This Podcast Will Kill You - COVID-19 Chapter 4: Epidemiology

Episode Date: March 23, 2020

The fourth installment of our Anatomy of a Pandemic series takes a look at some of the epidemiological characteristics of the COVID-19 pandemic. But first, we hear about the experience of Katie Burson, who was quarantined along with her family on the infamous Diamond Princess cruise ship in February 2020, when cases of COVID-19 were reported among guests. Then we review some of the disease ecology of the SARS-CoV-2 spillover event and walk through a timeline of the pandemic, which, we have to admit, is pretty chilling to hear. We are joined by Dr. Carlos del Rio (interview recorded March 20, 2020), who chats with us about updated estimates for the R0 of SARS-CoV-2, reasons for regional variation in case fatality rates, and what the deal is with the slow rollout of tests in the US. We wrap up again by going through the top five things we learned from our expert. To help you get a better idea of the topics covered in this episode, we have listed the questions below: Do we know what the R0 is for this virus? (27:44) Is there a risk for a second wave of infection in China or other places where the disease seems to be slowing down? (29:31) What are the stages of an epidemic curve and what does it mean to flatten that curve? (31:03) Are people who get infected able to be re-infected or are they immune? (32:45) What is the relative effect of social distancing vs herd immunity? (33:31) How can we convince people who can stay home to actually stay home? (34:40) What are the differences between populations that contribute to the differences in case fatality rate between China vs Italy vs South Korea, etc? (36:28) What might we see in terms of numbers of infections or how long the outbreak will last? What's the end game? (38:00) Should the measures that have been enacted in some parts of the US be happening even in places with fewer cases so far? (40:55) Is this virus likely to become well established and another 'seasonal' respiratory infection? (42:16) What's the deal with testing in the US? Why was rollout so slow at the beginning? (43:14) When should a person try to get tested if they suspect they're infected? (45:58) What has this outbreak taught us so far about our ability to respond to pandemics, and how can we do better moving forward? (46:36) See omnystudio.com/listener for privacy information.

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Val, bad fun. Outdo it with Intuit QuickBooks. Feature availability varies by product. So I'm Katie Burson. I live in Japan with my husband and two daughters, Louisa and Zuzu. They're five and three. And we had heard about the coronavirus,

which is what we were calling it at that point, maybe just a few weeks before we were scheduled to go on our cruise. The cruise was leaving out of Yokohama, coming back to Yokohama. It was really ideal because we didn't have to fly anywhere, which we thought would be safer. But, you know, my mom, who is actually a manager at a hospital laboratory, was all up in arms. She's like, please see if you can cancel. I'm really worried about it. And we were like, oh, mom, it's fine.

And so, you know, we actually had to meet with the preventative medicine officer because we're in the service prior to leaving just to make sure our vaccinations were up to date. And we were, you know, aware of what the risks were. And it didn't really come into play. We met with her two weeks prior than the week prior to our departure. And it wasn't a concern. It was just wash your hands, you know, like, don't be stupid. So my husband and my daughters decided not to get off the ship in Hong Kong because we didn't want to risk it with the girls. We didn't really know what we were dealing with, but I went ahead.

I wore, that was our second stop on the cruise. So we're like five days into the cruise. I carried my hand sanitizer. We exercised what we thought was, you know, extreme caution, which at this point, now we actually know what extreme caution is. But anyway, I came directly back onto the boat, got in the shower, washed the clothes. You know, we were trying to be as careful as we could. I didn't say hello to the girls. They were in their kid camp for the day until I had like thoroughly de-jermed.

But then, you know, we carried on. We didn't have any other real concerns or red flags with the virus until we got to Okinawa, which was our last stop of the cruise. And they said that, you know, the Japanese Ministry of Health is exercising caution and needs to scan each individual passenger prior to them deba boarding. So we were delayed somewhere between three and five hours getting off the boat because they were scanning everyone. And so we thought, man, you know, I guess things are ramping up.

It must be, you know, more of a concern, but we still didn't think or we didn't know. and I don't think anyone did know what it really was like the animal that we were dealing with. Until two days later, when we arrived in Yokohama and errands, this part was like so surreal. We're sitting there at our last dinner. And the wait staff must have known what was up. They must have been briefed because they didn't miss a beat. They continued serving. They didn't pause to listen.

There wasn't a reaction. But the captain came on and he spoke in English first. And of course, the dining room is primarily English passengers, Japanese passengers. So he spoke in English first. He explained that there was a passenger who had boarded at Yokohama, stayed on only until Hong Kong, and then de-boarded because he wasn't feeling well. And Hong Kong was his home. And he had tested positive for the coronavirus.

And so, you know, my husband and I just kind of look at each other. We don't want to react because we don't want to alarm the kids. And also, we didn't really know what that meant for us. So we sat and we listened. And then because we knew what was being said once the announcement was being made in Japanese, it was really kind of eerie because I'm looking at the Japanese passengers as they're receiving this information. And I could see the colors draining from their face.

Like they were great, you know, and it was very somber in the dining room. We finished our meals. And we went back to our room and we had to call, you know, a couple of people that my husband work with and say, you know, here's the situation. And we packed, you know, we were ready to get off the boat the next morning at seven in the morning. And of course, seven o'clock rolls around. There's no announcements. Eight o'clock rolls around. There's no announcements. Nine o'clock rolls around. The ship is being quarantined for a full 14 days. And so we just, you know, we took it.

as that, you know, it looks like we're going to be here for a while. We explained to our girls, there are bad germs. We don't think we have any, but we have to keep them away. We're going to be washing our hands. You may not leave the room. And every day was different as far as the information that we received. Obviously, the ship was in reaction mode. So we didn't receive our meals that first day until like three o'clock in the afternoon, which is really hard with kids. But we never blamed them. There was never any anger. It was just everybody's trying to do their best to keep this thing contained.

