Latest Coronavirus Developments: An Interview with Dr. Amesh Adalja
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Hi, my name is Amy Peekoff. This is Don't Let It Go. And I am very pleased this morning to welcome Amish Adalja.

Amish is a senior scholar at the Johns Hopkins Center for Health Security, and I urge you to Google him. He has been on government panels at all levels and is out on the media right now, truly the voice of reason during this global pandemic. So thank you so much for joining me here today and answering some questions. Sure. Thanks for having me.

Thank you. So I'm going to throw you a little bit because I'm going to ask you something that's a little different, I think. Mike Rowe has recently talked about sort of the, you know, kind of reaction of everybody during this pandemic. And he's described it as everybody being at different stages of grief, all the various stages of grief that we hear about. And so my question for you is, do you go through

any of this kind of stuff that the rest of us are doing in terms of emotional reactions to this? Or is it because you're a pro you don't? I don't think I went through those stages. I think that in the beginning,

everybody just, you have this curiosity that you want to figure out what's going on. So you started hearing about this in early January, and then you're trying to run down what reports you think are correct, which ones need more information. So I don't think I ever went through a denial stage. I thought as soon as we realized that this was a community spreading respiratory virus, that this was going to be a full-blown problem for most of the world. And I don't think I went through any of that. I mean, obviously I got angry with the way the response was botched in the United States and

And eventually, in the way that governors had to use very blunt tools like shutdowns, because that was all that was left to them. And that definitely made me angry. But I don't think I went through the stages in an exact succession. I definitely felt lots of different emotions as being somebody in the field that's been working on trying to fine tune this response for a while, basically, since I was a training infectious disease doctor to see so many things go wrong and so many problems.

Conspiracy theories prop up. So many bad things happen that we always warned about and thought about. But when you see it all happen real time, that definitely puts you through a lot of different emotions as a person in the field. Okay. So you have some of it, but maybe not exactly the same as all of us. And part of us, you know, we think about the risk. And I've heard you before say you just think at some point you're going to get it and you're not so worried about it. Is that right? Right.

Right. I know that I'm a healthcare provider. I'm the one that's going to be in the field seeing patients that I'm exposed to this all the time. And I know it's a virus that's in the community. So it's not something that I think I can completely isolate myself from. And the fact is, I'm an infectious disease doctor. I signed up for this. And this is sort of what the risk of the job entails. So I do think that I'm likely to get this if I haven't already gotten it.

Okay. Okay. And in terms of lockdowns, do you think we could have avoided them entirely if we had been properly prepared?

I think that what we could have done was have a much more refined approach to this. It may mean that certain places like New York City would still get in trouble because they're a place with high population density and very low hospital excess capacity, even on a good day, if you've ever seen an emergency department in a hospital in New York City. They may had to have done some type of social distancing that was enforced by law to keep the hospitals from collapsing. But many of the other states probably would not have had to have done that because they wouldn't have been

in the position of not knowing who was infected and who wasn't infected. Remember, that's what that social distancing, what was premises on it was the fact that we didn't have the testing capacity. We weren't testing. So we didn't know who was at risk, who wasn't at risk, where we were in the epidemic curves. So governors were scared. There wasn't much federal leadership at that point. And they basically had the only one tool and they used it. And

they use it in a very blanket fashion and there were differences across states and one state construction was prohibited. One state construction was okay. And you had all of these kind of governors having to, to make their own rules up as they went. And I think that wouldn't necessarily have happened if back in January would have said, let's get diagnostics, diagnostic testing stood up. Let's get hospital capacity addressed. Let's think about our strategic national stockpile so that we wouldn't be left with blunt tools. We would have had precision guided tools. And that's how we,

envision outbreak response being, and that's how it has been for other types of infectious disease outbreaks. Okay, yeah, and that sounds about right, but you would think it would be a proper function of government in cases, maybe, you know, places like New York, where it would be required to go ahead and institute those government-mandated lockdowns for short periods of time?

I do think when you have a contagious infectious disease, when people are at risk from other people because they're getting infected, that there is a role for government there. And it's usually the opposite of what happens. It's usually not starting with the most draconian thing and then slowly lifting it. It's usually starting with the least restrictive. But again, we were put in a position where there was just multiple failures, and then they were left with this undetected outbreak that had spilled into the hospitals, and there was a crisis that had occurred.

And I think when you look at it that way, the governor had one bullet there to use and they used it that way because he had no idea what was going on.

