Transcript of congressional briefing by Johns Hopkins experts

Experts from Johns Hopkins University and Medicine briefed congressional staff on Capitol Hill in Washington, D.C., on March 6 about various issues related to the spread of the new coronavirus that causes the illness COVID-19. The following transcript of the briefing was lightly edited for clarity and includes links to specific points in the recording for each speaker.

Introduction

Lauren Sauer: Welcome to this special briefing from the Johns Hopkins University of Medicine. Thank you all so much for joining us. I'm Lauren Sauer, the director of operations for the Johns Hopkins Office of Critical Event Preparedness and Response. Today we're here to talk about the outbreak of 2019 novel coronavirus, known as COVID-19, with five Johns Hopkins experts who have been at the forefront of the response.

First, we'll hear from an infectious disease expert who is internationally recognized in the field of public health, preparedness, pandemic and emerging infectious disease, and prevention of and response to biological threats. Second we'll hear from a researcher who created the outbreak map being used by officials worldwide to track the virus. Third, we'll talk to an expert of basic virology and influenza and other emerging and zoonotic infections. Fourth we'll hear from a health systems epidemiologist and infection control expert. And finally we'll talk to a nurse epidemiologist whose research seeks to streamline care approaches that optimize navigation, linkage, engagement, and retention in care for persons with infectious diseases. As the COVID-19 outbreak evolves, we'll hear from the distinguished panel of experts from across Johns Hopkins University and Medicine who will shed light on the understanding of the virus, its progression, and our response efforts.

Our goal today is to bring their knowledge directly to you. After short presentations from each of our panelists, the audience will have an opportunity to ask questions directly to our experts and will have more opportunity to learn about the virus. As Johns Hopkins experts have been at the forefront of the response to COVID-19, we recently launched the Johns Hopkins Coronavirus Resource Center. This website is a resource to help advance the understanding of the virus, to inform the public, and brief policymakers in order to guide a response, improve care, and most importantly save lives. You'll find links to subscribe to a daily update on COVID-19 from the Johns Hopkins Center for Health Security, webinars, and a new daily podcast from the Johns Hopkins Bloomberg School of Public Health. We encourage you to check it out at coronavirus.jhu.edu.

Before going further I would like to take the opportunity to thank Congress for its swift and decisive action on passing HR 6074, the Coronavirus Preparedness and Response Supplemental Appropriations Act. This $8.3 billion dollar package will fund a robust response to coronavirus, including vaccine development, support for state and local governments, and assistance for affected small businesses. And with that, I'll introduce our panel.

First, Dr. Tom Inglesby. He's the director of the Johns Hopkins Center for Health Security the Johns Hopkins Bloomberg School of Public Health.

Then, Dr. Lauren Gardner, co-director of the Johns Hopkins Center for Systems Science and Engineering.

Dr. Andy Pekosz, who is the co-director of the Johns Hopkins Center of Excellence and Influenza Research and Surveillance.

And Dr. Lisa Maragakis, senior director of infection prevention at the Johns Hopkins Health System and hospital epidemiologists at the Johns Hopkins Hospital.

And finally, Dr. Jason Farley, professor of nursing, a nurse epidemiologist, and a nurse practitioner in the division of infectious diseases in the Johns Hopkins University Schools of Nursing and Medicine.

I also wanted to let you know that C-SPAN is here, and to take an efficient approach to our question and answer and assure that we answer as many of your questions as possible, we'll be passing out cards for the Q&A. And so if you do have a question, please write it on a card and pass it along, and we will be sure to get it back to our panelists. So we'll start with a few brief words from each of our panelists. Dr. Inglesby.

Panelist presentations

Tom Inglesby: Thank you, Lauren. I was asked to say a bit about COVID-19's spread in the world and the disease, and a few points about U.S. priorities at this point. COVID-19 was first recognized in Wuhan, China, at the start of December, and in the following two months had grown from one case to more than 70,000 cases and had spread to all 31 provinces across China. As of March 5th, the disease has been diagnosed in more than a hundred thousand people—we'll hear more about that from Lauren Gardner in a moment—and has killed more than 3,300 outside of China. Leading countries include South Korea, Iran, Italy, France, Germany, and the U.S.

The U.S. is about seventh in terms of total cases of disease in the world. And as of March 5th, actually as of this morning, there have been approximately 215 cases in the U.S., with 14 deaths. Most importantly, 78 of those cases have no known link to known coronavirus cases. Those cases then we would consider something called "community transmission," which is transmission that's occurring without an obvious link to some other case. Patients who become sick with COVID-19 have coughing and fever, and in the more severe cases, can develop viral pneumonia. In the worst cases patients, develop a syndrome called ARDS, which is a severe pulmonary syndrome which mirrors the disease that was caused by SARS back in 2002/2003.

Some patients' initial symptoms can be GI symptoms: nausea, vomiting, or diarrhea. In China, approximately 80% of those with illness developed mild symptoms not requiring hospitalization, with people recovering without any medical intervention. About 15% of cases required hospitalization of some kind, and 5% of cases required critical care. Most of those would require ventilation in the United States. It's not clear exactly how many of those patients in China did receive mechanical ventilation. The overall mortality of this disease is difficult to calculate because of the different ways we are diagnosing the disease around the world. We believe that there is an over diagnosis or an over-representation of people who are the most severely ill.

We find severe cases first because they're the most obvious and they're in the hospital, so that is going to skew case fatality rates or mortality rates upward, and the more that we do diagnosis, the more that we diagnose mild cases, the more that will drive down the overall case fatality rate. But it's too soon to say how far that will go. We do know that in Hebei Province, the province where Wuhan City is, about 4.3 percent of recognized cases there have died. Again, that's not a case fatality rate, that's just a crude calculation of the number of cases of that have been identified and the number of deaths.

In Italy that number is about 3.2 percent of cases have died. In the Republic of Korea, only about 0.6 percent. I don't mean to minimize that, but lower number, 0.6% of those cases have died, and we think that that represents a much more ambitious testing strategy in Republic of Korea. More than 140,000 people have been tested over a short period of time, which does, we think, increase the number of mild cases that will be identified and decrease the mortality rate.

The mortality rate of those who've been identified over age 70 and over 80 is especially worrisome and is substantially higher than those who are younger adults. We have not seen serious mortality in children, although we are seeing cases. As opposed to what we initially thought, there are substantial numbers of cases, pediatric cases, in the 0 to 10 and 10 to 20 age group. The virus has a 1- to 14-day incubation period, with an average incubation of about five days. It's spread primarily via respiratory droplet, which means close contact, usually within six feet. And in China, we've seen in some studies that as many as 20% of cases have no symptoms, which makes containing this disease and slowing it down particularly challenging.

Major interventions have been put in place in countries which are experiencing serious outbreaks or epidemics of COVID-19 and I'm sure you all have seen in China they took maximum measures to try and contain it, including lockdown of cities, closure of travel routes, closure of schools, closure of business. As many as 760 million people or more were at one point confined to homes. And in Italy and Iran, they've also taken fairly substantial containment efforts, including cancellation of mass gatherings, closures of schools, and as of last night there were more than 300 million kids around the world that were out of school because of this virus. And then finally, closing with priorities that I believe are important for the U.S. at this point.

