21 October, 2020

UMD | Public Health Symposium on Coronavirus

good afternoon good afternoon and thank you so much for coming to the special symposium we're delighted to have you here and joining us on such short notice my name is du shankha Kleinman I'm the associate dean for research and the principal associate dean at the School of Public Health at the University of Maryland in College Park from the day we first learned about the new coronavirus less than two months ago it's hard to believe we've been living in the midst of a whirlwind of daily and hourly and minute by minute updates about its impact its spread and steps that are being taken to contain it and ultimately prevent it we're still in the very early stages of the epidemic and it's a time where we have more questions than answers so what we've done is designed this symposium to provide you with snapshot in time and I'm sure there'll be many updates we acted quickly to put the symposium together because we feel that informing our community and the university is an essential role of an academic institution and a School of Public Health we want to thank our colleagues in Student Affairs the Alumni Association and strategic communications for making it possible for us to join and produce this for you today we have a saying in public health the critical work that supports the health and well-being of our nation and our population goes unnoticed until there's an emergency the safety of our food and water the support for enhanced lifestyle behaviors the prevention of infectious diseases the work we do in hospitals in maintaining and managing chronic diseases health promotion in schools maternal and child and infant health and much much more so epidemics like this one captured the national and international attention and concerns and they shine a light on our public health capacity these events identify gaps in our response challenge the capacity of our communities or nations and our global coordination they also raise procedural social ethical and legal issues among local national and international governments and agencies they demand an effective response coordinated well constant and clear communication and collaboration in management and sharing of interventions and the conduct of research at the very end of January WH o the World Health Organization's health emergencies program declared kovat 19 this outbreak that we're in a public health emergency of international concern a few days later the World Health Organization released a strategic preparedness and response plan for the virus and the plan includes establishing international coordination and operational support scaling up country readiness and response operations and accelerating priority research and innovation our School of Public Health faculty members have experience with past epidemics they're conducting research in areas of relevance to this epidemic including exploring factors affecting compliance with recommended preventive measures such as this flu vaccine in addition our faculty members are contributing to university state national and international discussions relating to evidence-based practices for public health emergency preparedness and response so today's symposium includes four presentations to address several emerging questions dr.

Don Milton will address what we know about this new corona virus and how it spreads among us dr.

Milton is a physician scientist professor of environmental health at the maryland institute of applied environmental health his studies explore infectious bio aerosols exhaled breath analysis and development and he investigates the application of innovative methods for respiratory epidemiology one of his research projects includes the catch the virus study that involves undergraduate research assistants tracking respiratory infections in freshman dorms he'll be followed by dr.

hon G Lu who will provide an overview of the features of the Cova 19 epidemic with a focus on why it has spread so quickly in China but not at this time in other countries dr.

Lu is professor of epidemiology and also chair the Department of Epidemiology and biostatistics he studies social and Buffay behavioral aspects of hiv/aids and research epidemiology he's designed and led over 20 HIV related studies over half of which have been implemented in China he also was present in China in 2004 at the time of the SARS outbreak the severe acute respiratory syndrome at times of emergencies especially when confronted with the confronted with an unknown pathogen the onslaught of information is extremely overwhelming I don't know about you but every minute there's a new piece of information often information is conflicting and continually evolving dr.

Cynthia Bauer who's an expert in communication and health literacy will speak about effective risk communication as an antidote to fear uncertainty and misinformation dr.

Bauer is an indoor endowed professor and director of the Horowitz Center for health literacy prior to joining our School of Public Health in 2017 she worked in multiple senior communication leadership roles within the Centers for Disease Control and Prevention and the office of the Secretary of the Department of Health and Human Services she has led numerous national initiatives to define best practices and guidelines in health communication and health literacy and is the co-creator of the CDC clear communication index our last presenter is our dean dr.

Boris lushniak professor and Dean he will conclude the presentations but providing highlights of lessons learned from the 2009 influenza pandemic Dean Luce niak a physician with specialties and dermatology and preventive medicine is a retired Rear Admiral of the United States Public Health Service commissioned Corps during his tenure in the Corps he served in multiple agencies including the CDC the Food and Drug Administration and the office of the secretary and he served as the FDA is sitting Commissioner of counterterrorism policy the deputy Surgeon General of the US Public Health Service and also as the acting Surgeon General from January to March in 2015 he commanded the US Public Health Service Monrovia medical unit in Liberia and which is and was the only US government hospital providing care to Ebola patients we would like to acknowledge that there's an audience joining us including to all of you wonderful individuals in this room we're live-streaming this event and we welcome comments from those that are here in person as well as those that are online so this slide provides you a means in which to submit your questions and then to also go for further information to the university site where after this session you'll be able to see updates as well so I'd like to begin with our first presenter dr.