Ideally, it's not like that. Think about like Typhoid Mary. She's a great example of the use of government power in an infectious disease. It basically started with very minimal types of restrictions on her until she actually proved that she was a threat to public health because she wouldn't follow those. And that's when they put her on North Brother Island. So public health usually starts with the least restrictive and then moves as you need to move. They had to do it backwards because we were kind of in an

we were flying blind basically with no guidance and no understanding. And you had hospitals that were right at the level of crisis where they might have to ration care and people would be short ventilators, for example. Right, right. Okay.

So let's go on to the politicization that has been big and of course we see headlines about it today as well. This is a question from Benjamin. He says the COVID crisis obviously charges the politicization that was already underway. Now we see how a public figure like Elon Musk, who formerly was a poster boy for the green left by way of a few public statements is becoming a symbol for the anti-lockdown right.

Are you encountering similar pressures in your work because people expect you to take a certain position and how do you deal with it? I do think that this outbreak has been politicized by both sides from the very beginning. But I think that's the case with any issue that happens right now because we are in these kind of tribal camps now, including what television we watch, what newspapers we read, which politicians we like. All of that has become so balkanized that you can't really actually have any kind of way that you can have

have truth come through because anytime you say something, people want to know what angle is he coming from. So I definitely have seen that and noted it. I've not had any pressure. And one of the things that I've done is gone on all three of the major cable news networks regularly, CNN, Fox, and MSNBC. And I'm saying the same thing on all three of those networks. And I haven't had pressure. I can tell sometimes from the slant that you get from the questions that they want you to say something a certain way that supports their point of view.

And I still give the same answer. And you can sometimes detect a little bit of frustration. They might ask the question a different way. But no one has ever pressured me to say something that I didn't believe or not taken me for what I'm talking about. And I try to stay as a subject matter expert, talking about what I know best about this virus and what I know about how to respond to pandemics. Where you take that and how you translate it into policy, there may be some debate there. But I definitely...

I definitely felt politicization anytime I'm on television, just by who I'm on with and the host. And the same thing happened during Ebola, because I was on Ebola saying the same thing on all the networks back then. And on that side, it was actually the opposite, where you had Fox News, for example, wanting to

Talk about how disastrous it was going to be for the United States. And you had CNN and MSNBC saying, this is not, this is a manageable problem, which is the position I had. So it was really interesting how that is a little bit flipped with this outbreak, depending upon who was in power. And I think that really reflects how much politics has come to dominate science and medicine and any kind of public issue. Yeah.

Which is really sad. And then the latest bit of the controversy is supposedly the CDC is acting behind Trump's back and releasing guidelines that the White House didn't want. What do you think of these new guidelines? I heard 60 pages of guidelines. New York Times has a kind of bullet

summary of them, are they good guidelines? I do think they're good guidelines because what the CDC does is offer state support because the CDC does have the best experts in epidemiology and infectious disease outbreak response. There are people there that I really, really respect. I work with them. I've been on CDC panels. I've been in the CDC building. I think that they are really...

the top notch people in the world. And if you do infectious diseases and you work in the field that I do, the CDC is your go-to for all of that. And the fact that they've been sidelined in this outbreak has really been part of the reason why we've managed this so badly. From the very start, the CDC has been in a backseat. And there is an article today that was on CNN.com talking about that because now the CDC, some insiders are now speaking about all the politicization that happened and how they were basically

with coming up with things that support the president's line on this versus what actually was happening. And this just shows you the corrupting influence of even if they're not being directly asked, the fact that there is this cloud over all of them, that they have to worry about what the political implications of what they say are, has really clouded the way that they've

They've given guidance. And I do think that when states open up, you have to remember this virus is going to be with us and it's going to be part of our risk profile that we have to think about every time we step out the door. And it is important for people to know what are the best ways to keep themselves safe. If you own a gym, if you own a school, if you're doing...

doing any kind of activity. And the CDC has went through that and done and come up with guidance that you can implement in your place of business or in your house or wherever it might be. And I do think that's really important. That's one of the best functions that the CDC does is it stays in the public health lane and gives people recommendations on how to make things safe. And nothing is going to be with zero risk now that we have this virus until there is a vaccine. So we have to find a way to live with it. And I do think that the CDC does provide really good data on how to do that. And in a way that

that allows you to be able to enjoy whatever you're doing with some safeguards in place if you choose to follow. - And do you think it's going to be the case that we're gonna have a vaccine before we reach herd immunity that everybody is talking about? What do you think? - So I think herd immunity will, herd immunity is, it takes a while to get there with a virus like this. Probably about 60% at minimum need to be infected.