Really, the staff and crew on the ship really rallied to keep the kids entertained. I mean, gosh, they ate so many kids' meals and they had so many toys delivered. You know, we just exercised extreme caution. And it paid off. We all came off healthy and well. And then we went straight from the boat to another 14-day quarantine because we live on a military base. People look at me and they're like, God, you've been through something. And it must have been so hard.

But really, like truly, I got to wake up with my babies snuggled next to me every day. I didn't have to cook. I didn't have to clean. All we had to do was play and be together. and hope for the best. You know, like, you just control what you can. And as a military family, I have never, in my entire marriage, or since my kids have been born, had six weeks of my husband all to myself.

And really, the outcome of it, it was kind of just this, like, beautiful moment in humanity. Like, so many people cared. I mean, I was hearing from people that I haven't spoken. to in probably 20 years. And it wasn't just like a little message on Facebook. It was like this like in-depth message, like I'm praying for you. You know, we can send you things. What do you need? It was just really beautiful. People were delivering breakfast, lunch, and dinner as if I couldn't cook. Like they wanted to do nice things. They wanted to reach out and help. And it just made me feel like so love and so supported. And I think.

that would be like a really great takeaway from this tragedy is, you know, like when we can work together and support each other, it's a beautiful thing. And we should also value our older generations. So you just heard from Katie Berson, who we were so excited to connect with and talk about her experience on the Diamond Princess. She was on the Diamond Princess, y'all. Yeah. That's like, that's wild. A big deal. Famous. So. Thank you so much, Katie. Also, I just, Katie, what an incredible human. She had the most positive outlook I have ever heard from someone who went through something

like that and really helped me try and see silver linings in things as well. So I just really appreciated getting to speak with her, too. Absolutely. Hi, I'm Erin Welsh. And I'm Aaron Alman Updike. And this is, this podcast will kill you. Hello. Welcome to Chapter 4 of our Anatomy of a Pandemic series on COVID-19.

So far, we've discussed the biology of the virus, how the disease progresses, and the control strategies that we're using to slow its transmission. And in this episode, we dive into the epidemiological characteristics of this pandemic. We brought back the amazing Dr. Carlos Del Rio, who chatted with us in our first coronavirus episode back in February about the importance of investing in global health. You might remember his excellent Dolly Parton quote to go along with that. I sure do. So in this minisode, we ask him all about the are not of the virus, that reproductive rate of the virus, and how to bring it down, what flattening the curve means, and why we see different case fatality rates in different regions of the world, and the absolute necessity of acting

now to help slow the spread of this disease. But before we get into that, we have some business. to take care of. It's quarantine time. What are we drinking for this one? A pickle martini? Is that right? Yeah, that's the one. A pickle martini. Quarantini for our first ever martini? No, Bubo Bavita. Oh, you're right. That was so long ago. Does it even count? Steel trap, Aaron. Steel trap. Do you know how difficult it is to like think of, I'll be like, oh, this is a great recipe? And then I'm like, And I have to scroll through all of the old ones. Oh, if you also didn't know, we have a great resource of all of our quarantinis on our website, by the way. Yes.

You can click the Quarantini tab. And all of our Plessy Buritas, the non-alcoholic version, which will post the recipe for this. Pickle pickled jalapeno martini. Yeah. You could also just use a pickle if you don't have pickled jalapinas. I didn't have a pickle, so I had to use pickled jalapinas. Desperate times, you know? Desperate times.

I wasn't going to go to the store for a jar of pickles. No, of course not. It's shelter in place, Aaron. Shelter in place. Before diving into the interview, we also wanted to talk a bit about the disease ecology, since that's kind of our forte, of spillover events in general, and then go through a timeline of events to give us an idea of the spread of this virus. This timeline is, it's intense.

It's intense. But it really gives us a good picture of what exponential growth really looks like. And how fast a disease like this can spread across the entire world. Math, man. Who knew? Who knew? Mathematicians, that's who. Modellers, statisticians. Good point. Epidemiologists. Anyways. Anyways. The ecology of COVID-19 and its emergence, it deserves a more nuanced discussion than I'm going to give it here, because we want to get to the meat of this episode quickly. right? But we wanted to touch on a few things. As has been reported in peer-reviewed articles,

as well as from experts on these episodes, this virus likely emerged from a bat, which is also where SARS originated. From bats, the COVID-19 virus was probably passed to another host before infecting humans. This sequence of events, a virus spread from bats to other animal species and then to humans, it's not unprecedented. In fact, this has happened in many other disease outbreaks. And it does not mean, in bold, underline, it does not mean that killing bats or destroying their habitat will prevent spillover events. So don't get your pitchforks out and start to try to kill all the bats. No, we're not blaming bats, quote unquote. Blaming. This is how ecology works. It's just, it doesn't mean that bats are malicious or that we should kill the bats. In fact,

doing those things like culling bat populations or destroying their habitat, that has been shown to actually lead to an increase in disease outbreaks from bats and spillover events from bats. So bat conservation and the preservation of habitats is actually one of the most important ways that we can reduce spillover events and funding bat conservation, especially in regions that may not have the resources to do so. That is crucial in this fight against emerging infectious diseases. Also, bats provide really important ecosystem services. They're pollinators, their seed dispersers, they eat insects, ones that annoy us, for example. And they're also one of the most amazing and fascinating groups of animals on this planet. This is our personal opinion.