Don Milton and we will have each presenter come up give their presentation then sit down again and then after the four presentations we'll open it up for questions thank you the pleasure it's a pleasure to be here this afternoon and to talk with you and I hope that you find this talk that we're doing today be useful give you a better understanding of what's going on and give you an understanding of what you can do so what are coronaviruses we've been hearing that name a lot as though there were one coronavirus but actually there are a lot grown of viruses practically every living species if an animal has a corona virus that or two or three that it affected everything from rats and bats to beluga whales have corona viruses and these viruses mutate slowly you may be aware that other RNA viruses particularly influenza virus which is an RNA virus mutates very rapidly changes from year to year is why we have to change the vaccine frequently not so much with Quranic nurses they're more stable genetically but they're they still seem to come around and people get them one year after another therefore that people get common there they cause common cold like symptoms and they have names like OC 43 they'd be abundant green and they've been infecting humans we think for hundreds maybe thousands of years so they're nothing new you've all had them before our data on antibody levels on people on campus suggests that everybody has lots of antibodies and because we've all been infected with them before but there are three that have emerged recently the first was SARS 2003 the second was MERS in 2012 and the third is this SARS cofee or Kovan 19 disease that merged in December of 29 and those are the ones that we're talking about now because the other four that we get all the time are tend to be very mild there hasn't been a lot of work done on antivirals or vaccines because it didn't seem like it was all that important but this is just a little bit of data you heard that we are running something called catch the virus study is called characterizing and tracking college health and we have enrolled hundreds of students over the last several years and you can see that these lists of cofee 2 to 9 e and HK u 1 and so forth are the common for cold viruses there are a lot of other common cold viruses too but these are around all the time and 17% of people have had these common viruses in our cohort over the three years the weakness study you can also see for comparison that we see influenza every year two on campus different viruses each year and about 10% of the people who followed had Valenza fires this year we're seeing a little some influenza we're seeing rona viruses like the OC 43 and we're seeing lots and lots rhinovirus but we pay a lot of attention to influenza and we're gonna keep coming back to influenza here because it is the common killer hundreds of thousands of people died of influenza every year across the planet the case fatality rate is around the tenth cent seventy-five percent of the affected though are asymptomatic so that tenth of a percent is really a a over estimate the deaths in the United States run between twelve and fifty-six thousand people every year some years more in fact in a couple of years ago we had about sixty thousand people died of influenza many hundreds of thousands are hospitalized every year and huge proportion of population are infected but don't even know it meanwhile kovat 19 is new emerging infection has by comparison infected hardly anybody yet and has had caused the paltry number of deaths not that any death is insignificant but by comparison to the hundreds of thousands that will die of influenza this year the two thousand nine so far from rotavirus is pretty small so we're gonna be talking a lot about as you will hear later about why does this stimulate so much concern and part of it is because although the death been small the numbers of people infected have been fairly small and so the death rate case fatality rate so far as we know right now has been fairly high but we don't know the full scope effects we don't really know how people were affected but meanwhile in the context while all this is going on over in China there's been practically none here fifteen cases but there's been a lot of influenza here this year and could see in this plot which shows on the left the percent of of people who were coming to see doctors for influenza like illness each year in 2009 the 2009 pandemic there were a lot of people coming to see doctors for flu but you can also see that 2017-18 it was nearly the same numbers it was just shifted later in a year and this year is enroute to be a pretty bad year – that's happening here and now and you could see over on the other side the lot of pediatric deaths of young children dying of influenza and so far this year we've had 92 children die mine's the couple of years ago we had a hundred and eighty-eight so this is what we are really confronting right now so what can you do to stay safe well I hope you got the flu shot the flu shot is the most important thing you can do it's not a hundred percent but it does make a difference and then you can wash your hands cover your coughs dispose of tissues avoid crowds stay home avoid crows proximity with someone bill and avoid places that have poor ventilation and we'll come back in a minute why I think that is also an important recommendation so what is this new coronavirus what are the symptoms the the like Ovid 19 mostly presents with people with having fever and respiratory symptoms mostly dry cough sometimes a little bit of productive coughing buta a lot of fatigue muscle aches so most of these symptoms are pretty much indistinguishable from a from influenza but Ovid 19 probably has more GI symptoms and but even though they're fairly small proportion that popular it can infect the GI tract and so that is becoming important to understand so one of the ways that actually being diagnosed now especially when healthcare is overwhelmed and they're not enough excuse me test kids is to look at the chest x-ray and especially the CT scan and these figures up here are pictures of CT scans with a pro you see it and compared with the bottom row you see a lot of white stuff alone that's pneumonia and people are presenting with pneumonia as a key part of their presentation as we stay it's one of the first things that shows up clinically on a medical exam so this is a family tree or phylogeny of the corona viruses and the ones with the picture of the woman coughing are pointing to those four that I said are the common corona viruses that are around all the time but you all have had them before and the other three the Tsarskoe v is the one that emerged in 2003 the MERS Co V or Middle East respiratory syndrome virus merged in 2012 and the Tsarskoe v2 emerged last December and this new virus is called a beta corona virus in those last slides you see the blue things those are the beta corona viruses and at first it was clear that it was a beta corona virus it fell in that family tree and then as more data came along it became quickly apparent that the closest viruses that people had isolated before in that family tree were in bats and but SARS came from bats too but it didn't come directly from bats it came from bad specific cats and here we think the best data so far suggests that maybe but we're not quite sure yet that it got from the bats through the pangolins possible bridging species there's a picture of penguin I never heard of Englund before either so it looks like a cute little animal but it's an insect eater it loves termites hope I don't need one in my house and by looking at time here on the x-axis and mutations on the y-axis have only been 7 patients identified so far we see that you can trace this back in time and this is part of the evidence that it emerged in around December of 2013 in Wuhan so how is it transmitted how does it move from person to person well this graph comes from an article in the New England Journal from about two weeks ago looking at what happened at a business meeting in Germany there was a business woman from Shanghai who came to visit and met with some people in Germany and she infected a couple of people at that business meeting patients 1 & 2 in Germany and initially it was reported that her symptoms appeared later but it turns out actually that she had symptoms while she was in Germany she was taking some Tylenol or ibuprofen or something during that meeting she felt achy and tired and so she was transmitting while symptomatic but case number one didn't develop symptoms for another four days yet he apparently infected two other people who did not have contact with the business woman from before he got symptoms one of them patient free practically the same time he was getting infected so there's pretty clear evidence that transmission can happen before people start feeling sick now that makes this pretty different than a lot of other things one of the things about the 2003 SARS outbreak was that people were not very infectious at all if at all until they got pretty sick and a lot of the transmission actually happened in health care facilities before her proper infection controls got instituted and in the United States we didn't see much transmission at all all right because our hospitals did a good job on that one to cases that came here but we have to think about how this transmits what you can do to be protected now the modes of transmission of viruses we know mostly what we know it comes from in studies of influenza virus so we're coming back to good old influenza virus again most of the studies are of influenza because that's the big killer and we have to study this this is what we do here at the School of Public Health with the gesundheit machine and we have found that people shed influenza virus before without even coughing even though they're sick they're not coughing and so the modes of transmission can be airborne and be large droplets spray they can be also we're learning now fecal-oral because this virus the code 19 virus that's the GI tract and so we're having to pay attention to that too so how do you clean up and disinfect well you can look at the label if it's got enough ethanol enough alcohol in it or it's got hydrogen a lot of hydrogen peroxide or household bleach at 10 percent bleach which is a tenth of a percent that works the take-home message is wash your hands however your cost boy crowds don't be present when you're sick presenteeism is a big problem stay home don't infect other people avoid close contact with sick people and avoid sharing poorly ventilated spaces they're not the fresh air in your car so that is a friction about the coronavirus and something about transmission next we're going to talk about that the epidemiology how it spread fast in China and not so fast elsewhere and Angelou is going to thank you that mutant on I have closely monitored the new epidemic of Korea 19 because I have ferry members in China however Lunda I observed the less worried for my favorite members you will see why I'm going to you first briefly presents the features of the new epidemic of kuvira 19 followed with my answer to this question why has it passed spread in China or not in other countries this is group of the epidemic by February 20 by February 16 a total of seven thousand eight hundred seven cases has been reported worldwide and you can see that these two numbers are very close which means that the global epidemic of cruel a virus is largely determined by the epidemic in China but beside of China 25 countries reported a total of 600 three cases including three tests let me write here okay so I help me okay what's happened I won't go bad see okay sorry about that now the epidemic start in Wuhan huhai in the capital city of Hubei Province by end of last year a total of 89 cases were reported in the city of Wuhan and in the fall in 20 days epidemic fast spread all over the provinces are in China you can see the number cases dramatically increased the a different wave of the epidemic now there are two curves here the first curve display the distribution of patients according to they had a tough symptom unset the epidemic which peak at this point on the Sun on January 25 to January 29 now there is a second curve which is this curve this curve is a pleasant number of cases based upon that better report now pay attention here there is a lead period between these two curves this lead period had a facilitate the first rate of the epidemic in China because of unity the period changing still remain in the community they still transmit virus they have not been isolated they have not been treated currently the chance at who is exposed to these cases are huge consequently we see the various spread of the epidemic in China this is a disputing of cases outside of China and majority of the cases reported from other countries had direct or indirect contact with pension that you have or other cities in China that very few cases had transmitted virus to others therefore so far we haven't see an outbreak on our side China except one the Diamond Princess cruise cruise has the largest outbreak of the crew nervous in the cruise ship by far seventy percent of passengers have been infected they are totally due to the failure of quarantine on the cruise ship now these two tables are pretty busy let me summarize here the majority of cases were who Bay residents and who had mystery travel industry to ohan and I want you guys attention to the severity of symptoms most of the cases had a mild or moderate symptoms about about five percent of the cases had extreme severe symptoms for example the failure of lung function or failure of heart function however the tests only occur among patients with extreme severe symptoms not among these two group of people and also the mortality is higher among all patients who were 80 years old or older and among cases with call existing disease there are two thermistor you haven't heard in an epidemic why is reproductive on members the other is fatality the basically productive member measures the speed of an epidemic of also measure as a group of epidemic the fatality measure the severity of epidemic meaning what proportion of the cases who died of the disease so if as you equals to two meaning if I was pensioned I would Allah I have a chance to change my virus to the other two so the epidemic continues as long as our 0 is greater than 1 the epidemic oculd be n1 as you less than 1 I compare the two indexes across the 3 sorry the 3 respiratory diseases you can see that the material on Kobol 19 is 2.