I don't know that we want to get 60% of our population infected because when you see a country that's trying to pursue a herd immunity strategy like Sweden, you can see the high level of deaths that they have to incur. And that's a societal decision you have to make if you want to let this, because this virus is not influenza. This really will ravage nursing home populations, elderly populations in a way that we don't see with many other viruses. So that will happen if you go for a herd immunity strategy.

So I do think that those vulnerable populations are gonna continue to social distance even when stay at home orders are lifted across the country.

And I do think that we're going to need a vaccine to get herd immunity. So I do think that this is going to be something that we're going to be stuck with for a while and people are going to be having to protect themselves from this virus until there's a vaccine. And that vaccine deadline that you keep hearing about the end of next year is very optimistic. It's likely to be maybe two years or so in the best case scenarios. It would be great if it could happen. We're doing everything we can to get this done as fast as possible. But there are a lot of question marks and vaccine development is usually years, not months.

And you don't think we're going to be able through some combination of testing and tracing, basically get rid of the virus within the population. It's just going to be here until we get a vaccine and that's it.

Right. Testing and tracing is going to be crucial to keep the cases down to a level that's manageable by hospitals. And so that's why it's really important that we have that in place. But the virus has established itself in human populations. It's what we call endemic. It's not going to go anywhere. So we do need to think about how we cope with this virus and kind of find a path forward where we try to protect ourselves as best we can, especially if you're in a vulnerable population, and not allow the virus to become disruptive, but at the same time, try to go on with our lives in a way that's safe.

that allows us to enjoy the things we want to do and keep the economy going. Okay, one question that I had is, what about outdoor activities? So are people supposed to be concerned if they're too close to somebody outdoors, should be wearing masks outdoors? I saw one appearance that you had where they talked about the direction of the wind can affect this. What do you do personally if you're going outdoors and enjoying some time?

So outdoors, transmission risks are much lower than indoors. So that's important. So we want people to go outdoors as much as possible and be able to enjoy themselves outside. There are risks of transmission, specifically if you're very close to individuals. This virus spreads approximately about six feet in respiratory droplets. You can see papers that come out all the time talking about, well, the wind can carry a droplet this way or this can happen outside. That's usually, those are vital.

possibilities, but they're actually, they don't fit the epidemiology. When we see people getting infected, it's because they're in close contact with each other, not because of some wind gust that's blown someone's sneeze very far. You can think of all these far-fetched types of scenarios, but what happens on a day-to-day basis, how does this virus usually spread, is between people that are close, that are in close contact. So I think that's, that's fine. The mask wearing has been a bit of a controversy, and it still is a controversy in my field. Remember the masks, even,

Even now with the guidelines, the masks aren't to protect you, they're to protect other people. Because what happened was people started getting concerned about a phenomenon called asymptomatic transmission, people spreading the virus without symptoms.

And this is a bit of a controversy because we still don't understand what context that happens in. We know it happens in households, for example, and people that are in close intimate contact with each other. But we don't know if that happens during everyday life. But because of those asymptomatic cases, there were general recommendations for the public to wear masks, homemade masks, when they're in public.

and I worry about, you know, A, are they effective? Does asymptomatic transmission occur as much as we think? Are those masks, if it does, are those masks effective because they're homemade? And C, does the person paradoxically touch their face more adjusting the mask every five seconds because it itches? And there are certain rules, like for example, in New York State, that a two-year-old has to wear a mask, but a two-year-old will likely eat the mask rather than actually wear the mask. So I don't know that that's well thought out. It makes people feel better, but it's something that I think we're going to be...

It's going to be almost the price we pay right now for having reopening, but I don't think that there's strong science that supports this, but it's become something of a taboo to even question it now. But I've never been a strong supporter of homemade masks and being effective in transmission prevention. Okay, okay.

Back to the comparison with the flu, I've got a question from Michael. And he says, I feel capable of assessing my risk according to the data. He says, however, I find my assessment compromised by the lack of context introduced by generally poor journalism and sensationalism. And I've had this complaint too, Amish, about-- sorry, Amish. We had this discussion before, and I'm going to do the same thing Yaron does.