I think we need to continue to substantially expand diagnostic testing. That has really changed over the course of this week, now 45 states out of 50 are reported to have the ability to do testing and many hospitals will be coming online as well as they develop their own tests and get them validated. We also heard today news that Quest is moving to develop its own test, which is a promising sign because they have such large volumes of clinical testing around the world—rather around the United States. And so it's the, I think the goal is to get to a point where any patient who has symptoms consistent with coronavirus can be tested quickly. We are not at that point now, we don't have the bandwidth to do that now but that is the goal. I know that's the administration's goal and state health labs I think are moving in that direction.

We do need to do substantial work to get our health care system prepared for this virus there are many hospitals that have done that work, but others I think have much more to do. In Italy and South Korea and Japan and China, we have seen that there's been major pressure already on the health care systems there and we know that in the United States if we see similar numbers of cases, which we will understand better in the coming weeks, that there could be substantial pressure on intensive care units to be able to take care of larger numbers than usual of critically ill patients. We also need to make sure our outpatient clinics remain available to patients. In China we saw that cancer clinics and dialysis clinics have closed in an attempt to try and manage the virus, and that would be a really unfortunate secondary consequence of this disease in this country, which we need to avoid. And we also need to take very special care of our long-term care facilities.

We've already seen in Washington State how terrible this virus can be within a long-term care facility for people who are most vulnerable. We need to support our public health agencies, they are now already working 24/7 to try to isolate cases, diagnose them, to quarantine people who need to be quarantined. If cases significantly rise in this country, it may no longer be possible to pursue the strategy that's underway now around identification of every case and quarantine of all contacts. It may become too large a scale for our health agencies to be able to do that, and at that point we would need to shift to focusing on understanding the overall burden in the population, making recommendations to the public regarding isolation and testing, and possibly measures which we would call collectively social distancing measures, which might include closure of businesses or telecommuting, might include cancellation of large gatherings and could include in some places closures of schools. Those decisions will probably need to be taken and be taken by local health officials with local political leaders and business and school leaders.

And finally, a last word about medicines and vaccines. Vaccine development is likely to be 12 to 18 months away if all goes well. We've heard that consistently from the countries and internationally from vaccine scientists around the world. We should be developing plans for mass manufacture of vaccine when this vaccine is developed. Similarly antivirals and monoclonal antibodies are being developed by a number of companies. Those could be developed far sooner in terms of the process of developing and approving those medications and we will also need plans for mass manufacture of those medicines and hopefully in multiple places in the world as well. If the United States itself gets a new product there will be enormous pressure from around the world to be able to access that product, so even though it's not usually done this way, we do need to think about making medicines and vaccines in multiple places in the world at the same time. It's great to see this kind of attention and attendance in this kind of meeting on the Hill and I think the response has been very swift in terms of developing the emergency appropriations bill, and we're very excited that that is being aimed at hospital preparedness, public health agencies, the agencies of government that work with industry to make these important products. So I'll stop there and look forward to questions.

Lauren Gardner: My name is Lauren Gardner. I'm an associate professor at the Civil and Systems Engineering department at Johns Hopkins University. I'm leading the efforts behind the COVID dashboard that most of you are probably aware of. So I just am here to talk through a little bit about how this dashboard works, the features of it, and a bit about the data collection process behind it, and some of the user stats as well. ...

So what we're doing is clearly we're tracking total cumulative confirmed cases of COVID all around the world, and we have here in this now global view, the red circles represent the total number of reported confirmed cases to date by region. And the region, the spatial resolution of the regions that were reporting on, differs depending on where we are in the world. So for instance, in China we're reporting at the province level, at the U.S. at the county level, Australia and Canada, the city level, and the rest of the world at the country level for right now. Over here on the left is a list of all the countries, and on the right is the deaths and recovered which is we're also reporting and you can see the actual numbers by region. You can click on a location and it zooms into it on the map, and you also here can highlight the specific stats for that region. And then you can switch tabs here and you can see at the finer spatial resolution for that location.

Another thing that we're highlighting is in addition to the total confirmed cases is the number of active cases at any point in time, and so this is the total number of cumulative confirmed cases, minus the recovered, minus the deaths, and so this is really important because it kind of represents the more—or, better reflects the risk at any point, in time and I think what we'll see over the next few months is a shift of these, kind of, active cases from east to west. On the bottom right, we have a little timeline of the kind of temporal nature of this outbreak, and so here we're tracking the total cases over time, the total recovered over time, and the cases are broken down into cases within China and—within mainland China and outside of China.

You can switch tabs over here and see it at the logarithmic scale so we can kind of capture the exponential nature of the outbreak that we see at early stages. And then also we can track it at a daily scale in terms of the number of new cases or newly recovered cases reported on a daily basis. And you can kind of turn these off and on so you can see just one series. And what we're looking to do soon is disaggregate this red bar chart and split it between new daily cases in mainland China and outside mainland China, because we've recently passed the point at which case we now have more cases outside China than inside China on a daily basis, which I think is a pretty critical shift in this situation. And then on the bottom here is a text box with a whole bunch of really important stuff that I think nobody reads, and it includes a link to Lancet Infectious Disease article that—or letter that we wrote—which details the data collection protocol behind this and what the data sources are. There's a link to a mobile app and the link here to our blog, which details background about both the outbreak, the mapping efforts, and also some other modeling efforts that we're doing behind the scenes. And then a bit more about the data sources and some of the details about the map. So that's it for this. ...

And so as I said, this is all actually hosted out of the Whiting School of Engineering at Johns Hopkins, and so one thing about where this data is coming from—in two minutes, I cannot explain the details of the process behind this data collection but what I can say is that it spans the entire scope of pure manual data input to purely automated data input, depending on the source, and also some combination of both. And so, for example, China data is completely automated and has been since February 1st and is pulled from a particular website and updated every 15 minutes. At the moment the U.S. data entry is completely manual, and then the rest of the world is some combination between these two. Where the data is coming from is a variety of sources, and in general it's based on daily—it starts with the daily reports from WHO and the National Health Commission of the People's Republic of China.

But those only come out every 24 hours, so we use those kind of as a baseline and then throughout the day we supplement with local level, city level reporting and reputable news and media outlets and local health departments as new cases come available, because obviously these are coming out at the city level first, so they're not able to be incorporated into these national level reporting reports that only come out on a daily basis or less frequent. And so to kind of instill confidence and validate this data, what we're doing behind the scenes is we're consistently comparing our data on the dashboard with the data provided by those WHO reports, and so that's what's shown in these two maps on the left. And so what we can see is that at any given point in time, we're always presenting more cases as you would expect, because we have the cases that have at least always been reported previously by WHO, plus whatever the new cases are at the time, But what you can also see is that they follow the same trend, and so we are consistently reporting the reliable and, I think, accurate data.