3 however the fur trade in China is largely determined by the fatality info by province now outside the province the mortality was only point 4 and similar about perigee can be seen from cases reported from other countries now locate SAS in China in 2002 and 2003 the mortality was a 9 program which is really much much higher they cover the 19 now if you look at the influenza during this influences the United States about 45 millions through cases a modern 6100 either build to maturity of appointed the you 3 percent now you guys might know deadly armor hospitalized inference of patients the fatality is 7.

5 which is also higher than Kavita 19 so you can see that the fertility rate of huido is raisin sauce but similar to influenza now you look has the value of R 0 the value of i0 a very similar among three disease which tell us that the scope of Cavite virus a Covina disease and the speed of epidemic is similar to the other two to sauce and in freezer however the mortality of Cavite 90 in smaller than so similar to influenza we see in flu cases every day therefore I'm not quite worried about my family members in China now why is that dem Express spread so far in China but not in other countries so far let's because the Chinese girl Chinese China means very very important prevention opportunities before generally first the epidemic was localized in the city Omaha a total of 83 parties if the intervention action were taken she refers before that the spread of virus from one to other areas in China could be prevented and the epidemic could be reduced or localized in the city of hand however there was no effective actions until January 20th is too late at that point a lot of cases exist in our community continue to spread virus to others now three days later the city of Ojai was shut down at that point when Wuhan was shut down the virus had been spread to other province already it's too late and who has located in the center of China which is also the transportation problem before 2006 five million people left at that time it was Chinese first season spring festival seasoning which is equivalent to criminal city in the state people returned to home for family reunions they're not they bring food money to their family members but also bring Wireless to their hometown and also catering to the nine million rather than still remain in Wuhan they it is boss they had high risk to be affected by this number of cases still exist in Wuhan consequently you see the algebraic uses in what kind and in other areas in China now the epidemic can be prevented simply by use the traditional public health measures we call 3e loeli loeli identified in fact individuals the retreat pensions early quality and cruel countenance for 14 days 14 days is wine incubation period and three intervention have been successfully implemented in other countries for example in United States even though we have about 20 or study in project cases there is no outbreak England states so far and Chinese meet the China missed the opportunity to obtain three interventions constantly we see the fast spread of virus and faster spread of the epidemic in China this is Anna my plantation our next speaker is dr.