I've had this complaint too, because I have felt that a number of the stories that you see in the media are just, you know, sort of designed to get you to click on them and induce fear in you. And so they'll say, oh, there's this new mysterious condition linked to COVID. And I

you know, the way that I would articulate it is that a number of the more authoritarian politicians and some of the media would like you to think, but for the grace of the mysterious unknowable COVID go I, you know, and you're just going to walk around in fear all the time. That's how I feel. So I'm going to continue with Michael's questions. He says, if the same media were to report on the traditional flu,

or even the 1957 H2N2 if it happened today, would we see the same extremes? Would we see otherwise healthy people end up on ventilators or comas or all these different things? Or is the coronavirus really different in kind?

So it's a little bit of both. I would tell you one thing when you're reading newspaper headlines or online articles, don't read the headline, read the actual text of the story, because most of that, the headline is usually written by somebody else, not the journalist that's written it. And I've even had issues with things that I've been quoted in saying the headline actually isn't reflecting what I actually said. And they're like, no, that's what the editor wanted to make the headline. So read the story. Don't look at the headline. That's one thing.

And I do think, so if you look back in 2009, H1N1, the influenza, the last influenza pandemic we had, there were case reports and studies. There were cases reported in the newspaper about severe individuals that died. H1N1, it killed more children than any other flu season on record in the modern era.

And there were stories like that. There were a lot of that. So I think that's just a function of the era in which we live in, where there is a lot of sensationalism. Think about how many times you see headlines about brain-eating amoebas or flesh-eating bacteria. These things are- Murder hornets. Murder hornets. So that happens. I would say that this is different in kind in terms of

the virus itself because remember this virus is novel, meaning that the human population doesn't have immunity to it. So its attack rate is very high. Everybody is susceptible to it. So even if it kills maybe 0.5% of those that it infects, that's still 0.5% of a very big number. So it is doing things that flu doesn't do because flu has population immunity to it. We have antivirals that are effective against flu. We have a vaccine against influenza.

And we know how to treat influenza very well in a hospital setting. There's not much mystery to all of the different ways flu can present and how you manage a person with flu on a ventilator. There's a lot of unknowns with this virus. And I think that

That's what's caused a lot of the consternation over it, as well as the fact that it is more deadly on a pound-for-pound basis than influenza is. Flu doesn't kill this many people this quickly. And remember, our flu death is an estimate death, so we don't even, they actually maybe overstated a little bit our flu death every year.

So I don't think that we can think about this as influenza. There are some similarities in the fact of how it spreads and the symptoms that it causes, but it clearly is more deadly than influenza on a pound for pound basis in a season. And even more so than the 2009 H1N1 pandemic virus and likely to be more so than the 1968 and 57 pandemic viruses as well. - Okay, are you able to get a sense now of the fatality rate now that a bunch of numbers are coming in? What are you looking at if you're trying to assess that?

So all of the numbers still have that skew, what's called a severity bias, because we haven't tested everybody. And now it's almost too late because many of those people already recovered and their test is going to be negative. But we know it's less than 1% on average. And it's likely around 0.5%. We often won't know the actual case fatality ratio until after the first wave of the pandemic, where we can go back and do zero surveys and see how many people were infected.

So I do think it is probably less than 1%, but it's probably a multiple maybe of five times what we get with seasonal influenza. So seasonal influenza is about a 0.1% on average. This is probably about a 0.5%. And it's important to remember that's an average number. So if you're above age 70, your case fatality ratio may be much, much higher. And if you're below 40, it may be much, much, much lower.

Okay, that makes sense. So here's a couple of questions about special populations. Children, how this affects children has been somewhat of a mystery and data is coming in saying that maybe children aren't even vectors for this. Can you explain that? Are you getting any handle on why that would be?

Sure. So we know that children can get infected. We know that they can get high levels of the virus in their nose. We know they have lots of contacts, but there hasn't been much documentation of them feeding an epidemic or spreading the cases themselves, which is very different with influenza because influenza, they are major virus magnifiers. Children tend to have much lower severe disease in this. They're much less represented in hospital numbers or deaths.

And this is a little bit of a mystery. It might be, remember, this is the seventh human coronavirus that we've discovered, and four of the coronaviruses cause about 25% of our common colds. And we know children always have common colds because they're exposed to viruses. So there may be some cross-immunity there. There also may be some questions about the immune system and how mature it is because a lot of the severe symptoms come from an overreactive immune response, and it might be that children are more likely to have a dampened immune response.

