going on there, but if that type of scenario happens, we don’t have that kind of—we don’t have the ability to increase ICU bed capacity.
RWT: So let me be more specific about that, because what’s going on is, from what I understand, that 80% to 90% of the people who get this COVID-19, this new flu, new virus, it’s relatively mild, it’s like the regular cold or flu. But for 10% to 20%, it’s very severe, and for half of those people or maybe a little under half of those people, they actually require intensive care hospitalization. It requires being on a ventilator, and that’s the real rub of this, which is that—let’s say, 60 million people in the US get it, you have three million people who need intensive care. That is a huge overwhelming of the system, and that’s what’s going on in Italy.
Adalja: Exactly, and that’s what we’re worried about: an intense transmission that causes hospitals to go above their capacity, unable to meet that capacity, and then basically have kind of the systemic failure at the hospitals and that’s what—when we hear about “bending the curve.” What that means is kind of a euphemism for just, instead of having this really high spike, this really high peak, maybe making it more smoother, and come up more gradually. Maybe the area under the curve, meaning the number of cases, is the same, but if they occur over a longer period of time they never exceed the capacity of the hospitals, they stay below hospital capacity—then I think we’ll be okay.
So that’s why you’re seeing aggressive social distancing being performed here in the United States, kind of following the South Korean example where they haven’t had that type of disruption because they were pretty good at identifying people that were infected and isolating them so they couldn’t transmit to other people, and they’ve been able to kind of keep their curve down. And some of what China did—they did a lot of bad things, but if you piece out what was actual proper public health things to do, was identification of cases and isolating them.
Not all of the internal travel bans and the free speech suppression or the military people at the rail—at the internal travel controls, the military people at the train stations—that’s not the right thing to do. But actually finding cases and then keeping them away from other people while they’re contagious, that’s a core principle of public health, and that’s what really will work. And that’s why we’re trying the social distancing in the United States, and maybe it’s going to have some impact, maybe it’s not. But we’ll know in the next couple of weeks, I think.
RWT: What I’m also seeing in the US is that we were very slow to do the South Korean solution, which is aggressively testing, test everybody, find the people who have it, isolate people who have it to keep them from spreading it. The testing hasn’t really gotten off the ground or is just now getting off the ground in the US.
Adalja: Right, so what happened with the testing was that initially this was something that the CDC was performing. And that’s one part of it, that there was obviously a supply constraint. When you only have one lab doing this, they’re going to get backlogged. And the other issue was that the testing guidance was really premised on the fact that this was a travel-related illness, at least that’s how it was conceptualized by many people, that you had to have traveled to China. But we knew that this virus had been spreading since November in China, and it’s a respiratory-spreading virus that spreads efficiently between humans. So that means that it’s not going to respect borders. And you give a virus like that a head start, it’s going to be everywhere.
So we knew, even when first started thinking and hearing about this, that there were going to be more cases there, just like we knew during 2009 H1N1 that, when we saw cases in Mexico, that there would be cases everywhere, and it wasn’t going to be something that was restricted to just travel to Mexico. However, that guidance kind of persisted, and it kind of got seared into people’s minds, including doctors’ minds and hospital administrators’ minds. Many tests were not ordered on people, and even if they were, they would have been backlogged.
Then the CDC tried to put out their tests to the different state labs that were out there, and that kind of a really failed rollout, because there were some problems with those test kits, which then delayed it. And again, we’re having a massive capacity problem.
Then you have this other paradoxical thing that happens. We have a public health emergency declared, and by definition that makes things easier, usually, for manufacturers of vaccines and medications. But on the other hand, it makes it harder for diagnostic companies because in a normal era, there’s not any regulation of what are called Laboratory Developed Tests, LDTs, that big hospitals can make and companies like Quest and LaCorp can make. And those tests are used all the time on people, on their own patients, and they don’t go through FDA regulations. But during a public health emergency, they end up having to go through emergency regulations and that basically paralyzed them to make things quickly, because they had to make them in such a manner that they would pass the FDA muster. And that slows things down.
That’s been a major rollout problem with these tests. At the same time you have administrators and hospitals being very wary of their doctors just ordering the test because they don’t know what to do, they don’t really know what to do with these patients if they get them because they may end up exposing a lot of people in their hospital, because maybe the test kit wasn’t collected properly and people got exposed when they were testing it. And then that becomes like a cascading figure. So hospital administrators tell doctors, if you’re ordering a test we want to know about it and we want to adjudicate that test. So, it’s not seamless like the way a doctor can order an HIV test, for example.
They put a lot of barriers into our testing, and then you have the federal bureaucracy that happened with that rollout, and then you have the little hospital politics that play a role, and it’s really a recipe for disaster when it comes to diagnostic testing. And we never thought that—when you look at pandemic preparedness, we all thought the diagnostics are really important, but we never thought that’s where our failure would be, would be in diagnostic testing. Now we’re left with no situational awareness in the United States. And that’s why you’re seeing all these closures, almost one size fits all, because we don’t know what’s spreading in the community because we don’t have any testing done to know which communities are impacted more than others, and where they are in each of their communities’ epidemic curves.