And the role that some bat species play in some spillover events from wildlife to humans cannot and should not be ignored. This is a multifaceted problem. Ignoring it prevents a complete understanding of the ecology of these events and how they happen, and it can ultimately be more damaging to bat conservation. If we want to prevent spillover, we need the complete picture. If you would like to read more about the ecology of bat virus spillover events, there are a couple of great papers by Dr. Raina Plowright.

Boop, boop. She's awesome. And we'll link to those on. our website. We're also going to put up a paper that discusses a lot of the ecosystem services that bats provide that's by Coons at all on our website as well. Cool? Cool. Don't hate the bats. Don't hate the bats. But also don't ignore the role that they play in these spillover events. Right. Okay. Now on to the timeline. It's a big one. Let's start at the beginning. It's like eight pages of timeline. I know. But, you know, but, you know,

know, we're just going to work through it. But I will say that, you know, this is not even a complete timeline. Like we cut a lot of this out. And so what I have, one of the great resources I have found is, and so this is where we got all of this timeline information, basically, is from Al Jazeera. They have, they're continually updating a timeline about COVID-19 across the entire globe. And so if you want really detailed information, that's the place to go. Awesome. Okay. So Chinese officials are still looking for the patient zero, quote unquote, of COVID-19, but it's possible that they will never be identified. But what is clear is that the disease had been spreading for a while before it was recognized as a novel infection and one of concern. So what might be the earliest case of COVID-19 was traced to November 17, 2019 in a 55-year-old person, but that has a hasn't been confirmed. If it is, though, that predates the wet market where the first apparent

cluster of COVID-19 emerged. So community transmission might have been going on for a while before it was recognized, or it could have been amplified at that wet market. But the market may not have necessarily been the site of the spillover event. Which I feel like kind of makes sense to me in some cases, because I know early on they were trying to identify like what animal at the wet market and we couldn't really find a good one. So if it was a person at the market who just happened to be there infected that ended up causing sort of this spread, that kind of makes sense. Yeah. And honestly, a delay in recognizing a novel disease, especially a respiratory infection whose symptoms can pretty easily be mistaken for diseases caused by a number of other

respiratory viruses. It's not that unusual. It might take a while before you really realize, A, that there is an unusual number of pneumonia cases outside of the norm, and B, that these cases are caused by a new virus that you haven't seen before. So by late December, there were several cases of unusual pneumonia caused by an unknown virus in Wuhan, and Chinese health officials notified the WHO of this on December 31st. Yep. The next day, January 1st, the wet market, where this first cluster I mentioned was apparent, the Huanon Seafood Wholesale Market was shut down. At this point, there were more than 40 people infected.

On January 7th, officials announced they had identified a new virus, according to the World Health Organization. The novel virus at that time was named 2019 NCOV and was identified as belonging to the coronavirus family. January 9th, the first death from the virus occurs in China. January 13th, the World Health Organization, reported a case in Thailand, the first outside China, and a woman who had arrived there from Wuhan. January 16th, Japan reports a confirmed case again from someone who had visited Wuhan.

Between January 17th and January 20th, the U.S., Nepal, France, Australia, Malaysia, Singapore, South Korea, Vietnam, and Taiwan, all confirmed cases of this novel coronavirus. I mean, that's a matter of weeks. Yep. Okay. January 22nd, the death toll in China jumped to 17 with more than 550 infections. Airports in Europe and Asia increased screenings of passengers traveling from China. Wow, 550 by January 22nd. I know. I keep getting chills when I read this timeline.

Me too. January 23rd, Wuhan was placed under effective quarantine. At this point, the WHO said there was no evidence of the virus spreading between humans outside of China and the outbreak did not yet constitute a public emergency of international health concern. January 26th, new cases were confirmed in the U.S., Taiwan, Thailand, Japan, and South Korea. January 27th, the death toll in China rose to 106, with 100 in Hube province. Another 4,515 people in China were reported to be infected. There were 2,700 confirmed cases in Hube province. up from 1423 the day before.

It's like a doubling, essentially. On January 30th, the WHO declared COVID-19 a global emergency, as the death toll in China jumped to 170 with 7,711 cases reported. On this same date, India and the Philippines confirm their first cases of the virus with one infected patient in each country. January 31st, the next day, the number of confirmed cases in China jumped to 9,809. Russia, Spain, Sweden, and the UK all confirmed their first cases of the virus. And on February 2nd, the first death outside China was reported in the Philippines.

On February 6, the death toll in mainland China rose to at least 563 with more than 28,000 cases confirmed. Meanwhile, authorities in Malaysia reported the country's first known human-to-human transmission, and the number of people reported infected in Europe reached 30. 30. 30. 30. February 6th. On February 7th, Lee Wenliang, a doctor who was among the first to sound the alarm over the coronavirus,

died, and Hong Kong introduced prison sentences for anyone reaching quarantine. rules. On February 9th, the death toll in China surpassed that of the 2002-2003 SARS epidemic, with 811 deaths recorded and 37,198 infections. It's worth noting the SARS epidemic infected around 8,000 people. Yes. On February 11th, the WHO announced that the new coronavirus would be called COVID-19. As of February 12th, 175 people were infected on board the Diamond Princess cruise ship. February 14th, Egypt became the first country in Africa to report a case, and France reported Europe's first death from the virus. As of February 17th, there were 1,770 deaths reported in mainland China and 70,548 cases.