There are some reports of severe illness in children, though. For example, there is this inflammatory syndrome that we're hearing about. This is very interesting, and it's very rare. Most of those children do recover. But it likely is related to the coronavirus, but we don't quite understand who it occurs in, why it occurs, why it's really only being reported now. So there's a lot of things we have to answer about it. But it is something that we have to be on the lookout for. And I do suspect it is related to it. But it doesn't change the fact that children do fairly well with this infection.

What about the MMR vaccine? I heard one story and then I didn't hear any follow-up on it. Could it be possible that because the children have more recently received this vaccine, that that would contribute to their immunity as well? I heard this also. There was a preprint paper, one that had been peer reviewed, that talked about maybe that there's some

cross-reactive antibodies that are generated by the MMR vaccine that help against this coronavirus. I don't know that that would be the case. I don't know that I think that that's actually going to end up being the case because remember people have been getting the MMR vaccine for a long time and we have these other coronaviruses some of which are similar to this. There's no cross-reactivity there with the other four coronaviruses that cause some of our seasonal influenza. I think it's something that it's interesting to study but I don't suspect it actually is

is going to pan out in the end. There's lots of people even talking about, for example, the tuberculosis vaccine called BCG that's administered worldwide but not in the United States that could be something that has cross-reactive immunity as well. I don't think that any of that's going to really be borne out, but I think it's important to study and to think about, and these are all hypotheses that we have to run down, but I'm not convinced that they're going to end up panning out in the end. Okay.

Going on to sort of heightened risk factors in certain populations, we've heard, you know, hypotheses about obesity, maybe because of ACE2 receptors, diabetes, maybe again because of a heightened immune response.

What about people with autoimmune conditions in general? I heard a tragic story about a woman who had rheumatoid arthritis, but then there are a number of people like me who have Hashimoto's going on. Should we be more concerned about

Those of us with autoimmune. - When it comes to autoimmune diseases, it's a little bit complex. It's not gonna be one size fits all. What really drives this is are you on immunosuppressing medication? So people that have rheumatoid arthritis, for example, are on medications that block their immune response. And then we talked about the immune response being overreactive in some people.

But also an underreactive immune response or being immunocompromised is also a risk factor for severe disease. And I actually had one of the patients I've taken care of that died had rheumatoid arthritis. So this is something that puts you at higher risk when you're on immune suppressing medication. So you might be on steroids, you might be on injectable drugs, things that decrease your immune response. And that does put people at risk. But not every person with an autoimmune disorder is on an autoimmune.

on an immune suppressing medication. So for Hashimoto's, there is not immune suppression that you're on. So I wouldn't think Hashimoto's put someone at higher risk.

So I think it's important to think about it on a case-by-case basis. If you have an autoimmune disease that affects your lungs as well, so for example, scleroderma can affect your lungs, that can also put you at higher risk if you have pulmonary hypertension because of an autoimmune disease. So it's really on a case-by-case basis. Okay, okay. I have had questions about travel.

if you were going to be traveling, would you prefer, say, driving and staying in hotels all the time or would you prefer to fly? What are your thoughts on travel? So I tend to be pretty risk tolerant, so I'm not the best person to model their behavior on because I tend to be around these infectious diseases all the time and not necessarily worry so much about them in my everyday life. But obviously anything that puts you into contact with other people is going to be a transmission risk. Nothing is going to have a zero risk.

I think on airplanes, it becomes difficult to social distance. And people have to think about that if they're in high risk populations, whether or not it's worth it to fly because you're going to not be able to social distance the same way as you would be in a car by yourself, for example. And the same is true of hotels versus staying somewhere where there is not a lot of people congregating. But there's not going to be a one size fits all answer. And it's not going to be something I could prescribe for somebody. You're going to have to really look at these types of

these types of activities. Think about what's essential to you, what's not essential, where does it fit in the values that you want to pursue, and what risk are you able to take, and then kind of have to make these decisions. What do you think about the air ventilation systems in any of these various areas that we're talking about now? We're talking about airplanes, hotels, restaurants, for example. Restaurants, it's kind of even more of an issue, right?