There are a few discrepancies, for instance, on the bottom when Hubei Province changed their reporting criteria and started reporting clinically diagnosed cases, there was a huge jump of about 15,000 cases reported that day. We captured it at the time, WHO captured it a few days later. And then on the right on the bottom is something that I think is really important and critical about this dashboard, is it shows its ability to let the public know when a new region becomes affected and it does this in a really timely matter. And so what that shows are on the bottom is the countries that are reported in the WHO situation reports and the date that reported on. On the top is when we include the countries in our dashboard; blue means we did it before the WHO report came out and red means we missed it. And you can see that we almost always report countries on the dashboard before they're formally reported in the WHO reports, with only a couple exceptions and those exceptions happened in the first week of the dashboard when everything was done manually, and one of them was early Saturday morning when my PhD student was sleeping, I think.

So we're doing a really good job, I think, of keeping tabs of when new important events are happening and then we can see that the data that we are presenting is accurate and aligned with the official reports that are coming out, even though we're providing and collecting it in an independent manner. And this is all provided in the Lancet Infectious Disease Letter. And then a little bit about the user statistics, this has been really a bit of a shock. This is a curve of the daily requests. So this is not necessarily eyeballing. It's interactions with the dashboard on a daily basis. And we can see that it's been pretty popular for a while, and at the moment we're getting well over a billion requests per day, or interactions with this dashboard on a daily basis. A couple peaks happen, for instance, around late January when Italy first reported its first case, then there was another peak around the time that there was a lot of spread within the EU and around the Middle East, and then more recently with the U.S. local transmission. And so what this is is, this is showing where this usage is coming from geographically and it lists the top ten countries using the dashboard, with the U.S. being the one with the highest usage, and then the green is the rest of the countries aggregated together. So in terms of who is using this dashboard, as far as I can tell it's pretty much everybody. It's everyone in terms of the general public has really been the predominant users of this, and it's gone viral on almost every social media channel that exists, all the way up to our local, state, and federal governments, public health entities, and pretty much everything in between. And so I think that this really speaks to this huge demand for reliable, trustworthy, objective information, especially around situations like these, and so I think it's really important to kind of acknowledge this gap and support these kind of data procurement and data visualization tools moving forward that are to be made publicly available because this is clearly something that was missing and needs to exist moving forward.

And so lastly, this is definitely not something that I have done or could do or would ever do on my own, and all the other people that are part of this team really deserve all the credit for the work that's being done, especially the two guys on the right. This is Frank and Hong-run, who are two of my PhD students, and Frank has really been the pioneer behind this and led the efforts behind the actual building out of this dashboard, and these two have worked tirelessly to keep this running and we also have some other really great support out of the Center for Systems Science and Engineering, which is my center and where this whole effort is being led out of. And then we've had wonderful support from Johns Hopkins University Applied Physics Lab and also ESRI, who's the technology that we're actually using to build this dashboard, and this whole thing has been internally supported through Johns Hopkins University as well.

Lauren Sauer: Thank you, Lauren. Next we'll go to Dr. Andy Pekosz, and I'll just take a moment to remind you that the cards that are being passed around or for you to write questions on. If you write one just give it a quick wave and someone will come grab it for you so that we have them ready to go during the session.

Andy Pekosz: Hi, I'm Andy Pekosz, I'm a professor of molecular microbiology and immunology at Johns Hopkins Bloomberg School of Public Health, and I'm here to focus my discussion on issues related to the virus and the immune response to infection. As I'm sure you all know, Dr. Anthony Fauci from the National Institutes of Allergy and Infectious Diseases has provided important leadership in the public health response to contain the COVID-19 outbreak, as well as in driving forward vaccine development efforts. In January, he also called together a myriad of laboratories who were involved in research on influenza and other respiratory viruses and charges to bring resources and expertise to bear on the COVID-19 outbreak. I'd like to summarize some of the work that has been initiated and continues to go on through these efforts and other efforts.

The coronavirus family includes viruses that are responsible for a wide spectrum of disease in humans, ranging from the common cold to the quite severe disease caused by SARS, MERS, and of course now COVID-19. Understanding the differences between the original SARS virus and COVID-19 viruses, viruses that are similar genetically yet have very different disease penetration and perhaps transmission patterns is critical in understanding how the COVID-19 virus has been able to spread to so many parts of the globe while the SARS virus was eventually contained and then eliminated from the human population. We need to understand virus shedding in much greater depth, and that involves looking for infectious virus levels in respiratory secretions, and not only virus levels quantified by the current PCR tests. This will give us a better understanding of the true window of time in which a person can be infectious and will better inform our public health responses to the epidemic. The area of virus sequencing and genomic analysis has provided us with a powerful tool that allows us to follow chains of transmission by tracking unique mutations that have occurred in the virus genome during its replication. However, these same mutations may help the virus to adapt to its new human host and that might be associated with better virus transmission or altered disease potential, so understanding and monitoring changes in disease severity and how they track with changes in the virus genome is a high priority going forward.

We're also planning work to understand the immune responses to infection. Some basic questions such as: What kind of immune response is induced by infection? How long did those immune responses last? And does infection protect you from a second exposure to COVID-19? These are all critical questions that inform public health responses and will help guide the vaccine projects that are currently moving forward at a rapid pace and into clinical trials. The factors that drive disease severity need to be identified. As Tom mentioned, epidemiological data shows that age, gender, and pre-existing medical conditions are associated with severe disease, but we need to understand why that's occurring.

Understanding how disease in these populations compares to the milder disease seen in other age groups may help inform better treatment regimens for those high-risk populations. COVID-19 is sometimes compared to seasonal influenza and I think it's important to remind everyone that influenza is responsible for upwards of 18,000 deaths in the United States this year alone, and that's with vaccines, antivirals, and having a portion of the population that's immune from severe disease because of previous exposures to influenza. We have none of those things at our disposal to battle COVID-19.

A deeper understanding about what the virus is doing in humans will drive more informed and effective interventions and treatments that are essential and controlling the outbreak and minimizing the virus's impact on human health. Again, thank you for the opportunity to speak. I'll turn it over to Lisa.

Lisa Maragakis: Thank you very much. So my name is Lisa Maragakis, I am an associate professor of medicine and infectious diseases at Johns Hopkins University School of Medicine, and I'm the senior director for infection prevention for our Hospital and Health System. And what I wanted to talk with you today, what I wanted to talk with you about today, is our healthcare infrastructure and the preparedness activities that are happening across the nation in facilities and healthcare systems like Johns Hopkins Medicine to prepare and make sure that we are as ready as we can be to safely care for patients who become infected with this novel coronavirus. At the beginning I would like to just remind you that we have faced a number of infectious disease threats over the past several years, and the good news about that is that we learn more every time, we become more and more prepared. And I would like to point to the importance of the periods in between infectious disease threats and how building infrastructure and preparedness is critical for our ability as a health care system across the nation to respond to this kind of a novel pathogen, particularly pandemic respiratory virus. In particular there has been a large investment in emergency preparedness infrastructure in this country that began with the Ebola crisis in 2014 and 15 in West Africa, and the assistant secretary for preparedness and response regional approach to making sure that we have treatment centers for patients with highly infectious diseases, and a whole network of regional treatment centers and assessment hospitals and frontline care facilities. So really the emphasis is that all parts of our health care system maintain readiness and an all-hazards approach.