Cynthia a power Palestines R is an and Horowitz and the for house University great well hello thank you and good afternoon so as you've heard from my two colleagues from dr.

Milton and dr.

Lu we have the data on what is going on with this particular viral situation so if we were all perfectly rational and living in the United States we would look at the data and we would conclude what the public health experts have concluded is that our personal risk is low right now living in the United States but we are not perfectly rational beings we are affected by the things that we see the things that we hear what other people share with us and so that's what we're going to talk about now for a few minutes is what's going on in terms of the communication the information exposure that we have had and why some people may be feeling anxious or concerned or worried and my job is to show you that if effective risk communication is doing its job it should actually leave you more confident and more informed and better prepared to take care of yourself so right now we are in a situation not only of potentially ineffective control of the virus in certain locations but we've got ineffective risk communication going on because there should the anxiety and the worry should be appropriately adjusted to the data that we have so are you more likely to die today because of a distracted driver or coronavirus and the answer to that question is it depends it depends on the kinds of things that my colleagues just explained to you because if you're here it's probably a distracted driver but if you're someplace else under the conditions that you just heard about it might indeed be the corona virus so this is a very classic way of thinking about why people get concerned about different kinds of risks because we react to situations in terms of how much dread we feel about them and how much uncertainty there is about that situation and so you can see that we can plot people's dread and uncertainty in each of these different quadrants and so our reaction to the situation is going to reflect the intersection of those two factors so while some people can be very worried and concerned about a situation other people can go about their daily business their normal lives and not be worried about that same piece of information so you can see what we're really just dealing with here is perception right and we know that perception informs our feelings our thoughts and eventually our actions so we want to take a closer look at some of these things that are affecting our perceptions so one of them is this image this image is supposed to be conveying something to you and while it's very attractive it's very colorful it's information value is actually pretty low because it tells you absolutely nothing about the coronavirus and what your personal risk might be this is another set of images that we're seeing a lot of we're seeing people in this very protect you know protective gear you know suit it up cover it up so we've got an emergency chopper in the background those are the kinds of images that may raise our feelings of anxiety and worry because we know that those things are associated with danger people only put on that kind of personal protective equipment and use medical choppers when there's a very serious situation empty roads how many times do you see a perfectly empty freeway rarely if ever so again it's a symbol that somehow something different something unusual is going on so again even though our personal risk here may be low we're seeing these images and thinking oh well if it could happen there why wouldn't it happen here uncertainty as I showed you in that grid the level of uncertainty and dread that we have interact with each other and the more uncertain we feel the more anxious we're going to feel and as I said if the risk communication is working in the way that it's supposed to we should be feeling more confident more secure in understanding what our personal risk is so that we can take appropriate actions another set of images that we're seeing again people in that protective gear but one of the things that is all complicating this situation is the type of information coming from the epicenter of the outbreak is that the information as dr.

Lu said the information has been slowed it's been incomplete we don't always have a good picture of what's going on in the actual location where the disease is most severe so this is again complicating the situation and adding to our uncertainty because if they if we can't trust the source then that feeds our uncertainty and finally we know that there's a lot of information sharing going on in a minute we're going to take a look at what some of this disinformation is and you can ask about people's motivation why are they sharing this misinformation people can have a lot of different motives there can be political motives economic motives people can just be innocently sharing things because they think it's a value but misunderstand that it could start inciting a lot of concern and panic but this information sharing through particularly social media is really helping fuel a lot of the ineffective risk communication so if you want to find out what's really going on there are places that you might naturally think about going so you heard from dr.

