Today on A Second Opinion, we bring you our second special episode in our continuing series of providing up to date coverage on the 2019 novel coronavirus. I’m your host, Senator Bill Frist.
There is no better example of the critical importance of bringing together policy, medicine and innovation to address and ultimately solve the growing health epidemic of coronavirus. The novel coronavirus outbreak has been declared a global health emergency by the World Health Organization and a public health emergency by the United States Government. On A Second Opinion, we bring the nation’s most trusted experts directly to you, and the CDC is our nation’s most trusted source of information when it comes to infectious disease.
On February 7th I spoke with Dr. Jay Butler, the Deputy Director for Infectious Diseases with the Centers for Disease Control and Prevention. Dr. Butler has had extensive experience with serious global outbreaks. He directed CDC’s 2009 H1N1 pandemic vaccine task force, which achieved emergency vaccination of more than 80 million Americans. He also held leadership roles in multiple emergency responses including CDC’s response to bio-terrorist anthrax in 2001 while I was in the Senate.
Dr Butler’s update includes what the public needs to know about this new strain of coronavirus. We are taping on the afternoon of February 7th, 2020. This is a rapidly changing situation and some of the data and development shared in this interview may have changed by the time you hear this.
Bill Frist : Dr. Butler, let’s start off with just the basics. When people ask you what the 2019 and novel coronavirus is, what do you say? How do you keep it in simple terms?
Dr. Jay Butler: Well, this is a new coronavirus and that’s why it has the name novel. It was identified in December of 2019, which is why it has the 2019 attached to it. It’ll probably have a different name ultimately assigned to it, but coronaviruses actually aren’t new. Even back when I was in medical school, there were a couple of coronaviruses that were known to exist. They were known primarily for causing cold like symptoms. That changed though in 2003 when SARS, or the severe acute respiratory syndrome outbreak occurred in Hong Kong, and this was the first time we recognize that certain coronaviruses could cause severe illness.
Dr. Jay Butler: Subsequent to that coronavirus became a very popular subject of research, a very important subject. We learned much more about how coronaviruses exist in nature. That oftentimes bats serve as reservoirs and that these viruses can evolve and they can pass on to other species and eventually to humans.
Dr. Jay Butler: Another example of a coronavirus that causes severe illness is MERS, Middle East respiratory syndrome. This was first identified in 2012.
Dr. Jay Butler: Overall there have been other coronaviruses identified that also cause milder illness. So overall, this is the seventh coronavirus known to infect humans and we’re still learning very much about it.
Bill Frist : These viruses normally inhabit cats and camels and have an animal reservoir. When was it first documented, a jump from the animal reservoir to human, and then when was the first human to human transmission documented?
Dr. Jay Butler: For the 2019 novel coronavirus the recognition of the outbreak before it was really an epidemic that was involving multiple countries, was when there were a number of people diagnosed with a pneumonia of unknown cause in Wuhan China, and this is a metropolitan area in Hubei province of China in the central part of the country. Many of those people worked in a market, sometimes called a wet market where live animals or recently killed animals are sold for food, and so it raised questions about whether or not this might be a virus that had jumped from a food species into humans.
Dr. Jay Butler: That was not a clever imagination. That actually is what happened with SARS, that the virus had infected a couple of species that are used for food in China and sold through these markets. We don’t yet know what that animal intermediary might be in the market. There’s certainly been a lot of talk about bats. Looking at the genetic sequences of the viruses that had been recovered from humans, they have a lot of similarities to bat coronaviruses.
Bill Frist : This is February 7th and one of the things that I’ve said a little bit earlier in this show is that everything we say today is going to change tomorrow and the next day and the next day, so people will be checking as this is listened to over the coming weeks. But today is February 7th and so that was about six weeks ago that the first appearance or first case was. Do we have a date when that first case appeared?
Dr. Jay Butler: The first case was probably in early December. It was really recognized as an unusual event, an outbreak in late December. And it really does highlight how much things have changed in terms of how we can identify new pathogens.
Dr. Jay Butler: Within about 11 days, by January 10th the sequence of the virus which had been linked to the illness was actually posted online so that it was available to researchers around the world. By a week after that, CDC had developed a polymerase chain reaction assay to allow diagnostic testing here in the United States. And that actually was in our hands then when the first potential case was identified in the US, which was confirmed using that test. Actually the coming week, in second week of February, this test should be available in most state health labs.
