COVID-19Boris D. Lushniak, MD, MPH / Professor and Dean

DISCLOSURE and DISCLAIMER

• No relationship with commercial supporters• No off-label discussion of drugs or devices • Work supported by US Government (1988-2016)• Maryland State government employee (2017- current) • The views expressed in this presentation are those of the

author and do not reflect the official policy or position of the State of Maryland or the US Government.

Boris D. Lushniak, MD, MPH

Pandemic

• Geographic designation “An epidemic occurring worldwide…crossing

international boundaries and usually affecting a large number of

people.” (WHO)

• Three conditions• A new pathogen and no immunity• Produces serious illness

• Able to spread efficiently from person to person

Previous Pandemics of Influenza

1918-19 1957-58 1968-69 2009World Deaths 40-50 million + 1-2 million 700,000 151,000 - 575,000

US Deaths 675,000 (young adults)

70,000+(infants, elderly)

34,000+(infants, elderly)

12,469(children, working adults)

Type

Other

Spanish flu H1N1

Infected 20-40% of world

Asian flu H2N2To US in 4-5

mos; Global in 8 months

Hong Kong flu H3N2

To US in 2-3 mos

H1N1In US 60.8 million cases

274,000 hospitalized

21st Century Trends Affecting Pandemic Impact

• Global population larger and more urbanized

• Levels of international travel greater

• Over 1 billion passengers annually in US (2018)• Increased population of elderly and those with chronic

conditions

• April 15 – first case confirmed in US (CA) in 10 yo old (clinical lab study)• April 21 – work on candidate vaccine virus• April 25 – WHO declares a public health emergency of international concern

• “an extraordinary event…constitutes a public health risk…thru international spread…to potentially require a coordinated international response.”

• April 26 – US declares public health emergency• April 28 – diagnostic cleared by FDA under Emergency Use Authorization (EUA)• June 11 – WHO pandemic -community level outbreaks in at least one nation in a

different region (70 nations) • June 19 – All 50 States, DC, Puerto Rico, and US Virgin Islands report cases• July 6 – 122 countries with 94,512 cases with 429 fatal (US 33,902 with 170 fatal)• July – case counts stopped, > 1 million in US; reporting of hospitalizations and deaths• July 23 – start of clinical trials with new vaccine

Novel H1N1 Influenza 2009 Timeline

Novel H1N1 Influenza 2009 Timeline

• September 15 – FDA licenses 4 vaccines (a fifth added on Nov 16)• September 30 – States place order for vaccine • October 5 – first doses of vaccine administered• October – peak of activity, launch of vaccination campaign• November/December – easing of restrictions on vaccines• August 10, 2010 -- pandemic declared over

Novel H1N1 Influenza 2009• Two waves (peak in June and Oct)• Hospitalization rates highest in children age 0-4 and working adults• Estimated 60.8 million cases in US

• 274,304 hospitalizations and 12,469 deaths• 151,700 to 575,400 deaths worldwide

• Higher burden of disease in young• May be due to previous exposure of older persons to similar viruses

Shrestha et al, Clin Infect Dis 2011, 1; 52, Suppl 1:S75-82

National Framework for H1N1 Public Health Response

• Four major pillars• Surveillance• Community mitigation

• Nonpharmaceutical interventions• Stay at home when sick• Cover coughs and sneezes• Frequent handwashing• Cleaning of touched surfaces and objects• Reduce social contacts

• Vaccine delivery• Communication

A 1918 Pandemic TodaySevere Pandemic (1918-like)

Illness 90 million (30%)Outpatient medical care

45 million (50%)

Hospitalization 9, 900,000ICU care 1,485,000Mechanical ventilation 745,500Deaths 1,903,000

Pandemic Influenza“It is clear that pandemic influenza has the potential to pose disease control challenges unmatched by any other natural or intentional infectious disease event.” -- DHHS

FEDERAL MEDICAL SHELTER 2006

SPANISH FLU 1918

Coronaviruses• Large family of RNA viruses

– Infect many species from rats and bats to Beluga whales– Mutate slowly compared with influenza viruses (another RNA virus)

• Seven coronaviruses infect humans:– Four common cold viruses: OC43, HKU1, 229E, NL63

• Have been infecting humans for hundreds to thousands of years– Three new ‘emerging’ viruses cause severe disease:

• SARS-CoV (2003), MERS-CoV (2012), SARS-CoV-2 (2019)• COVID-19 is the disease, SARS-CoV-2 is the virus.