So I do think that the CDC recommendations do talk about increasing ventilation, but that doesn't necessarily mean that you have to get some special type of air conditioning unit or something like that. It just means that the more ventilation there is in a place, the less likely you're going to have crowding and people

and people being exposed to each other's secretions. I'm not so much worried about plane recirculation of the air. When plane transmission occurs, it's likely because people are sitting next to you that are coughing or sneezing on you or onto surfaces that you're touching. It's not an issue of the air being recirculated. I think that's a little bit of a myth about any infectious disease transmission. It's really the people around you in the seats that end up getting infected, not because of the plane's air circulation system.

But in the restaurants, it's not necessarily because of the circulation, but because, for instance, you're sitting downwind from the airflow that was coming from the system? Is that really what's going on in the restaurant? So there was one case report from China where there was an outbreak in a restaurant. And they speculate that it could have been because of the jet stream from a very aggressive air conditioner.

I think that's something that we're all looking at that case. I don't know how extrapolable it is to everybody else. We haven't seen any other reports like that. And we have to make sure that there wasn't another reason for this, meaning could the server have been sick and spread it from person to person to the other tables? There's lots of things we have to look at in detail. That's one hypothesis, but I don't think it's the only one.

It's not the only hypothesis, and it's only one case report that we're seeing, and we haven't seen any outbreak like this anywhere else. So I don't necessarily think it reflects ordinary life. But obviously, if you're at a restaurant, if you can sit outside, if you can social distance, that's all going to make your risk lower. But when the restaurants open there in Pennsylvania, you're going, you're not worrying about it, of course. No, I'm not worrying about it.

Excellent. Excellent. So when we look at the, you know, kind of prospects for the future, the various treatments that are being studied and developed, the vaccines, the tests, are there developments that you're particularly excited and optimistic about on any of these fronts right now? What's the latest on these?

There's lots of good things going on. So starting with vaccines, we've gotten some good data from a phase one clinical trial on a vaccine by Moderna that looks to be the leading candidate in the United States. Everybody's excited about that, but it is a phase one trial and it's going to take some time. So there has been great movement on vaccine technology. We're seeing just how fast some of these new technologies can get you into clinical trials, which is something unheard of even a decade ago.

With antivirals, we have one antiviral that got emergency use authorization called remdesivir. It's not really a knockout punch, but it does work. And there are other ones that they're going to make, antibody-based therapies that are likely going to be much more useful as we get further into this outbreak. Diagnostic testing has really gotten good now in this country. We've

gotten saliva-based tests, and there's a real encouragement of trying to get at-home testing and at-home specimen collection, which is going to have repercussions not just for the coronavirus, but for other diseases as well, because I think the FDA has seen how beneficial having all that diagnostic testing could be, and they've made it much easier for these companies to develop in a way that they hadn't in the past. I think in general, I'm

So I think those are probably the biggest developments that I think that I'm excited about. I think that we, this isn't something that's unsolvable. You just have to remember that coronaviruses were not something people prioritize that well, because they were common cold viruses and SARS was something that came and went in middle East respiratory syndrome or MERS never really took off. And it wasn't really something that people wanted to, to, to invest money in. But now with this pandemic, I think we're finally going to get a lot more investment in pandemic preparedness, as well as in some of the,

the countermeasures against some of these viruses because this isn't the only one. There are many other viruses waiting out there to start pandemics. And I think now people are going to take this seriously and really start to invest because it's much cheaper to invest in the upfront part than it is to deal with what we're dealing with now. All right.

Now with the testing, is there a particular test, for instance, antibody tests that you think is more accurate than the others? I told you I went to go get the Quest one. I still haven't gotten my results. I expect it to be negative probably. But is there one that's more accurate and worthwhile?

With antibody testing, a whole bunch of them came out. 'Cause actually with antibody testing, the FDA took an opposite approach than they usually do. They just said, "Just put out whatever you want. "We're not approving anything "or giving anybody a stamp of approval." So there was a whole bunch of kits that went out there and some of them were not very good. So then some private industry groups started to test them to see,

which ones were accurate, which ones had high specificity because a lot of them were cross-reacting with other coronaviruses and about a half dozen came out that looked to have good specificity. The ones that I recommend are ones that are being used by Quest Laboratories, which is a national chain, LabCorp as well, which is a rival to Quest. It's also a laboratory chain. And I, in, in,

I think LabCorp is now using the Roche assay, which is the company that has a very highly specific one. I don't remember which one Quest is using, but I tend to tell people to use Quest or LabCorp when they're getting this test done so that they have a reliable result. Okay. And if you took one of these and you were positive, what would your kind of approach be then? It could be a false positive or...