Japan also confirmed 99 new cases of the virus on board the quarantined Diamond Princess cruise ship. February 18th saw China's daily infection figures drop below 2000 for the first time since January, with the country's Health Commission reporting 72,436 infections on the mainland and 1,868 deaths. On February 19th, Iran reported two deaths from the coronavirus, hours after COVID. confirming its first cases. February 20th, South Korea reports its first death from the coronavirus. February 22nd, South Korea saw its largest spike in a single day with 229 new cases of the virus. On that same day, Italy reported its first two deaths, while Iran confirmed a fifth death among 10 new infections. A sixth death was later confirmed, though it wasn't clear whether this case was included in the country's 28 confirmed cases.

February 26th, the global death toll neared 2,800 with a total of around 80,000 confirmed cases reported globally. On the same day, Norway, Romania, Greece, Georgia, Pakistan, North Macedonia, and Brazil all detected their first cases of the coronavirus. On February 27th, Estonia, Denmark, Northern Ireland, and the Netherlands reported their first coronavirus cases. the number of infections globally passed 82,000, including more than 2,800 deaths. On March 3rd, Italy announced the death toll in the country reached 77, equaling the total deaths in Iran, which stood at 77. On March 7th, the coronavirus had killed nearly 3,500 people and infected another 102,000 people across more than 90 countries.

On March 10th, both. Both Iran and Italy recorded their highest death tolls in a single day. A total of 54 people died in Iran over a 24-hour period, while in Italy 168 new fatalities were recorded from the coronavirus. On the same day, Lebanon and Morocco reported their first deaths from the virus, while Democratic Republic of the Congo, Panama, and Mongolia confirmed their first cases of infection. On March 11th, World Health Organization declared the coronavirus outbreak a pandemic, as

Turkey, Ivory Coast, Honduras, and Bolivia confirmed their first cases. In Qatar, infections jumped drastically from 24 to 262 in a single day. On March 16th, New York City's bars, theaters, and cinemas are closed down as the number of cases continue to rise in the U.S. On March 19th, Italy overtook China as the country with the most coronavirus-related deaths, registering 3,405 deaths compared to 3,245 in China. The death toll in Spain soared by 209 to a total of 767 fatalities from the previous day. A roughly 25% increase in infections was recorded in Spain, taking the country's total to 17,147. On March 20th, which is just a couple of days ago, coronavirus-related deaths surge,

past 10,000 globally, which is more than the number of people infected with SARS during the entire course of the epidemic. The number of cases in Germany rose by 2,958 overnight to a total of 13,957. Spain, meanwhile, had a death toll of 102. On the same day, though, March 20th, in China, however, no new domestic cases were reported for a second consecutive day. It's a big deal. On March 21st, Europe remains the epicenter of the coronavirus, with Italy reporting 627 new fatalities, its biggest daily increase, bringing the total number of deaths to 4,032 amid 47,021 cases. Spain is the second worst hit country in Europe with more than 21,000 infections and at least 1,000 deaths.

On March 22nd, which is the day that we're recording this episode, the global death toll rose above 13,000 while infection count surpassed 311,000. So right now it is 1141 central time, U.S. Central Time, and there are 318,209 confirmed cases in the globe, and 13,6006. 64 deaths, 94,700 total recovered. Wow. It's a very chilling timeline. That is a very chilling timeline.

That was really helpful, I think, to go through, though. Yeah. Because even if you didn't catch every single number and every single date, I think it's very clear from going through that that this is a rising and spreading very rapidly. Exponentially. And B, that we're still in that exponential growth right now today, March 22nd. So how do we slow that down? Well, to answer that question and to talk about the characteristics of this disease, we brought back Dr. Carlos Del Rio. So let's let him take it away. Right after this break. Dinner shows up every night, whether you're prepared for it or not. And with Blue Apron,

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now available in Canada too. That's Q-U-I-N-C-E-D-com slash this podcast to get free shipping and 365-day returns. Quince.com slash this podcast. So my name is Carlos Del Rio. I'm a infectious decision and public health also expert. And I'm a professor of medicine and global health here at Emory University, where I'm also the executive associate dean of Emery-Gradie.

So at this point in the epidemic, we've seen a lot more about how the virus has spread in different places and in different populations, do we have a better sense of what the R-Not is for the virus? Well, you know, I think we're beginning to know better what, again, and we should define what R-not is, even though people are probably now hearing this term and a term that was a sort of an epidemiology lingo is now becoming like household dinner conversation term. But, you know, I've been talking to CEOs, so companies and others who now call me and I had a

CEO of a company today, call me, why do you think about the R not, you know, today? So it's interesting to see that R not has become sort of a lingo that we all talk about. But basically what this means is a reproductive number, right? It's the number of infections that a virus causes. So one person, infected person leads to other people being infected. And there are diseases like measles, for example, that may have an R&O 15. So one infection leads to 15. And if an R not is below one, then the disease dies.

It disappears. So MERS has typically had an R not below one. So we rarely see epidemics. We have not seen an epidemic from MERS. But this disease has an R not of about two and a half to three, which means that somewhere between two and a half and three individuals get infected after a person has been infected. And that's what causes what we call an exponential growth in this epidemic because, and I

try to explain this to people in simple terms. If you have one infected person, that person infects, let's say, two and a half person. So let's go with the lowered limit. So that means that after five days, you're going to have two and a half infected persons. So now you have that person plus two and a half. But then in 30 days, you're going to have 406 infected people. That's what we call exponential growth. Can you talk a little bit about the progression of the epidemic in China and in some other places where the disease seems to be slowing down?