Kleinman I used to work at the Centers for Disease Control and Prevention in Atlanta Georgia and what I do talks with students a lot of times if I when I ask them where do you go for information they'll say I go to CDC or I go to the National Institutes of Health or the Food and Drug Administration well so I went to CDC to see what they were saying about coronavirus and this was the first one Q&A that they had under disease basics and it says what is novel coronavirus a novel coronavirus is a new corona virus well novel and new are exactly the same thing that has not been previously identified and then it goes into this description as you heard that is like the common cold but then you get all of this very technical scientific information about the virus so if I'm just a member of the public without any particular medical or scientific background and I go looking for a plain language by nation of what the diseases unfortunately I'm not going to find it here and I also checked other credible sources like the World Health Organization and NIH and I also could not find plain language explanations of what coronavirus is so when we go to credible sources and we don't find things we understand what we do very logically as we start to fill in with what we do know and we are finding out that people are filling in with some very inaccurate information so when we started looking for what kinds of disinformation are out there we found these kinds of things so for example somebody's putting out there that FEMA is imposing martial law that people are abandoning their kids and airports that you know there's a hundred and twelve thousand people dead that you know all of these cases are showing up in American cities right so the disinformation is of a wide variety and very being very actively spread and this is again fueling all of that uncertainty so the social media platforms the search engines they are trying to scramble as the headline says to kind of figure out how to stop all of this misinformation but we know that people are still sharing a lot of it so this information environment that we're in continues to feed people's anxiety and uncertainty so these are some of the consequences that we're starting to see we are seeing fear we are seeing anxiety we are seeing bias and stereotyping and in fact we found out just before we started this symposium that the UMD Office of Diversity inclusion had put out a statement to help people understand you know how there are fears and anxieties could be contributing to racism and scapegoating so I would encourage you to take a look at some of those tips because really it's inappropriately causing a lot of problems by stigmatizing certain groups of people and also causing anxiety unnecessary anxiety for yourselves we also were seeing that people are looking to fake or harmful remedies so there can be actual we physical consequences if you start trying things that could all cause you more harm than good so again you think well it's just information right it's just I just say things well I saw something and you know what's the harm in sharing that well will potentially take action on those things that you're sharing so I would strongly encourage you to think carefully about what's the real evidence base of that information that you have and have you actually confirmed it with the kinds of evidence and data that you saw in the earlier presentation so I'm gonna give you a personal to-do list right so for everyone here everyone watching us everyone who might watch the recording afterwards I want to encourage you to think about we're talking about people here and that will if you do that that will help keep you grounded in the sense that each have empathy by those who are truly affected and that will keep this – you know at the human centered situation right it maybe will cause you to stop and think should I be sharing this information or should I be saying that thing or should I be you know thinking this about this particular group of people because empathy really says there are people here I need to think about what are the consequences of what I'm saying and doing I would encourage you to just adjust your expectations and assume that we are going to keep learning more so good risk communications set you up to understand that we're always learning something new so what we know today is not what we will know tomorrow about the virus so expect that you will keep hearing new information follow the kinds of precautions that you heard my colleagues talk about and that will put backup at the end of this presentation wash your hands cover your cough do those things that we know are good for infection control I want to encourage you to always test your assumptions about what the nature of the risk is and whether you're really getting credible data to make that decision don't just assume that because your friend shared it with you or you saw it on a social media platform or you read it on the Internet which is what I hear a lot of times that that makes it true really test out those assumptions and make sure that you have a good credible verifiable source of information I would encourage you to be a disrupter and a disrupter in a positive way disrupt disinformation stop that supply and demand make sure you are being a positive force in the information environment and finally I would encourage you take a break from constant news updates give your mind a rest it will help give you some perspective on what the nature of this situation is and it will help you conclude in an appropriate way what your personal level of risk is so thank you very much and I'm gonna hand it off to our last speaker or a solution yak who will wrap us up thank you so much Cynthia and thank you all for being here today and for our viewers and those watching this tape I hope thus far this has provided some information for you my job right now is to sort of wrap this up right prior to our use and aides after all this which case we'll all be sitting here answering your specific questions for those sent in via the various streaming methodologies out there and I'm here really to share kind of the optimism approach as you heard from from the the kind intro that he had is I've been here as dean for the last three years in the School of Public Health prior to that was 28 years in federal service I'm a public health practitioner and during that time 27 of those years as a uniformed officer in the United States Public Health Commission or in essences I've been blessed or cursed with the idea of having been a responder to multiple events in that time period World Trade Center the anthrax attacks Hurricane Katrina Ebola and yes the 2009 pandemic of influenza and in these next 10 minutes where I'm going to emphasize is we may not have all the answers and I'm not going to say that no matter what happens everything is going to work out just fine but in essence the optimism is what the optimism is there has been a system already tested and the system that if this goes in the direction that we're not expecting at this point that an essence is public health is ready to respond may not be and that response occurs where it occurs at the local level what's happening here on this campus that's local level response working with student health working with student affairs working with our communications in our response teams on this campus it spreads into the county level it spreads into the state level into region level national level and yes international levels of response this is my optimism slide as a public health person this has been on my office wall since 1999 right whenever I think oh we're not really doing that well I'll look back at this and these are the ten accomplishments of Public Health as listed by the Centers for Disease Control and Prevention my former employer as well and on that list notice that control of infectious diseases was a major accomplishment in the 20th century the year 1900 and 1999 if you look back historically what took place we started in the year 1900 with no vaccines available we didn't have antiviral medications we didn't have antibacterial medications right we didn't have Diagnostics so the idea of how science and Public Health work together in the course that century it didn't eliminate infectious diseases but certainly we had a better sense of what's going on in the human body our immune system in these other interactions of having the therapeutics and the diagnostics and other things out there to help us in this approach as already mentioned are most of our experience in the world of infectious diseases when it really hits big populations is what seasonal influenza and I'll remind you yet again right this is an annual respiratory illness we're in the midst of flu season right now this happens every year we have worse years and we have better years the impact globally up to half a million people die every year from influenza across the world does it necessarily make the news each and every day well when the news sort of picks it up right when dnews says we have an angle to it then it's not a it's on the news otherwise it's almost taken as if it's a given we have the flu season perhaps up to a fifth of the US population can a time have the illness during flu season we can see the range of death right is it 36, 000 is 50, 000 right now I think we're around 14, 000 people have died in the United States this flu season and of course it's repercussions in our society sometimes measured as economic cost but this is a major issue in terms of the economy in terms of impacting their society the reason I bring up flu is that oftentimes we sometimes neglect this idea of seasonal flu which is an annual event and we get it confused with another term and you're gonna hear this term a lot we're already talking about it notice we were very precise in our terminology in our lexicon in the words we're using we call it the current kovat nineteen situation as an outbreak we call it an epidemic but we don't use the P word well what's the definition of a pandemic World Health Organization the world body dealing with health issues part of the United Nations describes it as an epidemic occurring worldwide as opposed to regionally as opposed within a one jurisdiction process international boundaries and usually affects a lot of people that's a pandemic right and pandemics are always kind of scary to us like oh my god this is spreading this is gonna you know the white basalt this is you know it's it's the the essence of a board game right who's played the game pandemic it's a now on video and all this we play the role of infectious disease right but in essence it is potentially a problem and it is something that may evolve out of this in the next days weeks perhaps months we'll see if this Povey 19 becomes an issue and becomes a pandemic or not because in essence part of the formula is already there as listed here is it a new subtype of virus it's not an influenza virus it's a corona virus but to a new subtype and one that our bodies have not seen before so that's of concern here with kovat it's a virus that produces serious illness and the virus must be able to be spread efficiently from one person to another those are the major amateurs of a pandemic occurring now when we talk about pandemic in the 20th century and now in the 21st century these are our examples of what has taken place and once again I emphasize this isn't coronavirus examples historically this is influenza virus a hundred years ago 1918 1919 something we called the Spanish flu was a major killer mind you it was early in the 20th century before a lot of advances in public health before a lot of advances in medicine this was a major killer perhaps 40 to 50 million people died worldwide in those years during the Spanish flu 57 to 58 we had another pandemic of influenza 68 to 69 was a third pandemic at that point and ultimately the latest one just ten short years ago was a pandemic of 2009 in organism called H one and one and although I was part of the US government at that point and we were monitoring what's going on and in essence what's interesting is we were monitoring what was going on in China we were looking at a whole nother organism called h5n1 and we're monitoring looking where's it gonna happen is it gonna happen this is the potential pandemic and just shows you sort of the beauty of the world of viruses of these organisms because in essence is this was kind of a sucker punch he was a sucker punch because it didn't start in China it started in the United States it started in our own backyard and it ultimately spread from the world from here you can see the impact of that 2009 F epidemic or pandemic as listed here why are we so worried about pandemics well they things were bad at the early start of the 20th century with the fannish flu but you can imagine how life has changed in these hundred plus years now right the global population is larger and it's more urbanized what does that mean means we're living closer together right the ability of spreading disease from one person to another happens because of the in Fireman twerkin second aspect in the 21st century certainly we're traveling a whole lot more right it's it's uncanny these are 1 billion people these are 1 billion passengers so in that sense if I travel seven times a year uncounted seven times but in the United States this is domestic flights and international flights in our nation alone we have a billion passengers moving into 2018 a billion people that are moving around which means what it's not like the old days where I'm just sitting in my house and you know I go down to the store and they walk know we can spread disease very easily and certainly the demographics have changed in our society elderly population has increased and those were chronic conditions have increased which means the whole idea of susceptible people right people who are living okay but perhaps the immune system may be a little off perhaps there be higher susceptibility will petrol diseases my last few slides are going to be kind of busy but the key feature of these slides are what this is what occurred ten years ago and I want you to specially to pay attention to a timeline because this is the optimism slide right remember what I said we're looking at China for h5n1 what happens April 15 2009 I'll remember that day as if it was yesterday cuz I'm in charge of counterterrorism and emerging threats at the Food and Drug Administration right so we've been monitoring all this right what happens April 5th is we're told through the CDC that this is a few days afterwards there is a case confirmed a few days ago in California in 10 year-old boy through a clinical lab study that we have a very unique virus we have a novel virus we've not seen this one before ok so we're now ramped up a little bit two days later there's a second case now we're actually very worried mind you there's only two cases but this is a hundred and thirty miles away and in essence it's the same organism which means it's probably been out there may be asymptomatic maybe already being spread but we're picking up – by April 21st there's already work on the Candida vaccines science has changed and granted this as influenza we're already making vaccines every year but all of a sudden were shifting into another mode with two cases CDC starts activating its Emergency Operations Center there's two more cases in Texas we're getting case reports and from Mexico and Canada FDA where I'm working at has its Emergency Operations Center by the 25th of April w-h-o declares a public health emergency of international concern what does that mean same thing that's going on with Kovac 19 now an extraordinary event constitutes a public health risk through international spread to potentially require a coordinated international response by the 25th of 2009 we have a cluster in New York City we have cases in Kansas and Ohio the United States government declares a public health emergency and implements the National pandemic response plan part of that is a strategic national stockpile medicines and equipment that station throughout the United States is now moving notice how quickly this is ten days after the first case by April 27 w-h-o says yeah there may be a pandemic happening it's something called phase four human-to-human spread and there's community level outbreaks by April 28th we have a diagnostic that's cleared by FDA so we have ability to diagnose this under something called emergency use authorization which allows products that have just come on board to be let out there w-h-o pandemic alert level of level goes to Phase five human human to spread in two nations in one region that means a pandemic is imminent by June 11th it's a full-fledged pandemic it's phase six endemic community level outbreaks in at least one nation in a different region of the world we now have 70 nations affected by this influenza by June 19th all 50 states DC Puerto Rico US Virgin Islands are affected by July 6 we have 122 countries reporting over 94 thousand cases in the United States we have 33, 000 cases by July we stopped counting cases because over a million people are affected you can see this growth and yet there's already been there bond so that we're starting clinical trials with a new vaccine by July 23rd we have an approach with fxe vaccines still not made fully right but we're talking about certain target groups for vaccination right pregnant women caretakers of infants health care workers the young people by September 15th FDA licenses for vaccines a fifth is added on November 16th states get the vaccine doses are administered by October we have the peak of activity the launch of a vaccination campaign by November and December enough of the vaccine that we're easing the restrictions on its distribution and we're getting safety information back from that vaccine trial so what we saw in 2009 was two ways a peak in June and October hospitalization rates were highest in children zero to four and in working adults ultimately we estimated over 60 million people in the United States had that influenza we were kind of blessed in that it was a mild pandemic it was a true pandemic death lies were a little over 12, 000 perhaps a half million worldwide higher level of disease in young people from that pandemic and ultimately was declared but they're cleared over by August and 2010 so in conclusion what were the successes from 2009 the four major pillars that we rely on in public health one is surveillance which is we got to be looking out there on what's going on what's happening boots that are they spreading it are people severely ill are they dying the whole idea of working with our communities right this concept of community mitigation right a term called non-pharmaceutical intervention which goes back to a common message we've all been talking about through our presentations stay at home when you're sick you cover your coughs and sneezes real young kids have it down they're taught right off the bat you're gonna offer sneeze what do you do you do it into your elbow not into your hand frequent hand-washing cleaning of touch surfaces and objects and reducing social contacts during these types of times of illness vaccine delivery plating you in 2009 as did communication so as we prepare ourselves for what potentially is going to have to with coronavirus again it's unclear are we heading towards to put that pandemic I don't know but ultimately much like the Department of Health and Human Services has warned us all along whether it was the Spanish flu in 1918 or our preparations for the next pandemic pandemics have the potential to be major problems for us for our society for our people for the worldwide community and at the same time earned all right are we filled with hubris saying oh my god we can handle this well we're not cocky about this but we're pretty darn good so thank you so much for your attention now we're going to setup our time for the questions and answers thank you very much and thank you to all our speakers when we give them all a hand again we have set up two mics one on either side of the stage and you can line up if you would like to ask a question I'll go from one side to the other we also have been receiving questions from our online audience as well I will start with one question that we have been given and then we will see if there's others do not be shy any question is a valuable question at this stage and so please do I can see some of our wonderful students in the audience or faculty or community members we appreciate your coming here and we value your questions so the first question that people have been asking is when will there be a vaccine to prevent infection by this particular virus and I was going to ask dr.