That funding was really directed at viral hemorrhagic fever, but the great news is that it has allowed infrastructure to grow, partnerships to develop between the healthcare infrastructure on the front lines and public health authorities, and all aspects of emergency management and preparedness, and I think that that level of preparedness has really allowed us to pivot more rapidly to be prepared to meet this threat. That doesn't mean, however, that we don't have a lot of work remaining to be done because certainly we do. I will say that every institution has some manner of pandemic respiratory virus planning. We need to take those out and hopefully everyone has already done that. Certainly at Johns Hopkins Medicine we have. Dust off those plans and think about really the nitty-gritty of what it will take to operationalize and implement those plans.

Inevitably one finds that there are novel aspects of the pathogen that must be addressed in in applying those preparedness plans to the specific situation and also moving forward and making sure that all of the myriad details are in place that might not be contained in such a plan. So we have heard from some of the other speakers about mode of transmission, which is a major piece that plays into preparedness, and so I would say that most of the pandemic respiratory virus planning in this country and probably around the world has centered on the assumption that such a virus would be spread by the droplet route, by really larger droplets that are expelled when a patient infected with a virus coughs and sneezes. Those particles tend to go about 6 feet in front of that person and then fall because they're relatively heavy and they land on surfaces and the floor, and that's why it's so important to use environmental disinfection of high touch surfaces as one of our strategies.

However there's another category called airborne transmission, whereby smaller viral particles or "droplet nuclei" they're called, really remain aloft for a longer period of time so that they can float around in the air and be inhaled by someone who comes along a bit later, even after the patient may have left the room. So that's a different kind of threat that we're used to handling in healthcare environments with tuberculosis and varicella and other kinds of pathogens, so there is a notion that this virus, although most of the data suggests that it's spread by the droplet route, that it is possible that the airborne route may also play a role, especially in certain circumstances where procedures are being performed in the healthcare settings, like intubation of a patient who needs mechanical ventilation, for instance, that may cause those aerosols to be present. So out of an abundance of caution, the current guidance from the Centers for Disease Control and Prevention is to use airborne precautions for this virus, and so part of the work that is being done in healthcare facilities across the nation and around the world is to try to figure out how best to take that pandemic respiratory virus planning and adapt it for airborne pathogens.

That means several things. It means that we need to look and we all are looking at our facilities and the air handling in those facilities to determine critical planning for patient placement, and then staffing to go with the patient placement so that we can provide the safest care possible in our facilities. We all have airborne isolation rooms as they are called that have special air handling for treating patients who have tuberculosis, varicella, measles, etc., but what we don't have is a large number of the rooms. And so many facilities—and Johns Hopkins Medicine is certainly leading this effort—to look at air handling modifications that can be made to turn entire medical units in acute care hospitals into a respiratory isolation unit.

We are also working really around-the-clock about how to ready ourselves to handle an influx of patients, and a surge—we call that surge capacity planning. Many of our hospitals across the nation operate in a very lean sort of way, meaning that much of our healthcare delivery has been moved into the outpatient or ambulatory setting. So looking at the remaining inpatient acute care facilities that have really been streamlined for cost control—which is entirely appropriate—now we need to ask ourselves how we can ensure that we have the staffing and the readiness in case a large number of patients do need inpatient care all at the same time, particularly if they need critical care services and mechanical ventilation, etc. So that's a lot of the work that's going on, and even when we find the places for patients to be housed in the right air handling conditions, then staffing is another major concern, and we are working with our Human Resources colleagues and with our planners to make sure that we have the providers, the nurses, the respiratory therapists, and really every member of the healthcare delivery team ready, so that we can ensure that we can provide care to all who need it.

I wanted to take a minute and kind of walk through a couple of aspects of really how a patient might move through the healthcare setting, because it has implications really across the health care spectrum. As Dr. Inglesby alluded to, patients will have a wide spectrum of symptoms. They may be asymptomatic, they may have very mild disease indistinguishable from a common cold, or shortness of breath that doesn't really progress. One of our tasks right now is to make sure that we get the right care to the right patient at the right time, and that means keeping the worried well and the mildly ill out of our emergency departments and our clinics, where they might not need to be, and they might cause exposures to other people who are there for other medical reasons, and also kind of clog the system. And so we have services that provide in-home care, home care colleagues, we also have opportunities to use strategies like telemedicine and phone triage to support patients who are recovering at home and really encourage patients who are worried that they may have the virus but have very mild or no symptoms to recover at home. Turning then to those who present for care, testing is an enormous concern on our mind right now. As has been mentioned already, we need the ability to test rapidly, we need that to be at scale so that we can do widespread testing. I think you've heard today some reasons why we need that, to understand the epidemiology of what's happening in this country, but also for any given patient to decide on appropriate therapies and to get them immediately into appropriate isolation precautions, so that is a major amount of work that's going on.

A word about supply chain: this is of concern across the healthcare system and something that our supply chain colleagues are helping us tackle to make sure that we have all kinds of options on the table about personal protective equipment, which is of course top of mind to keep our healthcare workers safe. But in addition to personal protective equipment, having a large amount of manufacturing in China that has in many cases been disrupted has led to allocation or suggested caps, or enforced caps, on over 400 items across all kinds of categories that we use in healthcare. So I think we have some strategies to deal with this, but this is one of the challenges that we are tackling.

And I'll mention just a couple more things and turn it on to my colleagues, but partnership with federal and state health authorities is critical, and the more we can all work together, the stronger we will be able to respond to the needs that may come our way. And what would this look like? It might look like regional strategies for patient placement and staffing and a lot of the things I've described, so that it's not health systems like ours planning on our own, but really partnering with other health systems and federal and state and local public health authorities. I think we need to be mindful of accessibility issues and affordability issues that will be very important for patients, especially those who live far and have affordability challenge. And then finally I just want to mention that we are also preparing to participate in clinical trials. You've already heard here today we don't have a vaccine, we don't have therapies, but we do have some candidate therapies and it will be important to learn more about that and to make sure that we are offering the very best care at any given time, and meanwhile collecting data so that we can learn how better to handle this disease.

Lauren Sauer: Thank you, Dr. Maragakis. I'll hand it over now to Jason Farley. Dr. Farley, good afternoon.

Jason Farley: I'm Jason Farley, professor at Johns Hopkins University School of Nursing. I would like to begin by thanking our frontline health care workers who are on the forefront of COVID-19 response. I thank you for what you're doing and the work that you've done and continue to do on a daily basis, as well as our public health officials for keeping us all informed and up-to-date as this outbreak occurs. I'd also like to thank each of you who were here today and supporting the members and the tireless effort that you have for the work that you do for our nation. As my colleagues have already detailed throughout our discussion today, this is a quickly changing outbreak, one that is causing alarm across the nation and the globe. The WHO has dubbed the situation of COVID-19 as much an outbreak as it is an outbreak of misinformation, an info-demic is the word they used.

As the only nurse on the panel, I believe it is my duty to speak to you first and foremost about the frontline health care workers who are at the forefront of the response, and I really think it is they're following their duty and stepping to the forefront to care for patients with COVID-19. As many of you have seen there are growing concerns across the health care workforce related to their personal safety, as well as access to personal protective equipment. As well as timely testing that has been mentioned, it is important that we arm everyone with accurate information as well as personal protective equipment throughout the work health care workforce.

