Front Burner - 'The precipice of a pandemic'

Episode Date: February 28, 2020

From Iran to Italy to South Korea — there are new epicentres for the coronavirus. On Thursday, World Health Organization officials stressed the need for governments to have national preparedness plans and training in place for health-care workers.Today on Front Burner, infectious disease expert Isaac Bogoch returns to the podcast to talk about how the public health response needs to change to address the growing epidemic.

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hello, I'm Jamie Poisson. This is going to come soon, potentially. You've got to be shifting to a readiness, rapid response. There is every indication that the world will soon enter a pandemic phase.

This virus does not respect borders. So up until now, the majority of the over 80,000 cases of COVID-19, the novel coronavirus, have been in China. But despite this unprecedented attempt at containment, the virus has started to spread at an increasing pace around the world. In Italy, the government's racing to contain the biggest outbreak of the virus in Europe. South Korea authorities are in crisis mode. It's no different in the Middle East, where Iran has become the focal point of the epidemic. And it's even made its way as far as Brazil. In just 24 hours this week, seven countries reported their first cases.

Denmark, Norway, Estonia, North Macedonia, Romania, Georgia, Pakistan. And on Thursday, the director of the WHO gave what sounded a lot like marching orders to the world. He said we're at this decisive moment. This is your window of opportunity. If you act aggressively now, you can contain this virus. You can prevent people getting sick. You can save lives. So my advice to these countries is to move swiftly and contain it at its bed. Today, how do we respond? Dr. Isaac Bogosh is here.

He's an infectious disease specialist based in Toronto. And he spoke to us a few weeks ago when the outbreak was in its early days, so we wanted to bring him back onto the podcast. This is FrontBurner. Dr. Bogosh, thank you so much for taking the time today. Oh, thanks for having me back. So I want to start by picking up where we left off last time we talked a few weeks ago. And at the time, the big question was, how contagious is this? And how deadly is this?

And what do we know about that question today or those questions? Yeah, certainly in the last few weeks, we have a greater understanding of, you know, many components of this virus. And, you know, it does appear to be contagious in the sense that we know that people can certainly transmit this virus from person to person and an individual who's infected with this virus can certainly infect many other individuals. What's really interesting about this virus is that the vast majority of people, certainly around 80% of people or even more who are infected with this virus, seem to have a very mild syndrome. And it's interesting because many people who are what we

say subclinical, meaning not sick enough to reach the threshold for seeking out medical care, these are individuals who may be in large number who are affected with this virus, and these individuals may be unknowingly spreading the virus in the community. So that's one component. The other component is, you know, how deadly is this virus? If we look at the numbers of deaths related to the number of infections, you'll start to see things like about 2% or 2%-ish. And that's the mortality rate, also known as the case fatality rate. But of course, we do have a greater appreciation that many people are not coming to medical attention because they just have such mild infection. So

it's expected that that 2% number will likely drop to around 1-ish percent and even lower than that. will likely drop to around one-ish percent and even lower than that. So is it fair for me to say that it's very contagious but not as deadly as some other viruses that we've seen, including SARS? Oh, 100%. I mean, if we're comparing this toe-to-toe with SARS or with MERS, this is a completely different type of infection. And certainly for the vast majority of people, we'll have a much milder course. Of course, we have to appreciate that some people will still get rather sick with this infection. And there's a better understanding over the last few weeks about who those individuals are. People who are on the older age of the spectrum, typically over the age of 65, people who may have other medical conditions. These are people who are more likely to have a more severe course of illness and are more likely, sadly, to succumb to this illness.

Okay, so we've seen this real proliferation of cases around the world recently. It does feel like this week we've entered into this new stage. Another day in lockdown for tens of thousands of Italians. All 16 dioceses of the Korean Catholic Church have halted all masses. Spread worldwide with Iran and Italy getting hit especially hard. As of Thursday morning, Iran had reported 245 cases, 26 deaths. So I know that you and another Canadian researcher think the number is much higher than that. I want to talk to you about that in a moment.