In those places, is there a risk of a second wave of infections? You know, I think there's always a risk. So let's suppose we can decrease, I told you, you know, 1 to 2.5 to 400 at the end of 30 days. If you can decrease exposure, you can decrease transmission by 50%. So you can bring the R not from 2 1.5 to, let's say, 1.2, 1.25. Now at the end of 5 days, you'll have 1.5 infected people instead of 2.5. And at the end of 30 days, you'll have 15 infected people instead of 400. Now, if you can bring that R not below one, now at the end of five days, you'll have, let's say, 0.7 of a person infected, so not even one.

And then at the end of 30 days, you'll have maybe two people infected. So you will probably still see some cases, but as long as you can really decrease exposure, and that happens by two mechanisms. Number one, initially, China has done it by social distancing, right, by quarantining, by isolating people, by really, going into a national shutdown. But something that's going to happen eventually, as you get more people infected, you essentially have a herd immunity, and there's not enough people to infect out there. So the number of transmissions also goes down. So I suspect there will be little clusters here and there, but I don't think there's going to be

a huge wave again, assuming that there's immunity to this virus. And so kind of along those lines that you mentioned about trying to decrease that are not overall. Can you talk us through what the stages of an epidemic are and what it means to try and flatten that epidemic curve? How do we know when that actually happens? Well, we know when that actually happens. I mean, this is a complicated phenomenon, but, you know, the epidemic starts growing. It's really when you get that reflection point where the number, when cases are not growing by a factor of one. When you get to cases growing by a factor of only one, then you start seeing that flattened.

of the curve. Then you start saying, but by that point, it's a little too late. And I think about it like a plane taken off, right? Initially, you were seeing, you know, 10, 20, 15, 40, 100 cases. You know, the plane was just still running down the runway very quickly. Then the nose goes up. And then, you know, we start seeing in the U.S. 100 cases. And now we're, you know, whatever number of cases we're at today, we're like 16 or 18,000, right? So now the plane is at 18,000 feet. At some point in time, you're going to see it get to 30,000 and it's going to start leveling off. So just like a plane, you get to a point where you have enough people infected out there and you have enough transmission that the number of susceptibles is going down.

So I don't like to talk about phases of an epidemic because there's really no phases. The natural history of an epidemic is to continue until you infect it or you cause all susceptible to be either infected or dead, right? But what you want to be sure is that you prevent that. And what we need to do is do everything we can to shut down that are not. to decrease the R not to below one. If we can bring the R not below one, we will control transmission. Right.

And so that needs people to stay at home and practice social distancing and so on. But I'd like to revisit something you mentioned in talking about how the epidemic has progressed in China. And so one of the things that you talked about was herd immunity, which would require that this infection with this virus leads to immunity. Is that something that we have seen? Do are people who are infected with this virus and then they recover? Are they immune and resistant to future infections? There's been a lot of talk of whether you can re-infect it or not.

I think from what I can tell that people are going to develop immunity and are going to not get infected. So I think immunity is going to help us going forward. Gotcha. I guess like what is the relative effect that social distancing has had versus herd has had. You know, it's really hard to tease that apart. But I would tell you that if they hadn't done what they've done, the massive shutdown that they did, I think social distancing probably played a huge role there. And the reason I say that is because if they had not done

this, I think the numbers would have been staggeringly higher. And, you know, just I look at it today, you know. I mean, I was just in shock today. When I was just in shock today, when I I saw that, you know, China, as of today, has about 80,000 cases with 3,200 deaths. Italy has half the number of cases, 40,000 cases, but has more deaths than anywhere else. Italy has not surpassed China and deaths. But I think China really emphasized the social distancing. And that's why their number of deaths compared to the number of cases is so much lower. It's 4% versus Italy, which is 8%. Right. Right, right. And I think that's one of the things that this outbreak has revealed, particularly here or looking at the U.S., is that we have to slow the spread of disease. People need to stay at home. They need to practice social distancing. But I feel like, at least anecdotally, this message, and also from what I've seen on Twitter and on some other news reports, I feel like this message doesn't seem to have properly sunk in, especially in areas that may not be.

currently experiencing the same number of confirmed positive cases as other regions or in populations that have been said to be at lower risk. So how can we convince people just how important it is to stay home when they can? Well, you know, again, it's in your hands to become infected or not, right? If you become infected, you will then lead to other infections. So the best thing, I mean, the best vaccine we have for this is to not get infected. Because if you don't get infected, then other people won't get infected. And if other people don't get infected, then you'll stop the chain of transmission. And that to me is what we need to do right now.

So, I mean, the term flattening the curve, or the way I explain it is by saying, look, if I'm at the hospital and 300 people come in sick today, I can't take care of them. But if 300 people come in sick over a month, I can't take care of one. It's easy. It's easier, right? So we want to spread out the number of cases. but more importantly for the general individual, it's in your hands to prevent transmission. If you don't get infected, you're not going to pass it to others.