Dr. Jay Butler: So it’s a pretty remarkable story that over a period of barely five weeks, we’ve gone from a mystery illness to an infection that can be diagnosed in your state health lab.
Bill Frist : And so we really have come a long way. SARS, another coronavirus 2002, 2003 instead of being just a period of weeks it was months before we were able to really develop a similar sort of testing and diagnostic regimen. Is that correct?
Dr. Jay Butler: Yeah, it’s quite remarkable. I mean, if we look a little further back say to 1976 and the Legionnaires’ disease outbreak in Philadelphia, and this was an outbreak caused by a bacteria, not even a virus, it was five months between recognition of the outbreak and identification of a likely pathogen. So things have really progressed incredibly over the past several years. Not only that 40 year span, but even more so in the past decade.
Bill Frist : Dr. Butler, just for our listeners and for me, because language matters, epidemic versus a pandemic versus an outbreak, or I should probably say outbreak, epidemic, pandemic, in sort of simple layman’s terms, how do you distinguish between those three?
Dr. Jay Butler: Yeah, Senator, I liked the way you described that because you can almost think of it as concentric circles.
Dr. Jay Butler: An outbreak could also be called a cluster of illnesses such as what was recognized in Wuhan during December when there were a number of cases that were not being diagnosed, they were unknown cause, but had similarities and also had the epidemiological link at that time to the market in Wuhan.
Dr. Jay Butler: Epidemic is probably a term I would use for an outbreak that is really spread beyond a point source, and that we’re certainly in an epidemic phase now. The early cases were primarily associated with that seafood market, but as time has progressed, we’ve had more evidence of human to human transmission and particularly within Hubei province, we seem to have widespread transmission among people.
Dr. Jay Butler: A pandemic is a term that we usually use for the influenza virus. So I think of this is when we have a new influenza strain to which the human population has little or no immunity and that it can be sustainably spread person to person. An example of that would certainly be the influenza pandemic of 2009, which is a good example of how pandemics can differ. The 2009 pandemic was mild at least by measure of the death toll, but it also seemed to have a particular penchant for infecting younger people who generally are better able to survive influenza infection.
Dr. Jay Butler: The other end of the spectrum for severe pandemic would have been the 1918 flu pandemic, where it’s estimated that overall mortality was somewhere between 1 1/2 and 2%. And that may sound low as a raw number, but when we’re talking about an infection to which everybody is susceptible, that’s truly a scary number.
Bill Frist : They say we would call the novel coronavirus of today a pandemic. Has it crossed from epidemic to pandemic yet?
Dr. Jay Butler: I’ve been hesitant myself to say that. I don’t know if there’ll be an official proclamation of it as a pandemic, but here’s what we know so far. It’s a new virus. We don’t know if the human population is entirely susceptible to it. I know one of the questions that I’m keenly interested in is whether or not past infection with one of the milder coronaviruses, such as 229E, might provide some cross protective immunity. We do know that these other coronaviruses’ milder illness do not impart lifelong immunity, so I don’t want to get anybody’s hopes up about that.
Dr. Jay Butler: The next issue is can it be transmitted sustainably person to person? We know that human to human spread is possible. How sustainable that is I think is something we’re watching very closely. The epidemiological behavior of the virus certainly suggest that at least within Hubei province where the vast majority of cases have occurred and at the time of this recording we’re aware of some 31,000 confirmed cases, the vast majority are within that one province still.
Bill Frist : Have all of those cases, as I read these numbers coming out, and again for our listeners, these numbers are increasing at least over the past week about 10, 15% a day, have all of those been diagnosed with a diagnostic kit?
Dr. Jay Butler: Certainly the numbers that are reported from the United States, I can confidently say were diagnosed not only with the PCR diagnostic tools that were developed at CDC, but actually at CDC. We will now move into a period where that same diagnostic test will be available under standardized methodologies and also under review by the authorities to make sure that it’s a dependably performed test throughout the United States. What our understanding from our Chinese colleagues is that these are the number of infections that our laboratory confirmed using a PCR assay.