• Currently no vaccines and no antiviral medications available

Past Coronavirus Diseases• Severe Acute Respiratory Syndrome (SARS)

• First reported in Asia in 2003 • 8098 people (8 in US) in 24 nations with 774 deaths (9.5%)

• Middle East Respiratory Syndrome (MERS) • First reported in Saudi Arabia in 2012• 2494 people (2 in US) in 27 nations with 858 deaths (34.4%)

Influenza and COVID-19 Pandemic

294,000 - 518,000: global deaths/year1

Case fatality rate 0.13 to 0.16%75% of infected are asymptomatic3

• COVID19 (as of 02/18/2020)7864: global deaths (3/18/2020)

193,475: global confirmed cases in 164 nationsUS 7078 people and 116 deaths (1.6%) in 50 States/DC 80% mild symptomsCrude case fatality rate

~4.1% of confirmed casesUnknown #: undiagnosed symptomatic casesUnknown #: asymptomatic casesRate among all cases unknown – probably lower

1. J. Paget et al., J Glob Health. 9, 020421 (2019).2. M. A. Rolfes et al., Influenza Other Respir Viruses. 12, 132–137 (2018).3. A. C. Hayward et al., Lancet Respir Med. 2, 445–454 (2014).

Annual Influenza Infections in the USA2

Low High

Deaths 12,000 56,000

Hospitalizations 139,000 708,000

Outpatient Visits 4,200,000 16,700,000

Symptomatic 9,200,000 35,600,000

Asymptomatic3 36,800,000 142,400,000

Influenza COVID-19

Symptoms of COVID-19

• Respiratory / Systemic– Fever (43% at diagnosis, 88-98% in hospital), fatigue (38-70%), – Muscle and or joint aches (15-35%)– Dry cough (59-68%), short of breath (18-31%), sputum (33%),

sore throat (14-17%)• Gastrointestinal

– Diarrhea (4-10%), abdominal pain (2%), nausea or vomiting (5%)

D. Wang et al., JAMA (2020), doi:10.1001/jama.2020.1585.W. Guan et al., medRxiv, in press, doi:10.1101/2020.02.06.20020974.

Modes of Transmission?

MMWR Morb Mortal Wkly Rep. ePub: 18 March 2020.

Coronavirus disease 2019 (COVID-19) hospitalizations,*intensive care unit (ICU) admissions,† and deaths,§ by age group

— United States, February 12– March 16, 2020

* Hospitalization status missing or unknown for 1,514 cases.† ICU status missing or unknown for 2,253 cases.

§ Illness outcome or death missing or unknown for 2,001 cases.

Flatten the Curve

COVID-19 US Modeling Worst CaseAssumptions and Projections

• Assumptions• R0 (R naught) -- # infected by one person – 2-3• Hospitalization rate—3-12%• Case fatality rate – 0.25-1.0%• Lasting months to over a year with no non-pharmaceutical interventions

• Projections • 160-214 million cases• 200,000 to 1.7 million deaths• 2.4 million to 21 million hospitalized (currently 925,000 staffed beds)

NY Times March 13, 2020

Issues• Diagnostics

• Issues with CDC test (rRT-PCR); FDA EUA on 2/4/20• Public health labs, clinical labs, private sector (LabCorp, Quest)• Roche (3.5 hr test) approved• $1 million to DiaSorin Molecular and Qiagen for rapid test

• Personal protective equipment – N95 and surgical masks• Public health response

• screening, contact tracing, quarantine, isolation, social distancing, non-pharmaceutical interventions

Issues • Medical care response (surge capacity, shortages,

supply chain)• Research (antivirals, vaccine development)• Messaging (health communication, health literacy,

false information)• Consumer product shortages • Economic impact (stock market, events, travel, etc)

Interim Infection Prevention & Control Recommendations for Patients with Suspected or Confirmed COVID-19 in Healthcare Settings

• Minimize Chance for Exposures• For routine visits -- Call ahead, reschedule if symptomatic• For resp symptoms – triage by phone• Limit points of entry into facility• Adhere to resp hygiene and cough etiquette, consider triage • Physical barriers, hand washing supplies, receptacles• N95 respirators for aerosols, facemasks for splashes and sprays• Eye protection, gowns, gloves• Postpone elective procedures, surgeries, & non-urgent outpatient visits

https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html

Consequences

Mor

e di

stru

st

Fake or harmful remedies

ScapegoatingShortages

Anxiety

FearPr

ejud

ice

Racism

Bias

Stereotyping

Take Home Messages

Get the flu shot and…• Wash hands (soap works)• Cover coughs & dispose of

used tissues• Avoid crowds/Social

distancing • Stay home/isolate when sick

• Avoid close proximity to someone ill, coughing

• Avoid sharing poorly-ventilated spaces

• Stock up on groceries, medicine, resources (ready.gov)

But also…Express empathy for those directly affected

Expect changing and new information

Stay informed cdc.gov

Test assumptions of what's risky and credible

Disrupt disinformation

Take a break from constant news updates

• Everything we do before a pandemic will seem alarmist. Everything we do after a pandemic will seem inadequate. This is the dilemma we face, but it should not stop us from doing what we can do to prepare. We need to reach out to everyone with words that inform, but not inflame. We need to encourage everyone to prepare, but not panic.” • Secretary (HHS) Michael O. Leavitt, 2007