And if you don't pass it to others, you're cutting down that transmission chain. So cutting down that transmission chain is something that we all have the ability to do. Yeah, absolutely. Yeah. And so I had another question for you actually about in looking at the differences in fatality rates between like in China versus in Italy. How do you feel like that compares to something like South Korea where they tested very large numbers of people and the death rate there was as low as I think like less than

2%? Is that because of better identification of cases in your opinion or because of better social distancing and treatment methods or what do you think some of those differences are? I think that two things happen. I think that every country is a little different and there's some issues. Italy, clearly, if you look at who got infected in Italy, clearly Italy had a much older population, and I think that clearly was playing a role. If you look at the distribution of Italy versus South Korea, in South Korea, almost 30% of their cases were between the ages of 20 and 29,

and almost 20% between the ages of 50 and 59. In Italy, in the country, I would say almost 40% of cases were between the ages of 70 and above. of. So you have a very different distribution of cases in a population. You'll also have very different distribution of comorbidities in a population. So it's not simple. And we're learning very clearly that mortalities are very different in different populations, right? Right. And that to me, that to me is, it's very important because our populations look very different. Yeah. You know, recently earlier this week, there was that report that came out from the Imperial College of London that had these, you know, variety of modeling predictions based on, you know,

no control strategies, mitigation strategies, suppression strategies, but all of the numbers were fairly alarming. And so can we make any guesses at this point to what we might see in terms of numbers infected or just how long the outbreak will last? Like, what is the end game on this? Well, the end game is to stop it. And I worry that, you know, here in the United States, we don't have, we have, we have several problems. Number one, we don't have Wuhan. We have multiple Wuhan. We have a Wuhan in Washington State.

We have a Wuhan in New York State. We have a Wuhan now happening in the South. So we have multiple Wuhan. And I think that to me is one issue that, you know, we don't have one Wuhan. And the other thing we have, our public health. is centralized, it's not centralized, right? In China, the central government can say, do this, and it will happen. Here in the U.S., the federal government doesn't have that authority.

The federal government makes recommendations. And then after the federal government's recommendations, then the states, really public health is run at the state and local health department level. So you have states saying, oh, you know, California is saying, we're going to shut down the state and state of Florida saying, oh, you know, we're okay. You know, we don't want to. yesterday I was hearing the governor being interviewed and saying, you know, we don't really don't want to impinge an individual liberties.

If the college students want to be partying out there, is their right? So you have a very different approach. And if you put in the middle of this, the economy, and there's no doubt that epidemics have huge economic consequences. I mean, epidemics hurt business and epidemics heard consumption, and epidemics court have heard a lot of things. And we've seen already what the stock market has done and what, you know, it's going to happen to small business and to other businesses. So I can see a politician being reluctant to take the tough measures that are needed. And that's when you say we need an independent body that can help and make those recommendations. But unfortunately, we don't have such independent body in this country. It's all based on, you know, it's all based on political decisions.

And unfortunately, it's not going well. I mean, I think you and I will agree that the response in the U.S. has been pass at best. Yeah. in one of the things that that I think a lot of people are wondering is that at the beginning we were looking at this as a matter of weeks and as the epidemic as the pandemic has progressed it seems like now we're looking at this on the scale of months I think the more you delay the response the more the time is right and I think that's something that that people need to understand that as you take more time more time takes you you know basically it becomes harder to do the

things. Yeah. I mean, that's what it seems like is that even in places that have been relatively low impact by the virus, it seems like not even the tip of the iceberg, but the tip of the iceberg where we don't even know the extent of the community transmission that's going on. And so, you know, we see these actions like shelter in place that have been happening in California and in parts of New York and maybe going into effect elsewhere. But is that like, should that be happening now in places that have, seen the number of cases that those states have seen? The answer is yes.

When somebody says to me, we only have 20 cases. We got this under control. I said, if you only knew, right? By the time you have 20 cases, you're already, you know, 20 cases too late. So I would emphasize and say over and over, no, you cannot do that. I mean, that is a mistake that everybody has made. And I don't want to get political or anything. But, you know, I look at different.

Trump quotes through the epidemic, right? And his first press conference about this was we got, in February 28th, we fought 14 cases. We got this under control. Next week there's going to be no cases. And now we have a national emergency, you know? So you get distracted and this comes back to hunt you, right? Mm-hmm. Yeah. Absolutely. there's been a lot of talk about this virus potentially becoming another seasonal influenza type virus. What do you think about? Is that something that we think is likely at this point that this is now so well established that this is going to be kind of a recurrent seasonal thing? You know, I can't, I don't, it's possible. I'm going to, I think at this point in time, it's speculative to say that. I don't want to worry about the future. I want to worry about the present and the president. We have a, the house.

house is burning, right? We have a fire in the house. And I almost sound here like somebody's asking me, well, you know, once you rebuild the house, you think it'll be another fire again? I said, let's put the fire out again first, you know, let's worry about that later. So let's take care of the current problem. And the current problem is let's stop this. And then we'll figure out about the rest. You know, there's a lot of really good work happening in vaccines and other things. So depends whether we have a vaccine. That's, I think, is the answer. Yeah. Yeah. Absolutely. You know, I think one of the things in particular that I'm still trying to get a grasp on the entire timeline or an understanding of it is the testing and the controversy around the testing. Can you walk us through a little bit of that and why it was slow at the beginning?

What's going on now? Just sort of a brief on the testing aspect. Well, I think in a testing aspect, we have three things. Number one, we have panor new virus and the virus sequences were put. in the internet and the CDC developed a test. And then, of course, this is not, you know, people came on talking about a kit. This is not a kit. You know, this is not a something that you go to a store and you buy, right?

This is something that they developed. This was a homebrew, you know, this is the best I can describe it. This was a laboratory developed test. They did it in-house. And, of course, because it's a laboratory-developed test, and it had some challenges. And during those challenges, because of some regulations that existed, you know, Unfortunately, when the president activated or said this is a national emergency, that activated a series of rules that blocked others from developing a test at this point in time, at that point in time. So most people were not developing a test.