Milton to answer that there's a lot work now underway there are some candidates that have been produced but takes a while to get something through and I'm testing safety and and into human trials so it's going to be a while perhaps there's much of the air before we have axing Thank You Don right I'll put my two cents into that as well having been formally at the Food and Drug Administration you know as god has stated is part of it is that food the Drug Administration has incredible authority right but its ultimate goal is what is to make sure things are safe that's rule number one and then secondly is make sure they work so as these candidate vaccines are being looked at nothing's released to the public until safety studies have been done right those will of be small numbers of people that are given to vaccine volunteers right that an S people say I'm giving you the backseat we're gonna monitor how things are going that takes the while but the incredible authority that the Food and Drug Administration does have with emergency use authorization allows the product to go out there before it's actually fully tested in terms of whether it works or not it's never released unless it's theme stays but in essence if things really get bad there is this potential of releasing products earlier before all the studies have come in and then essence the studies go on as part of the pandemic or epidemic or outbreak so in essence those are relatively new rules that were started in the post 9/11 era but I agree with Don I think you know a year is sort of the the time period that we're all sort of saying in terms of a bunch of effects it'll take longer than just getting a new flu vaccine did in 2009 because we already had a lot of flu vaccines and it was just a little tweak to the flu vaccine this is like a major thing to come up with a vaccine for a virus that we don't have any vaccines for any related virus it yeah I want to add some of these hi this is I guess more of like a surveillance about the mortality dr.