RWT: It strikes me that, because of the testing problems, we aren’t able to do the South Korean solution, so we’re doing the more draconian version of the Chinese solution, which is: shut everything down.
Adalja: That’s one thing, because South Korea could just say, we know you’ve got it because you went through our drive-thru, we tested you, so you stay home and don’t expose other people for 14 days. We don’t have that luxury, so right now, you kind of have to assume that anybody that has a respiratory tract infection has this virus, and many of them probably do. And there’s no way to have these nuanced solutions that are perfectly targeted. You have to do this pretty aggressively, especially with word of what’s going on in Italy, if that is actually true. People are really worried about this exceeding hospital capacity and that we’re going to have a much harder time than we thought, because people assumed that we would be able to do a South Korean type solution, but our diagnostic testing has not allowed us to do it.
RWT: So that explains why I, like just about everybody, have been getting a steady stream of calls and emails in the last couple days that this is being canceled and that’s being canceled, and your kids are going to be home for the next three weeks, and all of that. And we’re doing that because we weren’t able to do that South Korean solution.
Adalja: We missed a lot of transmission chains that are out there that are just not come to notice because we don’t have any way to test them.
RWT: So we talked about what government did and what it failed to do. What should individuals be doing?
Adalja: Right now, individuals should be—not panicking—they need to be cognizant of the risk that to them might be very small individually, but they may inadvertently become a transmission belt for this virus into someone that could have a hard time.
So I think it is really good to be mindful about what you’re doing socially and trying to minimize your social contact as much as you can. We know this is going to be disruptive to people’s lives, and each person has their own hierarchy of what they think is important to them, and what is essential and what is nonessential to them. But we want people to start being mindful about it, especially if you’re elderly or you have other medical problems, maybe not attend mass gatherings, maybe try to minimize your non-essential travel, maybe find ways to modify your activities so that you are less exposed to people.
RWT: People talk about the no-contact greeting. I’ve been trying to get people to adopt the Vulcan hand gesture, the Vulcan salute. But the non-contact greeting, so that you are not touching people and passing things on that way.
Adalja: That’s definitely one thing that you can do, and washing your hands as much as possible, touching your face as least as you can, which is sometimes very hard for people. And then just kind of thinking about, can you work from home? Can you do other things from home? Do you really have to be there in person? And I think we’ll know maybe in two weeks or so if this is going to work. And I think by that time, we’ll have some idea of what kind of trajectory we’re having. If you start hearing about is ICU patients, emergency department crowding, we will start to know that probably within the next week or so. Which is kind of a scary prospect that we’re all going to see this soon and have an answer.
But I think this is something that we’ve been projecting happening. We were ripe for a pandemic, and I think that this is what we’re seeing right now.
RWT: One of the things—I know you’ve been tremendously busy the last week, that your field of expertise is suddenly greatly in demand, someone to tell people what’s going on here. I want to ask a question maybe you haven’t been getting because everybody’s been talking about the next couple of weeks. What’s the long-term end game on this? I mean, what does this look like a year, a year and a half from now. Are we basically trying to contain the spread of this thing, slow it down enough until we get a vaccine? Or until we get herd immunity built up or—what is a long-term end game for how this all ends up?
Adalja: So it is a combination of all of that. Coronaviruses tend to exhibit some seasonality in temperate climates. So we may see some dampening of the transmission, not completely, but maybe significantly.
RWT: It is going on in Australia, where it’s late summer.
Adalja: It’s not going to be ironclad because there’s no population immunity to help with that kind of seasonality, but there are coronavirus that do exhibit seasonality, that spike in the colder months and go away in summer, not completely, and we may see some of that. But I do think that this coronavirus is going to be with us for some time, that this has made itself endemic in the human population. We’re going to see a large proportion of the human population infected, and it will likely, probably hit us again in the fall next year, mixed in with flu season, which could be very harrowing. And I think that the only solution to this is going to be a vaccine, which we’re accelerating in development, but this is going to take some time. Vaccine development is measured in years, not in months. And that is going to be the only way really that we can control this infectious disease, like it’s been the way that we control any infectious disease. So I do think that we’re going to face this for some time.
I do think it will dampen as we get herd immunity, that it won’t be the same threat as more and more people get infected, but we are going to be in for likely a rough first wave.
RWT: So basically what we’re seeing is what eventually will happen is so many people either had the virus and already have antibodies to it or have had the vaccine that it can’t get going as a pandemic anymore, because they’re just aren’t enough people who are able to spread it.
Adalja: Right. It’s not going to have enough victims that it can use to spread in this kind of manner.
RWT: Well, I appreciate your taking the time. I know you’re tremendously busy right now. I appreciate you taking time to talk to me.
Adalja: Sure, any time.
RWT: My guest today has been Amesh Adela, an infectious disease specialist and an expert on the coronavirus spread.
Thank you for listening.