Some people were not developing tests, but others were not. So there was a lot of, I would say, things that I would describe between bureaucracy, unfortunate mistakes, and just dealing with something new that prevented us from developing what I would have been a robust test. And then now a lot of tests are being developed and companies are getting involved. But also, you know, initially CDC started getting tests out to health departments. And we know, you and I know, that health departments are there to do public health, but not to do clinical care. But if clinical patients were coming, then all of a sudden the health departments are supposed to be providing clinical testing, right, which is not what they're designed to do.

So now I think things are a little better because now you have companies out there working and doing and all this stuff. And that makes a huge difference. And I think we're seeing, you know, the FDA is approving test left and right. So I think there's going to be more testing. And I think we need a lot more testing. And as you've seen, the U.S. is way behind. The problem is, is that we would like to offer the test to more people, but we still have

are a point that we need to ration our testing. And we're in a situation right now in this country that we've never been before. We are rationing testing. We're rationing PPE. So I tell people, now you know what? it feels to be in a developing country, right? Because we're rationing things. And that's something that we don't necessarily feel comfortable doing, but that's the reality, right?

We are in a rationing environment, and rationing is very hard. Yeah, absolutely. So at this point, I know some of this that kind of varies state to state or even maybe county to county as well. But are there general recommendations at what point a person, if they suspect that they're infected, should go and try and get tested, even in spite of these shortages? If you have symptoms, if you are things you have the disease, you need to go to your doctor or you need to call your doctor, and then you'll be told whether you need to be tested or not. But one of people to know is that if you're asymptomatic and just, I don't want to worry

well to go get tested right now because the reality is just going to overwhelm the system and is going to take care of tests that we need for people who actually need it right now. So you've touched a bit already on that we're kind of learning as we go with this whole pandemic. But what do you think that this outbreak so far has taught us how to prepare for what we're experiencing right now? How can we do better, kind of moving forward? I think right now it's really hard to know. But when we're done with this, I think we have to sit down and do the post-morten, right? We need to do the, let's go over this and find out where were the mistakes, you know?

and what got us in the trouble we're in because we should have never been in this kind of trouble. And, you know, I would start with one thing. I think we have underinvested in public health for years, right? And many administrations not just a current, but I started with Obama, have really underinvested in public health. And, you know, CDC has, I think, over 700 vacancies. And now because we underinvested in public health for years, now we're having spent billions and taking care of the problem.

if we had invested in public health to begin with and had the surveillance, equipment and other things. And I'll tell you an example of underinvestment. The state health departments are having trouble scaling up testing the way they should. Why? Because they don't have enough machines. They don't have enough personnel because they're underinvesting. So I would really want to see people rethink public health and whether we have to put our priorities there.

If we don't invest in public health, then we are going to be having another pandemic. And, you know, I think about 2009, we had pandemic influence, and now we have this 10 years later. So let's rethink this so we don't have the pandemic of 2029. Yeah, absolutely. So I'll end with asking you a question that I asked in our first episode on coronaviruses. And I asked, what about this disease concerns you? And what about the response or how the epidemic has been handled so far? Is there anything about that that is caused?

for optimism? What concerns me the most about this disease right now is a transmission in health care settings because I tell people that are health care workers, doctors, nurses, you know, advanced practice providers, et cetera, you know, respiratory therapists, you name it, are in the front lines. They're fighting this virus and the battlefield. And we have been unable to give them all the necessary personal protection of equipment. So there's not enough personal protective equipment, and therefore we are civic into battle without enough protection.

And that to me, we're doing the best we can, but we're still not where we would like to me. And we're having meetings to talk about, well, you know, how do we use PPE more appropriately? I mean, if we had enough PPE, I would feel so much comfortable. So not having enough material to provide our doctors, our nurses, our healthcare workers, the necessary protections, that worries me a lot. because I think we're going to see a lot of infections among health care workers in this country. And that is bad. And that is something that it should be unacceptable. And we need to make a big cry about that.

But number two is I also worry that people are not taking it seriously and that people are still, you know, partying. And I saw the videos of the college kids in the beach in Florida saying, oh, this is no big deal. And what gives me hope is science. And I think, you know, what I've seen come together, how science, how industry, how the community is coming together gives me hope. Because where I come from, where my research has been with, my work has been, which is in HIV, that was the solution. We are where we are in HIV because the community, the scientist, industry, and governments came together and got us where we are. To me, it's unimaginable to see where we are. I could have never predicted that we'll be where we are in HIV.

And it's because of that coalition that made us better and made us stronger. So I have hope that between science, community, and everybody coming together will be in a better place. Anyone who works long hours knows the routine. Wash, sanitize, repeat. By the end of the day, your hands feel like they've been through something. That's why O'Keeffe's working hands hand cream is such a relief. It's a concentrated hand cream that is specifically designed to relieve extremely dry, cracked hands caused by constant hand washing and harsh conditions.

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And we are back for season four. We're talking to small business owners who are doing incredible things in their industries, achieving their dreams, being their own bosses, putting in the work, and enjoying all the benefits that come with it. This is our most exciting season yet. We're talking to more entrepreneurs about how they launched their vision and more importantly how QuickBooks on the Intuit platform helps them do more. more in less time. Working in QuickBooks just makes it easier to run the business, right? There's so much that you need to do when it comes to running a business, building products, setting on marketing campaigns. And to run a business, you have to make sure that your finances are an order. So it removes my anxiety from one side of it so that I can focus on everything else.