In a survey conducted recently by the National Nurses United, a union representing approximately 150,000 nurses, which is, granted, a small sample in comparison to the four million registered nurses across the United States but nonetheless it is the most accurate and up-to-date information that we have and the best I've seen thus far—about 6,500 nursing respondents to this survey who participated, with about 29 percent reporting that their hospitals had a plan that was in place at their facility for coronavirus patients.

Forty-four percent of these registered nurses said they perceived that they had received guidance from their health care system, another 30 percent in that same sample didn't really know exactly what was happening on the ground at their site, which is the most alarming fact. That means the communication in the individual healthcare system has fallen short in some way, but this is a mere glimpse of what's happening at the frontline of the epidemic. This is just a mere snapshot but it has led to activities such as the New York Times report and others reporting significant anxiety among the healthcare workforce, and I think that's contributing to community level anxiety as well.

So the CDC put out interim new guidelines, which they're doing quite frequently and quite rapidly, again, approximately two days ago and they recommended that health care workers who have potentially been exposed or in settings where there's community ongoing community transmission report every day to work and report whether or not they have symptoms and/or fever. They also noted that implementation of both contact and, as Dr. Marcus mentioned, airborne precautions in the healthcare facility would be implemented and recommended, despite the fact that we do believe the virus is most likely transmitted via droplet. Again that six-foot-high sneeze cough, that spray that everyone sees in those pictures that you've probably all seen across the Internet, but with that droplet transmission, close contact is generally required and the CDC has a clear definition of what we believe close contact is.

Close contact is defined by the CDC as that six-feet diameter, or contact for a prolonged period of time with someone with known coronavirus symptoms or known to have coronavirus now. Importantly, that can be both with personal protective equipment depending on the circumstances and without, and the CDC has given us a pretty clear roadmap for the type of exposure a health care worker might face in those circumstances, what's considered high moderate and low-risk has been clearly outlined in those CDC guidance so I invite you to take a look at that.

It will provide you a pretty clear picture. Also you will see across the media, I think, what is somewhat of a misrepresentation, often of an Ebola-like personal protective equipment response posted on multiple media outlets, and I really wanted to call our attention to what the CDC actually recommends for protection, right. We're thinking airborne precautions, right. we have N95 [masks for] health care workers [which] are fit-tested, meaning they've been specially tested and their face has been shaped perfectly for that mask. They've been evaluated to determine whether or not it works for them or not, which is why, yet again, we're not recommending the general public go out and seek that type of respiratory support or protection.

Also, there are personal air purifying respirators or poppers, which kind of look like a spacesuit, kind of comes down, covers your entire face again, really adds an extra layer of protection because it covers all the mucous membranes. That's another layer of protection that many healthcare workers have access to. I know at Johns Hopkins, we are all trained on the use of what we call poppers but that must be used in conjunction with contact precautions. So barrier precautions as appropriate as well as standard precautions as the case may be, in addition to appropriate health care worker and health environment cleaning so our frontline staff, our cleaning staff ,our housekeeping staff are as equally as important in stopping the spread of this outbreak both within facilities as well as in ambulatory care settings as our physicians are providing the care. Hand hygiene works, absolutely, you don't need a nurse to tell you though to wash your hands but Purell, whether it's alcohol-based hand sanitizers or water-based and soap water and soap, it's really both equally effective. So use what you've got at home, it's equally effective.

I think that's important in high-touch areas and high surface area so you're thinking about … the metro that you all wrote in on this morning, right, those are high traffic hand environments. Keeping a bottle of Purell in your pocket—it's a simple activity that you can do, a little alcohol hand sanitizer, keeping frequent hand hygiene is really, really critical. It's probably your most important protection when we think about current studies suggesting how long coronavirus will live on those hard surfaces. It depends [on] environmental conditions and also the type of media that was coughed or sprayed out, how quickly that dries—but estimates range from anywhere from a couple of hours to up to several days. I've seen estimates as high as nine days after exposure to an environment, but we must also keep in mind that the CDC interim guidelines provides us that clear exposure table for health care workers and has given us clear guidance, which I'll go into now for the community.

One final thing before I leave the healthcare workforce recommendations, we are still in the middle of influenza season and so we also must think about other respiratory viruses that could be causing [disease]. I was in clinic last week and diagnosed a patient who came in with influenza B, so we are still seeing a record number of influenza cases that are quite common in our environments. As we move to the general public infection control precautions and things you could do, I think first and foremost is we've heard lots about staying at home if you're feeling ill or sick, and all of us again who took that Metro in this morning, have heard the coughing, sneezing, sniffling, and stuffy head, you know, Nyquil commercial kind of symptoms on that Metro, and I think it's really critical that we are taking heed of it. If you're not feeling well, stay at home. But also from a patient- and human-centered response, know that there are millions of health workers throughout this country who do not have the option of staying at home because if they do not report to work they do not get paid. So there is a balance that we need to achieve with that recommendation.

Finally, we know about general cough hygiene, coughing into your elbow, lots of elbow bumps as opposed to hand shaking, there's some basic principles and practices that one can employ there. And as I mentioned N95s, those special types of masks that healthcare workers use, are in very short supply. I was in a conference call in some of the work I do in tuberculosis in South Africa, and the cost of an individual N95 mask for healthcare workers in TB wards in South Africa have more than quadrupled in the last month. And so we're seeing a global shortage of N95 both for in the United States for our health care workers and some sites reporting that they are having challenges with achieving enough N95s, but in global settings as well, and in the world's leading infectious disease killer, tuberculosis, we are having challenges with healthcare workers. So again, pay very close attention to those options.

If you are sick, a simple paper mask, one of those slight blue masks [may] not prevent you from getting ill but prevent you from infecting others by stopping that droplet transmission, right, that cough and that sneeze. Still if you are concerned and living in the community, and there's community transmission, we've talked about social distancing, meaning staying at home, telecommuting possibly, watching your Sunday services or Saturday services or whichever day you worship, those services online or through some other means as supposed to congregating in those settings. Also limiting travel, we've seen lots of limitations that have occurred and recommendations on limitations with travel.

And then really thinking about, as Dr. Maragakis pointed out, we do not have the capacity for a large influx of worried [people], meaning if you simply have a cold, you're feeling fine, certainly talk to your primary care clinician, seek advice. But over-running the health care system at this point is actually the opposite of what needs to happen. And then finally, just on public health messaging and communication, clear, consistent, trusted messaging is extremely important. We need, again, a people-centered approach, meaning we must raise awareness without raising panic and fear. And so that's a delicate balance that needs to be struck.

Also, we really have to avoid—and I think the data that's being presented by Dr. Gardner is very important, because it helps us to realize that the over-generalization of any region of the world and any population within the world is…. clearly, we've gone beyond that. And so there were some initial points of reports of stigma and discrimination that were occurring for people from certain parts of the world, and that is not something that any of us would like to see happen, and I think that we should use an evidence-based approach and look at this data to know that stigma, discrimination of any kind, particularly as it comes to COVID-19, is not something that should be supported by any evidence that we have available to us. Thank you.