But we're also seeing cases in neighboring states around Iran, and then 500 cases in Italy, 1,700 and counting in South Korea. What do these hotbeds of COVID-19 tell you about where we are with this outbreak right now? Looking at the case numbers soaring in South Korea, in Northern Italy, and of course in Iran, really changed the course of this infection. And earlier on, many people's messaging was, all efforts should be on containing this in China. But the second part of that message was,

we should still be prepared for the scenario that this is not contained in China. And now we're in that scenario. So we see certain, you know, day by day, we're seeing a greater number of countries detect cases. And we're also seeing countries that have known cases show greater numbers of cases. So, you know, I know the term pandemic seems to be a bit of a sensitive word. Right. And last time we spoke, you weren't willing to use this word. And the WHO is also even now not willing to use this word. Yeah. But I mean, essentially, if no one's willing to

use this word today, then we will be using this word in a day or two days or a week from now, then we will be using this word in a day or two days or a week from now. Because that's essentially what this is. I mean, all a pandemic means is widespread global transmission of an infection. It doesn't talk about what the infection is. It doesn't tell you about the severity of the infection. It just means widespread global transmission of an infection. However you want to define it, that's kind of where we're at right now. I want to go back to Iran for a

moment. So there are concerns that the situation there is much more serious than Iran says it is. And as I mentioned, you were involved in some preliminary analysis that suggests it may be upwards of actually 18,000 cases. And this was earlier in the week. Briefly, why do you think it's worse in Iran? So this was really precipitated by having a person fly to British Columbia from Iran and present to a hospital and ultimately getting diagnosed with COVID-19. One of these individuals is very likely and we're quite confident is the source for the case that we announced on Tuesday. I know it seems like a million years ago, it was only a few short days ago, but during that time, Iran was not thought of as a hotbed for this infection. And, you know, that sort of raised

a red flag. And we sort of looked into this a little bit further. You know, if there are people flying from Iran affected with this, and then, you know, we found out there was, at that time, there were two deaths related to it, you know, the burden of infection in that country must be significant if people are, A, flying out of the country with the infection, and B, succumbing to this infection. The take-home point isn't the exact number, but the point is that there are a significant number of cases in Iran. And, you know, we're not here to shame and blame anybody. This is really just a wake-up call to Iran and, of course, neighboring countries and, of course, the world to say there's likely significant transmission in this region. And we should

certainly recognize that we need to expand our focus of where cases may be exported from. Right. And of course, your research is bolstered by reports coming from inside the country, people who are accusing the government of essentially not being honest about the number of cases. The state TV gives us statistics, but when we go to the hospitals, we see something different. TV gives us statistics, but when we go to the hospitals, we see something different. This presenter actually claimed that perhaps with warmer temperatures, the virus may vanish. Maybe the weather will warm up and it will go away, like the flu. Have some patience. I know when we talked before, we were looking at China and these incredible measures that the country was taking to contain this virus, the proliferation of cases that we're seeing, does it mean that that attempt at containment failed?

Yeah, 100%. But I think that another way of looking at it is containment may, question mark, lots of question marks, have been possible if it was performed on that scale significantly earlier. And the key word there is may. And many people might disagree with me on that. And of course, that's fine. But the other key point is those tremendous public health initiatives in China certainly slowed down the progression of this virus on a global standpoint. The Chinese have put really exhaustive measures in place. WHO is already working very closely with China

and information is being provided. And it certainly bought the rest of the world several weeks, maybe a couple of months, to really prepare for more and more exported cases. And most of the people who are watching this closely appreciated and knew that this was only going to buy time and that containment was unlikely. And hopefully, governments and healthcare systems use their time wisely to really scale up capacity such that they will be prepared for, you know, the inevitable introduction of cases to their country and also, you know,

the possibility of locally acquired cases in their country as well. In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization. Empowering Canada's entrepreneurs through angel investment and industry connections. I want to pick up on that, the idea of using this time wisely and come back to Canada with you. But first, I want to play you some tape from Thursday's World Health Organization news conference. The director general laid out a list of important questions. He said if the answer to any of them is no, the disease will exploit this gap.