Bill Frist : So probably, and I’m not sure if you can state there, but probably if they’re 31,000 that had been diagnosed in the laboratory, and I know some models show 100,000, several hundred thousand cases are the more likely number, but I guess that’s really an unknown today.
Dr. Jay Butler: Yeah, and you’re absolutely right. If there’s going to be a bias towards whether or not these cases that are laboratory confirmed is an underestimate or some type of overestimate, it’s going to be an underestimate. What we don’t know is how much of an underestimate. There’s certainly every reason to think the people who have very mild illness may be much less likely to be tested
Bill Frist : On the diagnosis, again, this is one of the great values of our remarkable CDC in this country is that with rapidity, we can go out and get the diagnostic test, develop it, refine it, and then get it out to the various states. Practically speaking, if I were here in Nashville where I am today, will that diagnostic test be here within a week or a month or two or three days or do we not know?
Dr. Jay Butler: Yes, it should be actually available and ready for prime time within the next week.
Bill Frist : And then just again so I know, is that an hour or a four hour test or a day test or a two day test?
Dr. Jay Butler: I understand your question. Once the specimen is in the laboratory it takes about four hours. It’s a process extracting the RNA from the specimen and then actually running the polymerase chain reaction assay. In general that takes about four hours.
Bill Frist : Yeah. And SARS back in 2002, 2003 people are looking a lot and I was involved because I was in China during the height of that episode, in terms of the course itself, if I remember correctly, it was about an eight month course of ebb and sort of flow and then sort of demise. Is there any way to look back at that period of time and project and predict what this virus will do in terms of length of lethality, transmissibility, how long it’s alive?
Dr. Jay Butler: Senator, you’re really touching on some of the important questions that we’re asking and we’re all certainly looking back at the SARS experience, and many of us were involved in that response and so have not only the academic published papers, but also our own experience in the response to that epidemic.
Dr. Jay Butler: SARS differs in some ways, even though it is another coronavirus disease. We already have many more cases of the novel coronavirus infection from 2019 than we ever had with SARS. The SARS epidemic topped out at about 8,000 cases and actually was contained, and there have been no cases of SARS in the world since 2004. This virus is behaving differently and certainly suggests that it may be more transmissible. We don’t know that for sure, but given the rapid increase in the number of cases, it certainly suggests that.
Dr. Jay Butler: The mortality rate is also significantly lower. When SARS was first recognized it had a very high mortality rate, but even with more aggressive case finding and testing, still the mortality rate was just under 10%. Right now for the novel coronavirus, the numbers from China suggest a mortality rate that’s a little bit under 2%. Looking at the cases that have been diagnosed from outside of China and as of this date, and this number will certainly change very quickly, there’ve been over 300 cases diagnosed in 27 different countries around the world and of those the mortality rate has been a little less than 1%. So based on what we see right now, it looks like it is a milder illness overall, but it’s still one that can be deadly.
Bill Frist : The transmissibility, people listening in terms of infectious disease will be thinking of SARS because of the impact it had 2002 and ’03, the economic impact to the measles, tuberculosis, typical seasonal flu. How would you describe along the spectrum, and I know we don’t know for sure yet because we’re still collecting that data, but develop a spectrum for me and drop where you think we might be today in terms of how transmissible it is? As I understand this is more by droplets and less aerosolization, but for our listeners, explain a little bit about how transmissible it is vis-a-vis the other types of diseases that we’ve heard of.
Dr. Jay Butler: Well for coronaviruses in general, the predominant mode of transmission is going to be respiratory droplet. That means that when someone coughs and sneezes droplets containing the virus can come out, they will not float in the air, but just based on the force of the cough, they can fly as far as anywhere from three to six feet. So we consider that the area of highest risk.
Dr. Jay Butler: Now, the other coronaviruses do have some ability to survive on surfaces in the environment for a short period of time, generally measured in terms of minutes or hours. So we do also worry about the ability of the virus to contaminate a surface, and if someone comes along in a short period of time and is exposed to that, say picks it up on their hand, puts their hand to their mouth, their nose, their eyes, they could inoculate themselves.
Dr. Jay Butler: That’s why one of the real focuses of prevention is frequent hand-washing. I know we say that a lot because it actually does work for a number of different respiratory pathogens including influenza. For the coronavirus, it’s even more important as right now we do not have things like vaccines where there’s some investigational drugs, but even the options for treatment are fairly limited.