Q+A session

Lauren Sauer: Thank you so much. I'm going to go ahead and start the Q&A session. I would say about a third of these are focused around testing capacity, so maybe I'll start with one for Dr. Maragakis and Dr. Inglesby. Do you think the testing capacities is adequate in the U.S., and do hospitals with labs have access to everything they need to either package up and send or perform the tests?

Lisa Maragakis: Thank you for that question. I think the short answer is no. Testing capacity is not currently adequate and we need more. We need this as soon as we can have it, and I think there are a variety of efforts underway to provide access to that testing. One of them is that test kits have been distributed again from the CDC to the state health labs, and many state labs are now coming online to provide testing for their areas. In addition, microbiology labs like the one at the Johns Hopkins Hospital have taken a number of steps to develop their own testing, and we hope that ours will come online in a matter of days, if all of the validation steps go well. So I think all of those individual efforts are to be commended because we desperately need the testing.

And then finally we also know that commercial laboratories and companies who develop diagnostic tests are also working on this issue, so that hopefully we will have—and I think this is probably in a matter of weeks, hopefully not months, but hopefully weeks—that we would have access to more rapid forms of diagnostic testing, that were not so labor-intensive as the tests that we have now.

Tom Inglesby: This is the process that occurs when a new emerging infectious disease is discovered and the country needs to test for it, in that CDC is the developer of the initial test and then they move that out to state health laboratories around the country. But neither CDC or health labs are intended or designed to handle very high clinical volumes around the country, and for that to occur we need to have our major clinical diagnostics companies fully involved, and it seems that they are at this point. I think the only question is when will they be able to get their tests online. I think they're working quickly to do that and hopefully in the next week or few, we'll be able to see much more scale at clinical sites around the country.

Lauren Sauer: Great, thank you. The next question's for Dr. Farley. As we start to see more people infected and more cases rise, so as the testing capacity increases and we see the cases that may or may not be already there, what's the best way to keep people calm and informed and message what those increased numbers mean?

Jason Farley: This is a setting in which having more appropriate testing will ultimately lead to greater public calm. Because I think the data Dr. Inglesby reported to us from South Korea and the actual case fatality rate data in a setting in which we know that testing was rolled out quickly and adequately and to a large number of people, we saw numbers of total cases that were having severe disease and/or subsequent death declined significantly. And I think that really will help us to message correctly right now, because of the focus on testing for those most ill, we've got a really large case fatality rate, I mean, and larger than we would we hope to expect it will ultimately play out to be. So I think that's the first thing.

The second thing is messaging around that needs to be one of the public health experts providing that knowledge and expertise, and I think we've seen some great data coming out of Dr. Fauci and Ambassador Brix, as well as Dr. Redfield from the CDC, providing that clear and consistent and calm message to the public.

Lauren Sauer: And a follow-up question to that possibly for you and Dr. Maragakis, what should we be doing to better protect these vulnerable populations such as people with disabilities, seniors, and the populations that are going to be most affected by this disease?

Lisa Maragakis: Sure, thank you. It's an important point that we are not all—lwe are all susceptible as far as we know to this virus because no one has immunity since it's a novel virus—however we are not equally susceptible to the severe consequences of this infection. So our data suggests so far that 80 to 85% of people who become infected will have very mild to no symptoms, and it will be a self-limited disease. And so really what I think you're alluding to is the very vulnerable populations, which at this time seem to be older individuals who have suppressed immune systems or underlying medical conditions. And this is very familiar to us, this happens every year with influenza as well, some of the same populations that when infected with respiratory virus like this can exacerbate the underlying medical conditions and lead to severe consequences. So measures that we can take, I think, first of all is knowing that and taking—we've heard a variety of strategies here today so I won't list them again—but taking extreme caution with those who are more vulnerable. One spot of bright news I think for this virus is that the youngest children don't seem to be as vulnerable, and that's a blessing in this case. We're not sure exactly why that seems to be the case, but it's a difference for this virus.

Lauren Sauer: Great, thank you. And a follow-up question to something that Dr. Maragakis and Dr. Farley touched on, maybe for Andy Pekosz: How long can the COVID-19 survive on surfaces and how are scientists starting to look into this question of analyzing that?

Andy Pekosz: A very important question and has been mentioned here before, you know, how long a virus survives on a surface is dependent upon a lot of different parameters: how large the droplet was that was deposited, what was in that droplet? There're some interesting studies that suggest that sometimes your mucus that's present there can actually stabilize these viruses and maybe extend the amount of time that they're there. So some of these studies are ongoing right now, and we can't give you a firm answer, but I think it's also very clear that all the disinfectants that we can use against standard viruses work very well against this COVID-19 virus. So almost irrespective of how long the virus can survive on a surface is the fact that if you simply do a good job of trying to clean these common areas, these areas that people are touching on a regular basis, you will be reducing your risk to getting infected.

So good cleaning techniques, good disinfection techniques, being aware of your environment, and the weak links that people have, like the doorknob or the door that we'll be pressing as we're leaving here is a common area that—what are we, about a hundred of us?—are going to be touching, so understanding those kind of surfaces, you know, and intervening there is probably the best strategy to try to minimize transmission.

Lauren Sauer: And perhaps washing your hands as soon as you leave the room. Dr. Inglesby, we have a question about the emergency authorities that are available to the president and governors and other political leaders when we have a public health emergency like this: what circumstances would you think that activating these authorities may be necessary? Are we there yet? Do we have more to go?

Tom Inglesby: In the U.S., public health authorities are mostly devolved to the states, and in most states there is law that allows governors to do what they think is right in the interest of public health and protecting public health. So if necessary, governors around the country will likely have the power to cancel gatherings, to quarantine individuals that they believe need quarantining, and perhaps to use facilities that would be used for isolating cases or quarantining cases. I think local decision-makers will make those choices, hopefully in ways that are the wisest for their communities. And I think we've seen that governors who have cases have already invoked emergency authorities to allow them to do these kinds of things. So I think they're in place. I don't think it's so [that] it's not a large barrier for them to use them, and I think they'll use them in the ways that they feel like are most important for their communities.

Lauren Sauer: Great, thanks. A question maybe for the whole panel but particularly Dr. Maragakis: hand sanitizer is very hard to get these days. Many stores are sold out, so when you go to the store and it is sold out, what are the alternatives?

Lisa Maragakis: Great question. I actually took a picture last weekend of my local store's empty shelves. There was no Purell, no store brand, no kind of any alcohol-based hand sanitizer. The good news is that it was surrounded by shelves of soap. And so I think we've heard here today that good old-fashioned hand washing, soap and water, will work. And so far, I don't think there's any shortage of soap, so I think we shouldn't panic by those empty shelves, and just wash our hands, get back to the sinks and the soap. And the other good news I think is that alcohol-based hand sanitizer—and perhaps the companies will be unhappy with me for saying so—but, you know, we can make it. There is a key ingredient there that is the alcohol, so you know I'm not too worried about this.

Lauren Sauer: Great, thank you. Dr. Farley, could you talk a little bit about first responders and how they can prepare for the outbreak and things that they can do to protect themselves, and how we can support them?