So let me just play you this clip. Are we ready for the first case? know the disease will exploit this gap. So let me just play you this clip. Are we ready for the first case? What will we do when the first case arrives? Do we have an isolation unit ready to go? Do we have enough medical oxygen, ventilators, and other vital equipment? How will we know if there are cases in other areas of the country? Is there a reporting system that health facilities are all using and a way to raise an alert if there is a concern? Do our health workers have the training and equipment they need to stay safe? health workers have the training and equipment they need to stay safe? Do our health workers know how to take samples correctly from patients? Do we have the right measures at airports and border crossings to test people who are sick? Do our labs have the right chemicals

that allow them to test samples? Are we ready to treat patients with severe or critical disease? Do our hospitals and clinics have the right procedures to prevent and control infections? Do our people have the right information? Do they know what the disease looks like? Are we ready to fight rumors and misinformation with clear and simple messages that people can understand? Are we able to have our people on our side to fight this outbreak? Dr. Bogash, is the answer to any of those questions here in Canada no? I mean, first of all, that is a great list of questions.

That is extraordinarily well thought out and really encompasses a holistic approach to epidemic preparedness. And, you know, I can look at that list of questions and certainly opine on all of them, but I really think that we are well prepared in Canada, especially relative to the rest of the world. I mean, we have, over the last few weeks, really worked on, as a Canadian healthcare community, as a public health community, as a laboratory community, Canadian healthcare community, as a public health community, as a laboratory community. I mean, there has been certainly the scale-up of, you know, preparedness for diagnostic testing, for communication, for systems of managing patients, you know, and, you know, we have very senior public health officials in the country, both at the federal level, Dr. Theresa Tam, and at the provincial levels, and even at the city levels, and sometimes even at the hospital levels, we have very open communication as well. The other thing I think is important is that, you know, there's a small silver lining here. We always talk about,

you know, hospital crowding and, you know, a burdened health care system in Canada. One of the silver linings is that when this starts to pick up or when this is at least anticipated to start to pick up in Canada, our influenza season will be closing or closed. And certainly it is busy. The hospitals are busy during the influenza season. Luckily, I'm not sure if that's the right word, but a lot of this will be lightening up around the time we're expected to see more cases. That's interesting. I hadn't thought about that. What about other institutions like schools and workplaces? What should they be doing right now? Yeah, I mean, I think it's all hands on deck at the moment. And certainly we hear a lot of discussion about, you know, making alternative arrangements for perhaps workplace shortages,

you know, ensuring people have appropriate time to, you know, work from home if that's a possibility and, you know, ensure that people don't come to work or come to school if they're sick. You know, now is the time where we're really starting to hear communication from senior health care officials in the country to really inform the general public about how we're going to prepare for the coming weeks and months ahead. I was listening this week to the CDC, the U.S. Centers for Disease Control and Prevention. Our goal continues to be slowing the introduction of the virus into the U.S. This buys us more time to prepare our communities for more cases and possibly community spread. The new virus represents a tremendous public health threat.

They said that they're now expecting COVID-19 to start spreading on a community level in America. You mentioned this idea before. So they've identified a case in California where someone got the virus without having traveled from a country affected or being in contact with someone who was there. So basically, the way I understand this community level spread is that they don't really know where it came from. Health officials confirm a new case of coronavirus of unknown origin. It was diagnosed in Northern California. We don't know where this person picked up the coronavirus nor exactly how long they've had it. This was a person who had not traveled to anywhere, did not have any significant risk factors for getting this infection, and was probably sick and shedding virus for days before this individual went to seek health care.

And now we hear that this person was at one hospital, the term is intubated. They didn't do any tests for coronavirus because the person didn't fit the mold of somebody who might have coronavirus, didn't have those risk factors. So this person was in that medical center for an unknown amount of time making contact with an unknown amount of people. So you have to think, you know, A, what is the burden of infection in Northern California where this individual was living and where did this person acquire this infection? B, how many people did this person infect?

And really, as we sort of chatted about a few moments ago, this is an arrow pointing in the direction that, you know, there will be community transmission of this infection. The governor and state health officials really tried to quell anxiety surrounding the coronavirus. As of today, we have 33 confirmed positive tests for the virus. Five individuals have subsequently moved out of state. So there are 28 people that we know in the state of California that are positive. You know, it goes beyond just imported cases.