Dr. Jay Butler: If we had to compare based on what we see right now, and again, this could change, what will this be like, I mean it’s behaving a lot like influenza, so it could be like an influenza pandemic, although perhaps not as severe as 1918 but maybe more like what occurred in 1957 and 1968.
Dr. Jay Butler: The huge caveat though is this is still very early on and we’re getting all the data we can and looking at it. We want everybody to be prepared for what may be coming. Currently there is people in the United States in communities are at very low risk. However, we encourage everybody to monitor the situation very closely. A good source of information is the CDC website. That’s cdc.gov/ncov, short for novel coronavirus. And there are daily updated informations including what is the status of the epidemic and what’s happening in the United States.
Bill Frist : As you know, this is changing every day and so again, the website we’ll put that on the screen as well so people will know who to contact.
Bill Frist : The treatment and you mentioned it, but let’s review it just quickly in terms of what treatment. If somebody came in with coronavirus today and they were sick and they had a pneumonia, how would you treat them A, and then B, a little bit more on the vaccine and vaccine development, how long that takes? You can cite some historical examples. But also is there any hope that a vaccine would be available within a year?
Dr. Jay Butler: Okay. First of all, in terms of treatment, let’s say I acquired the infection and was coming into the hospital, I would be evaluated probably as anybody with suspected pneumonia would be, particularly if I was short of breath, there would be a chest x-ray or perhaps even a chest CT depending on the situation. There would be a measure of the amount of oxygen in my bloodstream and then a decision made for whether or not I need supplemental oxygen or perhaps more aggressive support. This is what we call supportive care and it’s really all we have when we don’t have specific treatments.
Dr. Jay Butler: There is an antiviral drug that is being evaluated called Remdesivir. There may be others as well, but Remdesivir is one that’s available under compassionate use. It’s actually being studied in a trial in China as well. So we hope to have some more data in terms of how effective it may be or whether perhaps it’s ineffective and not worth trying to use. It is a very broad spectrum antiviral that’s active against a number of RNA viruses. So based on what we know about the drug and what we know about coronaviruses, it certainly seems to be an option to pursue in terms of clinical studies.
Dr. Jay Butler: Regarding vaccine, it’s a little different from influenza where of course, we already have FDA approved influenza vaccines. We are continuing to work of course, towards improving our influenza vaccine production capacity, but we basically have the infrastructure in place already and the technology in place to have influenza vaccines that can be adopted to new emerging strains of influenza.
Dr. Jay Butler: For coronavirus, there are no currently approved coronavirus vaccines for humans. There was development of a vaccine that could be used for SARS. Of course, the disease went away, so the vaccine never entered into the kind of large clinical trials that we would want to have before it was approved by the FDA. In this case, even though technology has advanced quite a bit, I think it’s unlikely that we would have a vaccine within the next year.
Bill Frist : It’s really interesting when people hear the word quarantine. And essentially we’re using the same public health measures to contain as we used 10 years ago, 30, 50, 100 years ago. US public officials took a rare step in issuing a mandatory quarantine, and the last one if I recall, was 50 years ago of some sort. What is the significance of quarantine and a mandatory quarantine, how effective they are, and is there anything different about a quarantine today than there was 50 years ago?
Dr. Jay Butler: Well, quarantine is a fairly dramatic step. As you pointed out, it’s the first time there has been a quarantine order at the federal level since 1961. So this really is in the lifetime of most of the responders, this is an unprecedented step. It is not one that we take lightly because there’s always the balance of what can we do to be able to protect the public health, but also to be able to respect civil and personal liberties. So we always want to go with the least restrictive means to limit the spread of any infectious agent.
Dr. Jay Butler: In the current instance because the virus is primarily being transmitted broadly and being transmitted out of Hubei province, it seemed reasonable to have a period of quarantine that would focus on people who are coming out of Hubei province so that it would minimize the risk of there being infectious and present in the community.
Dr. Jay Butler: As we look at the 12 cases that have been diagnosed as of the time of our discussion now, only one is actually been identified as an ill traveler. So how we focused on travelers is something that we’ve tried to use in a step wide fashion.