Whether you're a long-time listener or just getting started, tune in and join us. You'll be so glad you did. Listen on the IHeart Radio app, Apple Podcasts, or wherever you get your podcasts. Dr. Del Rio, he said we could call him Carlos, but it just feels wrong. Carlos, thank you so much. We really, we really appreciate it. I mean, all of the people that we have talked to, I know we keep saying this, but all of the people that we've talked to took time, precious time out of their incredibly busy schedules to talk with us and to help spread some factual information about this disease. And for that, we thank you so, so much. Yeah, really. Thank you so much. So what have we learned? What have we learned? I think one of the things,

number one, that we've learned, is that there does appear to be immunity to this virus and that this immunity could substantially contribute to what slows this pandemic. So even though we have talked about the horrible concept of using herd immunity as a strategy, it could be what happens naturally as people do get infected, especially since we're seeing this exponential growth now, that might be what helped to contribute to the decline of cases in China. But more importantly, is the social distancing measures. And we'll talk about that as well. Absolutely. Number two, an important thing that we learned from this episode is that we have to consider characteristics of this disease and this epidemic in the context of the places that are being affected. So we're seeing different infection rates

and different case fatality rates in different regions, in part because the populations that are affected in those regions are different. And we don't at this point necessarily know exactly what all those differences are that are driving the differences in case fatality and in infection rates. That's something that we might only be able to recognize in retrospect once we make it through the other side of this outbreak. And I think that's really important because, you know, there's been a lot of talk about, well, the case fatality rate is this in Italy versus this in South Korea. And we don't fully understand exactly what those differences mean in this context yet. Right. And how much they're going to change as we test more people, as the number of

cases grow, as our knowledge about this disease grows. Exactly. Yeah. Number three, we have underinvested in global health security and an international public health and pandemic preparedness on national scales, international scales, regional scales, local scales, state scales, whatever. Every single scale. On every single conceivable scale for years and years and years. this lack of investment in global health security and pandemic preparedness, it is coming back now to haunt us. And so the amount of money that, you know, speaking for the U.S., the amount of money that we have saved by cutting programs such as the CDC and pandemic preparedness initiatives, that number is infinitesimally small compared to the bill that this is going to lead to. And that's just the economic bill. The psychological impact.

the social impacts. I mean, this is going to have repercussions for every aspect of our lives. And I think it is going to fundamentally change the way that we live, the way that we work, the way that we communicate, and the way that we think about our own health and safety. Say it, Aaron. Number four, we learned from this interview that there were a lot of different factors that contributed to the slow rollout of tests that we've seen in the U.S. We're doing better now, for sure. There's a lot of different private labs and private hospitals and public hospitals

that are developing their own tests, and people are working really hard to try and roll out more and more tests. But that delay has really prevented us from getting the precious knowledge that could have helped to slow this disease. And I think you can't really underestimate just how important that was. Like this is a thing we've kind of botched. And like Dr. Kraft mentioned in one of our episodes, it's not like we could have made this overnight, right?

But it was kind of months of not ramping up production on something like this to be able to start rolling out these tests well. And now we're running into further issues of running out of protective equipment, of running out of swabs to actually run these tests. Like we have a lot of issues in the actual supply chain of testing for this virus. Absolutely. You know, and I think that if we want a silver lining this, then this is hopefully something that we can take and learn from.

Yeah. We've talked about this before in terms of epidemiologists, either always being viewed as over-prepared or underprepared or overreactive or underreactive. And it's a huge challenge. It is. Point five. I think this is a really important one, and this is something that we have hammered on in other episodes in this series so far. We can bring down the are not of this virus through control measures and personal decisions.

Our individual actions, each one of us, has the power. to help slow the spread of this disease. We really need to take this seriously. So there was a really great modeling study that looked at the data from Wuhan, like retrospectively after the fact. And they suggested from this that the restrictions that were implemented and people actually, by people actually changing their behaviors, they were able to decrease the R-Not in that infection from around 2.4 to 1.4.

So they cut it by 100%, which is massive, massively important. Yeah, it can be done. It can be done. It has been shown to be done. So let's do it. Let's do it. Let's do it. So. Okay. Sources? Yeah, so that paper that I just mentioned, that was a paper by Lee at all. in science, published in science on March 16th, entitled Substantial Undocumented Infection

Facilates the Rapid D dissemination of Novel Coronavirus. And then there's those papers that we mentioned earlier by Plowrite at All and Coons at all. We'll post those papers on our website. And for more details on the timeline as well as for updates on it, that we'll post the link to that Al Jazeera article as well. Yeah, it's awesome. Thank you again so much to Carlos. We really appreciate it.

We do. And thank you to Bloodmobile for providing the music for this episode and all of our episodes. And thank you to you, listeners, for sticking through one more episode of this. There's more coming your way. Until next time, wash your hands. You filthy animals. This is Bethany Frankel from Just Be with Bethany Frankel. Listen, I have a bone to pick with these dog food brands calling themselves fresh, natural.

healthy. Sounds great, but a lot of these, quote-unquote, fresh dog foods in your fridge are not even 100% human grade, which is why feed your babies. Feed your babies, just food for dogs. It's good enough for big and smalls, my precious babies, so it's good enough for your babies. 100% human grade, real ingredients, beef, sweet potatoes, green beans, delicious. These are foods that you would want to eat. Not that the babies would ever share. Just food for dogs is the number one bet recommended fresh dog food back by over a decade of research. No marketing fluff. My dogs lose their minds at dinner. They run to the bowl, tags wagging, pause tapping, full Broadway performance every single night. So I do care about the food I feed big and smalls. So go to just food for dogs.com for 50% off your first box, no code, no gimmicks, just real fresh food.

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