Jason Farley: Sure, well obviously you know when we think about the sharp end of the spear, our first responders are that sharp end of the spear and really a critical component in the chain of survival for so many of our patients. Our first responders, EMS and others, are very well-equipped with personal protective equipment in ambulance vehicles and others. Where it is probably less clear at this moment is what one needs to do as the spread occurs more generally in the community in terms of how they would respond to each individual call, because remember our first responders walk into scenarios where they really have no background information other than 911 called, right? And so each jurisdiction and each area will need to make its own EMS-related decisions as to what level of PPE [Personal Protective Equipment], as, you know, depending on the spread within a given community, the first responders would actually use. It may get to a point if there's long-going community transmission that it would make sense for a slightly elevated level of personal protective equipment for first responders, but that would be on a community-by-community, EMS-by-EMS basis.

Lauren Sauer: Great, thank you. Dr. Gardner and also for Dr. Farley as well, you both sort of touched on this, but there is a lot of misinformation out there and there's a lot of false data out there. How do you combat both misinformation and also analyze whether the data you're seeing are real and accurate and trustworthy?

Lauren Gardner: So I'll start with this one because it's obviously relevant to the dashboard. It is really tricky, there is a lot of misinformation. We aren't focusing so much on that as much as spending all of our efforts really finding the sources that are reliable, and so like I said the dashboard is built on data collection that spans everything from fully automated to fully manual entry. The manual entry is because—especially at the moment, for example, all the US entry and the Canada and Australia entry is done manually because we're actually checking each case as it's reported and looking into what is the source that was reporting it and making sure that it is a valid source coming out of some kind of public health department and a real confirmed case. The automated data that we're including we include only after we have vetted it and observed it for a period of time and so that we're confident in the data that is being basically provided on these sources that were scraping and automatically updating into the website.

And then the other thing, like I said, is we do put a lot of energy into what the data is that we do include in the dashboard, and then as kind of a second double-check, we continually compare the data that we're presenting with WHO data, which is the completely independent source and make sure that our data aligns with that data and again I mentioned the only discrepancy is based on at a given point in time, we want to expect it to be the exact same. We would expect ours to be higher because it's built in real time but we can see that at least over time, the trends align and so I think that really one of the huge motivations behind this, and clearly why it is so popular, is because there is just such a need for having trustworthy, reliable, objective information today given all of the noise that is out there, and so that's—we just basically do the best we can to provide that as one single source.

Andy Pekosz: I wanted to mention one thing that you know there have been a number of rumors that have been started in a number of, perhaps, preliminary, perhaps incorrect, sort of scientific papers that have been put out there in this quest for rapid dissemination of information, and I do think that there is a small cadre of scientists that are actively out there on social media that are really patrolling for these things, and not just responding in terms of, "oh, this isn't true", but actually using fact and evidence and logic to actually argue against some of these things. And well, in some cases one can say, well, if someone says something truly incorrect, that's very inflammatory, perhaps the genie is out of the bottle—but at the end of the day, having responses that scientists have put together that really, point by point, discredit or disprove or cast doubt on other people's conclusions is something that is really important out there, in terms of, for most people having some level of confidence that the right information is getting out there and that there's a level of policing of the information so that not everything is getting out there and being freely disseminated.

Lauren Gardner: Actually, I will add to that one of the best things about having a billion eyeballs on our dashboard is that essentially in some ways, this is crowd-sourced information and there are so many people watching it and so as soon as where you become behind on cases, people send us that information—which my email inbox is not happy about—and usually the source with it, and so we're actually guided right to the correct information if we are missing it. And if we ever over-report, we will be corrected on that too, and so we're actually kind of cross-checked by the public on this because of the way it's designed.

Jason Farley: I would just add that each of—particularly those of you in the room that are staffers with members—you have in your in your possession a digital influencer, someone who has the social media capacity to influence fact-accurate information and to prevent misinformation from moving forward. Who also has a personal responsibility to vet and validate things that we share on social media. So if you are sharing things that you personally don't know the source of that information or don't necessarily know that you would trust it for your own health, why share that particular piece of information on social media? And then finally, I want to applaud both CDC and WHO for working with our social media giants in helping to dissuade misinformation, the propagation of misinformation on various platforms. There have been a lot of buy-in of many of the platforms to take down un-factual and misinformation on their platforms and I want to just say that that is an exact type of response that we need from them at this time.

Lauren Sauer: Great. Thank you. I'll hand this one over to Dr. Inglesby. As we heard from Dr. Maragakis, Hopkins has an impressive presentation of medical capabilities for this and even we are working overtime to prepare to and respond to this outbreak. What would you say [is] the state of readiness of U.S. hospitals, broad scale across the country looks like and what can we do to improve it?

Tom Inglesby: We don't really have a completely systematic way of answering that question. It's not that we don't have systems that can pulse every hospital and understand it's complete state of readiness. Hospitals have been involved in receiving support through a federal program called the Hospital Preparedness Program which is administered by ASPR [HHS Office of the Assistant Secretary for Preparedness and Response], and they work with their state health agencies on that. In the end, even though it's a substantial grant program there are many hospitals in the country, so the overall support for any one hospital is still relatively modest. So I think at a high level, I think we have to say that the readiness level across the country is quite varied, and in big institutions that have large teams I think we can expect that readiness is higher. I think if we think about health care institutions that are smaller or away from cities, I have more concern that they have less surge capacity, less training around infection control, less access to information than some of our best hospitals and our biggest cities might have.

So in our planning at a federal and state level I think we need special attention to some of the smaller institutions with less resources and with less access to some of the top leaders or protective equipment or other kinds of strategies that we've used for the big institutions.

Lauren Sauer: Great, thank you. I'm going to combine two questions for the whole panel so anybody who wants to take this on can, particularly thinking of our population that cannot telework or telecommute, or work from home—how can the public, especially if they do have to go out during this outbreak, protect themselves while taking public transportation, going to schools working, if they can't work from home etc.

Jason Farley: Hand hygiene, hand hygiene, hand hygiene—number one. If you're sick, stay at home. And those are your two most important features. Please note the statistic of eighty to eighty-five percent of people who are known to be infected with coronavirus are doing very, very well and so most of us that are out in that workforce, particularly young, healthy able-bodied people, are very low risk of clinical complications from this virus, and that's an extremely important message. So hand hygiene. If you're concerned about touching surfaces or else will fall over if you're not holding onto the rail in the Metro, it takes a little small package of Clorox wipes or some other thing, and wipe it down before you grab it. It's all it's all just basic kind of general personal hygiene techniques and practices.

Lauren Sauer: Great, thank you. So if viral particles can remain airborne and for a certain amount of time or … this disease can create droplets, can you talk a little bit about the advice that is out there on not wearing masks and why that's important for the general public? Maybe I'll hand it off to Dr. Maragakis and then Dr. Pekosz.

Lisa Maragakis: Sure. This is another area that I think we need a lot of messaging to the general public because we do see a lot of images of people around the world wearing masks in public settings. The current guidance is that is not necessary and in fact may not even really add to protection. I think the things that we just heard about washing our hands, even though it sounds so basic, it's just—that's the critical link. We touch surfaces. We touch doorknobs. We touch our face, and that's how viruses get access to our mucous membranes. So if we wash our hands, that is the very best way to prevent infection.