And these imported cases can start chains of transmission in a community that are just not recognized by the health care system for some time, likely because most of the people aren't sick enough to seek medical care. And then there's a sentinel event where someone gets really sick, like this individual did. Someone raised a red flag and appropriately ordered a test, and voila, you have a positive case. But that's clearly the tip of the iceberg. With this concern of community spreading, should we be changing how we've been screening people here in Canada? Yeah, I think in Canada what we're doing is we're really trying to keep up with the ongoing global spread of this infection. So, you know, when we look at places that we should be screening for, we've added Iran, South Korea, Singapore, several countries that have known burden of infection to this list. I think eventually what's going to likely happen is it's going to be a syndromic identification of cases for testing,

meaning someone presents with like, you know, a fever and a cough and we'll say, you know what, that's enough. It doesn't matter where you were. It doesn't matter who you've been in contact with. That's going to be enough to order a diagnostic test. I think we're going to be headed in that direction soon enough. Is it possible that we may never eradicate COVID-19 or that it will take a very extended period of time to eradicate it? Could this just be endemic? You know, some people say this might just burn itself out. Other people say this is going to

integrate itself with seasonal viruses, and we're just going to see this come back in the wintertime. Other people say that there's just going to be low-level transmission year-round. And, you know, these are all speculative, and that's fine. I mean, I think it's really important to think about the future and plan for it. But really what this tells me is that significant efforts should be poured into vaccine development. You know, clearly, it's not going to be the last coronavirus we see. And clearly, this is the most widespread of the novel, I'm trying to use my words carefully, but the novel coronaviruses that have emerged over the last couple of decades. Right. This is something that we talked about last time you were on the show,

something we've talked about with your colleague, Dr. Cameron Kahn as well, this idea that we haven't necessarily in the past taken the steps that we should have been taking to be prepared for these kind of epidemics and pandemics. I know we've covered a lot of ground today, and I wonder if you have a clear parting message for someone who might be listening right now, who is worried, who's concerned about this and is hoping to be reasonably prepared. Yeah. I mean, we're all really sitting here as individuals at the precipice of a pandemic. And I think it can be daunting. It can feel daunting. What can I do as an individual? But, you know, just I guess with a uniquely Canadian message, you know, you keep your head

up and your stick on the ice. Be aware of the world around you. Get some good resources and sources of information that are quality, like from your local, provincial and federal health agencies. The WHO has a great website as well. And these are places where you can really keep your head up and have quality information about what's happening in the world around you. If you have chronic health care issues, now is the time. Now is the time to go to your physician and make sure that those are tended to. Now is the time to fill those prescriptions that you have.

Now is the time to make sure you're up to date on all your vaccinations. Also, the other thing is, I get it. This is not the flu. This is certainly, this is not influenza whatsoever. But the same rules apply. It is a respiratory illness. Okay. Dr. Isaac Bogoch, thank you so much for coming back on the podcast and hope to talk to you again soon.

Anytime. Have a good one. All right. So before we sign off today, concern over the spread of the coronavirus globally, well, it is having some pretty significant impacts on the global economy as well. Financial markets around the world rocked overnight amid new concerns about the spread of the virus. Global markets tumbled Thursday for the sixth day in a row. Roughly $2 trillion has been wiped from the U.S. stock market in just a matter of days. The last time the Dow fell this much in a week, it was during the 2008 financial crisis. A big drop came after announcements in the U.S. and Germany this week that they both had these community-level cases, what Dr. Bogosh

and I were talking about, cases where public health officials can't trace the source. News broke after our conversation that California is now monitoring 8,400 people for symptoms. California is now monitoring 8,400 people for symptoms. That's all for this week. FrontBurner comes to you from CBC News and CBC Podcasts. The show is produced by Mark Apollonio, Imogen Burchard, Elaine Chao, Shannon Higgins, and Derek Vanderwyk. Our sound design this week was by Billy Heaton, Matt Cameron, and Mandy Sham. Our music is by Joseph Chabison of Boombox Sound. The executive producer of Frontburner is Nick McKay-Blocos.

I'm Jamie Poisson. Thanks so much for listening. And talk to you all next week. Actually, Josh Block from the podcast NXIVM is going to be sitting in for me on Monday, but I will see you on Tuesday.