Liu one of your slides showed the number of deaths and and you'd sort of indicated the percentage was mostly those over like elderly adults and those with other conditions are we seeing anything yet showing that this might be targeting a healthier population like we saw with the 2009 influenza well as good person on the virus has been spread to medical care medical care workers especially physicians with health care pensions however this transmission occurred in a special situation because there is close contact between physician and pensions therefore the intense intensity of the Bulger II between pensions and adductors with Hughes you can finally we see some doctors are also infected by virus however so far we haven't seen any lying so-called super spreader in our hospitals that clear also crazy did I answer Chrissie yeah based on the surveillance the surveillance data from China the majority of deaths came from who the patients were still OCD 70 Daily News they stopped you know my former student who is a chief epidemiology in chances CDC based on their observation the virus in muted the tax rate of the virus has been reduced in China you know it is interesting from that perspective of also the sort of the uncertainty of these viruses right and in essence it's it's very perceptive of you to sir pick up of this idea the difference between 2009 and perhaps any other data that goes on 2009 really took us by surprise and part of the explanation may have been that although h1n1 was a novel brand-new virus there was a similar virus like in the 60s and 70s and the sense was maybe the older population had at least some tweak of immunity the body remembered that old virus that had enough similarity so the severity severe cases really were in the working adults and younger population that never had exposure to that you know a virus similar virus in the seventh yes place I came in a bit late so apologies if you covered this I have two questions one is what's known right now about potential alternative transmission modes I know there's been some reports in the news about possibly the virus being spread in feces as well and so what's known about that currently and then second is a question about sort of the preparedness and the list of I know you know vaccine developments right up there but what kind of formal procedures are there to really study transmission modes and latent periods in these kinds of outbreaks because that seems incredibly important for managing responses yeah so there's recent you could you sort of repeat the question so the question was about modes of transmission and particularly they are our feces containing virus though is there a fecal oral transmission mode second part was about how are we studying transmission so yes so there's increasing reports that it's known that the the way the virus attaches dispels is through something that's present in the lungs but also present in the gut so that it can infect the gut and although most of the emissions have been through the respiratory tract there have been some through the gut and there were for example there was a hospital outbreak where a patient was admitted with abdominal symptoms to a surgical service and infected other people in that surgical service and they got abdominal and so it suggests that if you get a fecal oral transmission it's probably gonna turn up with abdominal symptoms diarrhea whereas if it you're loved you're likely going to get I so it can be transmitted that we're very much has been transmitted through the fecal oral but it's mostly been through the respiratory really and a lot of what's being done now is looking at you know taste histories and trying to understand what's happened in households but there also are a number of efforts out there now to try and collect air samples in hospitals and other places where there may be cases to try to understand is it present in the air just from the air and there's a lot of work going on in several countries now in Singapore and in China and Comm to work on okay thank you Dan we're gonna take two more questions I'll start at the right and then on the left I would like to know I have two questions one is why is it 14 days that the quarantine lasts and the second one is why haven't we develop a universal vaccine that can eliminate all infection from all of the strains of influenza first question was the 14 days why the 14 days is based on the observation that people yeah they hadn't not been shown positive virus symptoms within 14 days they didn't turn up later so observations on a lot of people and dr.