Dr. Jay Butler: All but two of the other cases have been in people who were well when they returned from Hubei province but were diagnosed, and actually they were very good in terms of calling the healthcare provider in advance and saying that they had just arrived from Hubei province a couple of days ago, they were now becoming ill.
Dr. Jay Butler: And one of the things CDC does in addition to the traveler screening is to provide a travelers health alert notice to each traveler so that they have specific instructions to monitor their health and to contact a healthcare provider if they become ill. The healthcare providers so far have all done exactly the right thing in terms of being able to receive a patient with appropriate infection control precautions in place and be able to get the appropriate diagnostic testing.
Dr. Jay Butler: The two remaining cases actually were acquired in the United States and I think that’s very instructive in terms of how we learn how this coronavirus can spread. These were both household contacts of people who had recently returned from Hubei and the transmission most likely occurred in the household setting. To date, there’s been no other instances of transmission from those individuals, which is somewhat reassuring, but I don’t want to be overly comforting on this. We need to continue to be very vigilant about the risk of transmission. Ultimately though, we know that quarantine may slow the entry of the virus and slow its spread, but there’s no way that it will be completely kept out of the United States.
Dr. Jay Butler: So the goal is to be able to spread out the impact of this potential pandemic if indeed that’s what it turns out to be and that’s in keeping with many of the pandemic influenza plans as well. That would buy us time to be more prepared to be able to handle more widespread transmission. Give us more time to confirm, develop and confirm the efficacy of therapeutic agents and also to have a vaccine in hand.
Bill Frist : Dr. Butler, thank you really so much. I would love to do this periodically with you. I think the one final question I would have, and it’s in part a statement because it has real implications for support of surveillance both here at home in a generic sense as well as global surveillance.
Bill Frist : Could you just comment on transportation, the style of life that we live today, that civilization lives today, does that mean that we are going to increasingly see these periodic appearances of a novel virus, or will there be some end to this every few years a new virus coming up and threatening us and threatening our public health infrastructure?
Dr. Jay Butler: Well, of course infectious diseases don’t need passports to cross borders and really an outbreak anywhere in the world could become an outbreak everywhere in the world. And it’s not necessarily something new. If we look at the 1918 pandemic, there was a period of about three weeks for the virus to spread in the west coast of the United States, all the way to the Seward Peninsula of Alaska and actually out to some of the remote villages where it had a very [inaudible] impact on the local population.
Dr. Jay Butler: Today, of course we’re not mostly traveling by ship or dog sled, but by air much faster and really can be anywhere in the world within about 36 hours. Your luggage may not make it, but you can make it. And that’s probably the most important thing to know about how infectious diseases can spread around the world.
Dr. Jay Butler: I want to be very clear that that interconnectedness is very important for how our society is structured nowadays. So just sealing off the borders might not be the best response because we receive many of our medical supplies from outside of the United States. So these are all issues that require serious consideration before we do things that are drastic.
Bill Frist : Dr. Butler, I can’t tell you how much we appreciate and the American people appreciate your leadership and the leadership of the CDC in addressing what can be frightening to people and appropriately send a strong signal that we need to be paying very close attention, all of us in this evolving threat.
Bill Frist : If you could give us one more time that CDC website because it will be very important for people to stay in constant touch and if there are questions to be able to get that information from a trusted source, and there is no better trusted source in America than the CDC.
Dr. Jay Butler: Yeah, my pleasure. That’s cdc.gov/ncov.
Bill Frist : Dr. Butler, thank you very much and we’ll stay in close touch. We appreciate it. Thank you.
Dr. Jay Butler: My pleasure, Senator.
Bill Frist : This episode of A Second Opinion was produced by Todd Schlosser, the Motus Creative Group and Snapshot Interactive. You can subscribe to A Second Opinion on Apple podcasts, Spotify or wherever you are listening right now. You can also watch our interviews on YouTube and on our website. And be sure to rate and review A Second Opinion so we can continue to bring you great content. You can get more information about the show, its guests and sponsors at asecondopinionpodcast.com. That’s asecondopinionpodcast.com.
Bill Frist : A Second Opinion broadcast from Nashville, Tennessee, the nation’s Silicon Valley of health services where we engage at the intersection of policy, medicine and innovation.