Well, first I want to know what brand it is that they took. If I took one of the ones that I thought was a good brand, I'd say, okay, yes, I was exposed. I have an antibody. It likely means that I was infected and I didn't know about it.

And I would think that I'm likely protected for a period of months to maybe a year from getting reinfected. And if I get reinfected after that, it's probably going to be very, very mild. So I would have some reassurance if I was positive. It's not that we don't know that this happens. We assume from many infectious diseases, including other coronaviruses, that after you're infected, you can't really be reinfected for a period of time. We need to figure out how long that time is, but we just need...

we actually need time to do that because you have to follow these people out in what's called a natural history study, watching them to see when they're exposed if they get infected. And I do think it would make me a little less worried about becoming infected, but I'm not super worried myself about getting infected. But I think it is something that we're gonna have to use to think about this in the future once we figure out how to operationalize this type of testing.

And of course, with all of the testing, the other thing that we could use to sort of boost the value of the results that we get is tracing. Have you been following the efforts to institute some sort of tracing app here in the United States? Do you know what's going on with that?

Well, so contact tracing is something that's going to be essential as we move forward because it keeps the number of cases manageable because you're finding the contacts and isolating them and doing all the testing. Each different municipality, each different county, each different state has a capacity for contact tracing. And all states are now trying to ramp up the amount of people that they can test. And it's going to be different depending upon what...

depending upon what their baseline is. We want to make sure that the technology is actually useful to people because one of the things is when you're a contact tracer, you have to make sure that people are trusting of you, that they're telling you what they, who they were in contact with, where they were.

And you want to make sure that they feel secure. So you don't want them paradoxically to say, oh, this app is giving all my privacy away. So I'm not going to be very forthcoming. You want them to be forthcoming. So you want to make sure that the app actually helps the contact tracers. I do think that for many people, it will help. I have no problem downloading these apps and helping out.

But they're going to be people that don't. So you want to make it voluntary and you want to make sure that it doesn't create more work for the contact tracers because they really need the most help they can get when they're doing this. And if anything, that makes their job, you want everything to make their job easier. And I can see in some situations it could be harder if there was a lot of technology there and people being paranoid about what kind of privacy concerns, over privacy concerns.

You know, I heard that several weeks ago there was already an app that was in use in Australia, for example. Do you know what the holdup is here for doing this? Because it does seem like it could help quite a bit.

I don't think that there's a specific holdup. I think it's just about getting it operationalized and deciding if they, if each, because this is going to be done at a county level. Does this county health department want to use it? So I think you're going to see a lot of different local decisions being made. So I don't think that there's a specific holdup. I think it's just about operationalizing them and getting these things stood up. And you'll probably see some of the more innovative solutions

health departments do this first and then see it trickle out. Because some places don't even have the capacity, you know, many health departments are still using fax machines for everything. So they don't even have the technology, technological bandwidth yet. So just, it won't be, it's going to be patchwork across the country because our health departments are chronically under-resourced in terms of when they need to do things that are in their core function, because they're often distracted by other things that they're working on, like pollution and obesity and all of these other things. And their infectious disease divisions are really under-resourced and undervalued.

So the thing is, though, couldn't it be done by a private company? Couldn't some private company just make an app based on the protocol that's been developed by Apple jointly with Google and just put it out there instead of these local governments all doing it? Why don't we have this as sort of a nationwide thing that we could all voluntarily opt into? As I understand, they've built in privacy protection into this app.

- You could do it that way. I guess it's just that the health department that has the authority to do isolation and quarantine, and they're the ones that are in charge of it. So you still want them to have buy-in and actually be using the tool.

because you really couldn't, I guess you could use it for your own self and then and decide to self quarantine yourself if you've been exposed, but it would still need the health department to keep track of all of that. So I think that's probably the issue because that is one of the government rules when it comes to communicable diseases, the isolation quarantine and the contact trace. But you could do, you could have people empowered to do it themselves as well. That would likely help.

Yeah, I mean, I think a lot of us would prefer a more private solution because many people are scared that once, you know, government institutes tracing like this, that they're not going to let it go. We had the Patriot Act after 9-11. We're going to have some app that traces us everywhere we go after this global pandemic. People are concerned about that. So I think, believe it or not, that I may have...

reached the end of my list of questions. I was going to ask you one more, which is what is the day in the life for you? You wake up at oh dark 30 and just go all day, burn the candles at both ends nonstop. What do you do? It depends on the day. Sometimes I'm working clinically in the hospital and then it's actually a little bit more manageable because I'm in the hospital and not as available to deal with all of the other stuff going on.