Andy Pekosz: And yes, I'll also emphasize that a mask sometimes gives you a false sense of security. As was mentioned, here we get trained on how to put these masks on and they're verified in terms of how well they're fitting, they're working. Just before I came here, my biosafety officer actually walked by and jokingly gave me a razor because I'm going to have to shave to be refitted, tested for an N95, because having facial hair—it precludes me from using an N95 effectively. It's these kind of things that I think the general public doesn't really understand, and anytime you know something like a face mask, that has the potential to help you—if it's not used correctly, again, as a false sense of security, [it] may actually help facilitate behaviors and exposures. So I think the training behind those masks is something that needs to be emphasized to the general public. It's not just having a mask, it's knowing how to use it effectively and safely.

Lisa Maragakis: I can just add one more thing, and that is that I think we've already talked about some of the supply chain challenges, so I'm just really trying to get the supplies that we do have to the people who need it most, and where we know it is effective.

Lauren Sauer: So we have a couple of questions on the illness itself, so I'll just combine them all and then anyone who wants to chime in can. How long after contracting the coronavirus will it take for someone to test positive and are false negatives possible and if so what does that mean for spread? And then, if you recover from COVID-19 can you get it again and if yes what does that mean for vaccine research and development? So anybody who wants to grab one of those go for it.

Tom Inglesby: So we know that the incubation period has a wide range, so from the time that you're exposed to the time that you are sick can be anywhere from a day to 14 days. The first patient that came back from China and was diagnosed with coronavirus had very mild symptoms at the start and eventually self-identified, brought himself to the hospital, and over a period of time developed cough and fever, and then at some point mild shortness of breath. But it can take some time for those symptoms to accrue for people who get really sick. It can be five days, six days from the time that you start with symptoms to the point where you feel really ill and need hospital care. So it's important, even in people who have initial mild symptoms, just to be aware that your condition might change over time and might need hospitalization at some point. Again, most people will not need that, but there are the cases that do have some progression of illness over time.

Is it possible to have a false negative test? Yes it is. People are tested multiple times over the course of illness when that's possible. It's possible. We've heard reports of people testing positive, then testing negative and then testing positive again. Most scientists don't believe that person is being re-infected but that's just the nature of the test. It's not a perfect test. You might test negative. But still, again, a better test or a subsequent test is positive, so in most cases, repeated tests negative are required before someone is discharged from care.

Andy Pekosz: You know, the question about reinfection is a really important one. I think we've only now gotten to the stage where we've had people who have been infected, recovered, and recovered long enough for us to actually start asking those questions but that also is going to require the development of new types of tests, tests that are based on antibodies that tell you not that you still have the virus but what your history of exposure to that virus was. Our best guess is that antibody levels are going to be predictive of whether you're protected from infection, so these antibody-based tests that people are now developing and will soon be hearing a lot about are going to give us a lot of information about how strong your immune response is, how long it lasts, and how well that's going to correlate with protection. So I think the answer is we'll know more over the next couple weeks. As a case with a lot of questions about this, this outbreak

Lauren Sauer: Great, thank you. I'm going to ask Dr. Maragakis this one because we just had a conversation about it. We've been seeing a lot of people bumping elbows instead of shaking hands but be transmitted this way because people are also being told to sneeze our coughs into their elbows instead of into their hands.

Lisa Maragakis: What a great question. So you know I go back to the earlier comment about hand-washing. I shook hands with someone two days ago and they looked at me astonished and said you're still shaking hands? So you know, I do think that anytime something like this happens, we have to look at our cultural practices in in this country. Handshakes are almost second nature. I know our European colleagues are also looking at the kissing each other on the cheek, and … that falls into the category of social distancing. So yes, bumping elbows is one way. There are other ways so probably I would say we need to come up with a different kind of accepted cultural greeting that everyone can utilize because this is the threat that's with us today, and we know that respiratory viruses sweep through every season so that would be a good habit to get into. As far as sneezing into your elbow, that's a good point. I hadn't thought about that.

Lauren Sauer: I'm going to ask one last question since we're short on time, and so anyone who has thoughts on this one, I'm sure there are a lot of people in here who would love to hear it. We do have spring break coming up and people are making decisions. I'm canceling plans and changing travel arrangements. Maybe we could just go down the panel and give us some thoughts on what it means to cancel plans or if you should be thinking about cancelling plans.

Tom Inglesby: They're very difficult set of questions because at this point just thinking about domestic travel for spring break, we are going to learn a lot about the extent of disease in the coming week or two, as State Health labs and hospitals begin to test more. I think what we're going to see is that there's disease in most places in the country, and whether your risk is higher when there's 20 cases in a state versus 50 cases in a state I don't think we have that kind of perfect knowledge, so it's not clear yet that going to special places in the country is likely to increase your risk, and federal health authorities have advised that they don't think there is any need yet for any kind of domestic travel restrictions.

From studies on airplanes with other viruses, we think—just using airplanes as one mode of travel—that there is risk if you're sitting very close to someone with coronavirus or with another respiratory disease in a row or two in either direction, but typically the whole plane isn't considered to be at risk. It's really, do you have the bad luck of sitting next to someone with a particular disease or in a row in front or behind? So to some extent, these are going to be decisions that people need to make on their own. There probably isn't going to be guidance that is clear for everyone in every condition. I think a lot is going to depend on what your destination is, whether it's national or international, and just understanding again, appropriate things that we can do in our own control to reduce risk around hand hygiene or trying to avoid people who are actively sick in your presence. I think these decisions will be changing over time but at this point there isn't any national guidance around travel restrictions domestically and there's pretty clear guidance around where the US government believes people should not go or should only go for essential work reasons.

Andy Pekosz: I'll tell you what we're dealing with. I don't have an answer to this either, but what we were dealing with too is the question of scientific conferences so the past president of the American Society for Virology, an association over 2000 virologists that annually gets together to discuss wide-ranging issues on viruses. Our meeting in the middle of June in Colorado State, and we're having very significant discussions as to whether that meeting should go forward. People are coming from all sorts of areas of the country, areas that have exposures, that have transmission areas. Areas that don't.

I think even more importantly, there's the financial considerations for individuals where perhaps we'd like to wait and make a decision but at some point in time, airlines may not refund tickets, hotels may not refund hotel costs. And so, there are all those other factors that are also coming into our decision-making, outside of just the question of whether or not this is this thing that we should be doing at this point in time regarding epidemic control and COVID spread. So it's a very, very complicated question that I think a lot of societies are also dealing with as well as individuals.

Lauren Sauer: Great thank you. Well we are out of time and this concludes our briefing. I want to thank you all so much for being here, I think judging by the number of people in this room we can tell that this is an issue that's on everyone's minds. I will encourage you to visit the Johns Hopkins Coronavirus Resource Center online at coronavirus.jhu.edu, where you can find all the Johns Hopkins resources to help advance the understanding of the virus, to inform the public, and brief policy makers in order to guide a response, improve care and most importantly, save lives. At Johns Hopkins, we're guided by the principle of creating knowledge for the world. My colleagues at the Johns Hopkins Office of Federal Strategy stand ready to assist you with any policy or research support you may need on COVID-19 and countless other issues. Thank you so much for attending and for tuning in, and I'll remind you to wash your hands after you leave the room. Have a good afternoon everyone, thank you.