Liu's may want to be and as far as the universal vaccine against in fall influenza viruses is concerned there's a lot of work going on to that NIH is putting out a number of requests for proposals there's the problem with influenza is that it mutates rapidly and so it changes from year to year and just like these corona viruses that newly emerging corona viruses they're a lot of influxes in wild birds and they then gradually move sometimes to the human population and when we see that often through pigs and these new emerging viruses are really different than the ones we've had before and so it's hard to come up with a way to make a vaccine that cover this large landscape okay thank you John our last question thank you my name is Mancha Lee I'm from behavioral and social sciences school actually my question is to pass some question that I have been asked by some international students especially a Chinese student or chinese-american student and even some what faculty with Chinese background because uh by talking with them many similar experience and I was told as that usually when they go to they come to the campers and then usually the most common to question they were being asked is did you go to China recently or have you been to Wuhan or hope a province so those kind of things that and then since the repeal they've been asked and then people and have this conversation and people say that I understand and people get pretty worried or and there is an anxiety about the virus better how can I help people to divide it Varis than a human being and how can I explain myself and how can I help others to remove their worries so then I can be if you are I can feel comfortably be part of this event thank you thank you so much for that very rich question I'm going to ask dr.

Bauer to respond but I think it's something for all of us thinking of it was really appreciate it so you know go back to a couple of things that we talked about first of all we would encourage everyone to retain a sense of empathy this and this is one of the things that was on the office of diversity inclusions checklist was to remind the university community at large that they should cultivate a sense of empathy about this situation and remember that there are real consequences from expressing those kinds of attitudes about you know bias or stereotyping and the second thing would be to encourage people to go and get accurate information about what you know in terms of like what was presented here today what's on the University's web pages for this topic other authoritative sources because and really be informed in terms of their understanding the nature of the risk because that's what we're trying to convey today is that if you look at what the actual circumstances are people here should have a very low sense of what the personal risk is and so this is part of why this forum exists is to inform and educate the university community we hope that this will contribute to that effort to help people understand a little bit better about why they don't need to be quite so anxious or fearful has been very proactive about right and my mic if people should be aware that the campus has been very proactive about trying to reach out to people who have been in China and that I have been incredibly impressed with how seriously people particularly people who were coming back to campus and been in Wuhan were about self isolating and waiting the 14 days and being very careful about not exposing other people until they knew that they were safe and I want to really take this opportunity to thank all of the people who did that from the bottom of my heart I've just been really really impressed that I think they've been really great and thanked and we're all safe you know one of the things that I'm thinking of here is we're sitting here together that we are all learners through this process whether we have learned lessons from before we need to have fresh eyes with each new emergency new event such as this one and we're really fortunate to be here at the University of Maryland to learn from each other's our other disciplines but also from our personal experience and thoughts and Bo able to share them candidly and openly and so I want to take one more time to thank the panel but then also ask Dean lushniak to make a few closing comments and thank you so much for your patience and for your presence great thank you so much for moderating to sashanka thank you for your attendance those of you in the room here and once again to the world out there in in space right on the internet on YouTube you want to review this later on this is going to be on the university's youtube channel we'll send out some information it takes a community oftentimes to work the gadget to get through difficult times and we know at this university I've been here for three years there's been a lot of difficult times for us to get through right there's been a lot of discussion there's been a lot of sense of introspection of who we are as a community and how do we battle the next crisis next issue right what this university has proven to be in my short three years here is one of resilience and of ultimately of a community coming together and dealing with an issue now again I can't none of us can predict where this is going to go as an infectious disease right we are impressed as a School of Public Health the key component of this university community of what's going on out there the incredible work of student affairs incredible work of the Health Unit the incredible work of communications of all the entities right looking at this right this began during winter break and during winter break those of us who were here on campus realized we have to prepare their students coming back some are coming back from China there's faculty people coming back there's tourists coming back right and in essence in a few short weeks we're gonna have the community back together again and the key feature that we want to share with you is one that one that's critical and I think dr.

Bauer made it an important message here which is in essence its transparency it's us sharing information right as a community now we're not alone in this right if this really gets big if it gets big this is now not just the University of Maryland what were part of the community of the state of the county of the nation right we then will get information for multiple sources but ultimately we also have a role in this community one to share the right information so don't be as already stated a source of missed formation on this hey you have questions you asked us will point you in monitor the site here at UMD dot edu virus info that is going to be updated all the time about any major changes here second aspect is you'll learn something today we hope something that we have to even as public health professionals remind ourselves that often times it ends up being the basics that we don't necessarily have to wait for the vaccine or the antiviral or some agent that's going to assist us that ultimately what we did in 1918-1919 is actually applicable today despite the science despite the advances it's great the scientists there it's great that we have the advances but ultimately one take care of yourselves right eat well that's a public health message but it plays a role especially in the time of epidemics right exercise right moderation in everything except exercise and eating well but you know the sense is take care of yourself take care of the people around you right be concerned about your community right be concerned about the psychosocial aspects health is about what about physical mental and social well-being that's what this community wants to be part of right now and ultimately if you do get ill people know about the health unit is here to help I stay away from class let your professors know those of you who are students those of you who work here let your supervisors know that you're not feeling well and then ultimately optimism all right optimism what's up here is important and the sense is that we have potentially and their shoe in front of us we have an issue that's taking place in China that may become an issue here and one is of optimism of us understanding how things are different in 2020 compared to past similar type issues so we thank you so much for your attention thank you to my dear and beloved faculty who were presented here today to the Shanker Klieman also on the faculty of the school of public health and thank you all and now I do something that as former as the former acting Surgeon General of the United States I used to do very often everybody raise your right hands and you are now deputized as public health and information givers and members of the public health community go forth and spread the news about this disease.

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