But it's a mix of seeing patients, doing lots of interviews, reading all the stuff that's going on, conference calls with my colleagues that are working on these issues at Hopkins. It's been basically a whirlwind since January. I've been doing this nonstop now, and it's been five months of this. It's exciting.

you know, this is something that I've always thought about what would happen during a severe pandemic and how it would happen. And it's very surreal to see it all happening kind of in front of me and being in the middle of it a little bit with all the media that I'm doing and all of the projects and efforts that I've been pulled into. But it is why I chose this career because it is such an important topic. And I think this really...

to me, concretizes how important people that focus on pandemic preparedness can be during these types of events because of the sheer amount of information that the public needs and having to try and trying to be the best trusted source of information, the most giving the most objective information that I can and trying to help people guide them through what's really an uncertain and scary time for many people.

I know your time is limited. I've got two more questions for you. So one of them is, you had talked about the media, whereas sometimes you feel like they're asking you slanted questions, but they don't really try to get you to say anything that you wouldn't want to say. Have you felt pressure from other places, either at Johns Hopkins or from any government bureaucrats or people who try to pressure you to say things differently than you're doing? How are you doing on that front?

No, I have not. I haven't felt pressure. I was mindful of what I'm saying. And I often, I think I'm going to get pushback from what I say and have to explain myself of where my position comes from. But I think I need to be prepared to do that anyway with anybody I talk to. But no, I worry sometimes about

about being contrarian on certain issues or not following the orthodoxy, but I have not seen any kind, I've not necessarily had any kind of pressure to change what I've said. I've had to explain myself, but that's, I think that just goes with what I would expect anytime that people want, especially in my field, want to understand what my reasoning is and what my rationale is behind a certain position that I take, but no, I have not.

Okay, well that is really good to hear because whereas with the media I might expect all sorts of pressure, the thing I'm always most concerned about is whether you're getting pressure from government or otherwise. And actually, I'm sorry, I do have two more questions. Once a vaccine comes out from this, should people be concerned with, you know, the fast ramp up time or anything else? Should they be more concerned about the safety of a vaccine that might come from this era than any other vaccine?

I do think that we're going to go very quickly and we likely will get an FDA approval under what's called emergency use authorization before the phase three clinical trials are completely done. So we won't have full safety data the way we have for other vaccines. So people do have to think about the,

the risks of getting the vaccine. And hopefully we'll have enough data from phase two clinical trials to know who's at risk for side effects, what those side effects are, and be able to counsel people accordingly. But yes, anytime you're doing anything abbreviated, the safety data is not gonna be as robust as if you went through a full phase three clinical trial, but nobody really wants to wait with this pandemic. So I do think that there's gonna be that emergency use authorization and those caveats to go. But I do think there's not,

I don't have any specific concerns at this point yet about what I've seen in the vaccine development and the vaccine data. So I suspect it will be a relatively safe vaccine, but I want to see more people injected in the phase two trials to be able to say that with certainty. Okay.

Well, as you said, this is not going away for a very long time. And I do hope later to be able to do a follow-up with you somewhere down the road, come back up on your list again when things are changing, especially when we have a vaccine and things like that. But let me ask you now, so far, the five months that you've been at this and everything, what is the most interesting thing to you personally that you've learned so far? Or anything that you would want to share that you haven't been asked in an interview so far?

I don't think I've been asked that question before. I mean, I think one of the things is that as someone who works on pandemic preparedness, you think about all the plans and how all should work like clockwork, everything should go off without a hitch. And then you see that the implementation can be fumbled very badly. And then you get put into a position that you don't even want, that you don't want to be in. And you're stuck with, you're stuck in a situation where all these economic shutdowns are going, all of this type of

all of these cascading impacts are happening. And you know, the answer was back in January, we should have done something. So I think that's important because the United States was ranked as the most prepared country to a pandemic. And I still believe it is the most prepared country, but we really messed it up. And I think that to me has been the most interesting is understanding how these mistakes were made. And we still don't know all of the answers of what happened because a lot of things we, from a textbook answer, we knew what the answer was, but those textbook answers weren't the ones offered back in January and February.