Fang Lind began to feel feverish just as the weather was starting to turn dry. Fang made it through that day and night, having to pause during his work in the chop room to catch his breath, and he took frequent cigarette breaks on the back stairs. The next evening, when he went up for a cigarette break and sat down on the back steps, he couldn't get up. His fever had climbed, probably to over one hundred three degrees, and he found that no matter how deeply he breathed,
he felt perpetually winded. His body aggs had reached a point where whatever position he stood or sat in, he felt as if his muscles were being pulled from his bones. The anti febrow medication did nothing to assuage his fever, which may have spiked north of one hundred four point five twice. He was unable to rouse himself from his sleeping palate in time to reach the toilet in the hall, each time, soiling his trousers. He found that if he moved even slightly to roll over or sit up, he
would be completely out of breath. The muscle agges were so severe he recalls that he found staying still unbearable, yet any movement would leave him gasping for breath. What was happening to him? Fang knew he was ill, but he still assumed he was suffering from another of those respiratory infections that regularly burned to the click. Everyone seemed
to have a hacking cough of some sort. Whether it was due to cigarettes, persistent asthma, or air pollution was impossible to say, but he had been on his back for several days now and wasn't feeling any better. Most terrifying for him when he was conscious was the sense that, no matter how deeply he breathed, he felt that what he was inhaling was not oxygen, but some other odorless, tasteless gas with similar properties, but without the life sustaining
force of simple oxygen. He was running out of air, yet he felt he was breathing freely. He now had to stay perfectly still. To move was to suffocate. Stay still and breathe breathe as deeply as possible. On about the sixth day of his illness, he lost all track of his environment. From then on, there were only dark dreams and the sensation that his life was literally being
squeezed from him. His muscle aches would come in steady, rolling waves, and would peek as gripping cramps around his spine and in his neck and upper legs, a dreadful tightening that would coincide with a gasping inability to draw in enough oxygen. He lay still and struggled to stay awake so that he could focus on maintaining his steady, ineffectual breathing. He feared that if he fell asleep, he might forget to breathe, and that would be it. Perhaps
that is what dying is. He wondered, your body forgetting how to breathe. But he did begin to drift off, always remembering even in his unconscious state, that he must stay still. Any movement at all, even a wiggling of toes, even blinking, used precious oxygen. That was air he didn't have. So he lay perfectly still, and in those moments between severe cramps and muscle aches, when his bowels were settled,
he would drift into dark snatches of unconsciousness. But it was a cruel sleep, one that never let him forget for even a moment his suffering. During those naps, he would always feel very far from home and very alone, a terrified idea began to glow in the darkness. He would die far from home, away from his family. He understood finally the importance of that Chinese tradition of rushing home when you were ill, even if only to pass away.
And then he thought of another matter. Who would pay for the cost of his funeral arrangements?
Oof?
Aaron Oof indeed Erin. That was adapted from chapter seven of China Syndrome by Carl Taro Greenfeld, and that description was of SARS SARS. Yes. And on this episode of this podcast, Will Kill You, we are talking all things coronavirus.
Because you guys asked for it and we oblige. I'm Aaron Welsh and I'm Erin Alman Updike.
Welcome, Welcome. So this episode we're talking all things coronavirus, which means the endemic ones that cause basically like a mild cold in humans, SARS mers and then the twenty nineteen novel Coronavirus, which doesn't yet have a catchy acronym, right. And the reason that we're talking about all of these is because, for one thing, they are all related to one another. And what we can tell about those twenty
nineteen novel coronavirus. A lot of that comes from the information that we have from these other coronaviruses, so we wanted to give you the full picture of all these things.
We were not planning on covering coronavirus this season, no, but yeah, it's making big headlines and for good reason. So we want to help everyone to understand what coronaviruses are and as much as we can let you know about what's going on with the current coronavirus outbreak. A few things to keep in mind, we are not experts.
Once more, for the people in the back, we are not experts, so.
We are not the ones on the ground doing this research working on this outbreak. We are going to tell you what we know, and because we're not experts, we're going to bring in some people who have much more expertise than we do to talk about what's going on with the current novel coronavirus outbreak. But we will do what we do best, which is tell you about the biology and the history of coronaviruses in general.
Yeah. Should we also note that we are recording this on oh nine thirty am on February second.
This is something that's happening so rapidly that by the time you listen to it things will be drastically different.
The earliest you would be hearing this is on February fourth, so it's likely that some of the numbers that we are reporting about the twenty nineteen novel Coronavirus will have changed, but hopefully the broad strokes will still be enough to get you the information that you want and will.
Also point you in the direction of where you can find reputable sources to stay abreast on what's going on with the current outbreak.
Yes, I guess though we should start with quarantinies.
We should because we must.
This week's quarantini is called the breath Taker, and it's called that because that was the colloquial name for Sars in China when it first started making the rounds. I love it, and Aaron, what's in the Breathtaker?
Well, it has to start, of course with a Corona.
And we should also point out that Corona beer has nothing to do with coronavirus.
At all, and this is not sponsored.
Not sponsored. It also has Ento Ray's chili liqueur and some lime juice and some Tomatio salsa.
A little spicy something or other to get you through this episode.
Yeah, it's basically like immachillada.
And we will post the full recipe for this quarantini as well as our non alcoholic plus e ber rita on our website, This podcast will kill you dot com and all of our social media channels.
Okay, I mean I think we should probably just jump right it, and people are already chomping at the bit.
Yeah, they want it. We should just we should stop messing around here. Let's take a quick break and then we'll talk biology.
Sounds great.
Straight off the bat, I want to let y'all know that coronaviruses are nothing new. Nope, nothing new. This novel coronavirus that's making headlines is a new individual specific virus. Yes. However, coronaviruses, like say, influenza viruses, are a large group of RNA viruses that we not only have known about for a long time, but have been circulating among humans and many many other species of animals for a very very long time. Okay, fun fact, this is my only fun fact the whole episode.
Corona means crown, and the reason that coronaviruses are called crown viruses is because when you look at them on a scanning electron microscope. They have a little halo crown of proteins around the outside.
Oh, cute viral royalty, Yes, royal virus.
That's the end of my fun fact. Here's how kind of this episode biology is going to be structured. All right. First, we're going to talk about the most common human coronaviruses in general. These are the ones that circulate all the time. Almost definitely if you are listening to this podcast, you've been infected with a coronavirus at some point in your life. And then we'll talk about the three big headline grabbing coronaviruses that is stars, Mers and the Newest twenty nineteen and Covy.
Cool gotcha sounds great?
All right, So coronaviruses in general, there are several different large groups of coronaviruses and a lot of them actually infect animals, all different kinds of animals, pigs, chickens, cats, and in animals they often cause gi illness, so like diarrhea and stuff like that, but they can also cause respiratory illness. There are four human coronaviruses that are really common and they cause the common cold. Yeah, so these
are upper respiratory tract infections in general. So the question first that we like to answer is what exactly do they do in your body and how do they make you sick? What is their path of physiology? It turns out that for the four human coronaviruses, we don't entirely know their path of physiology because, like for many viruses, we don't have really great animal models to study them.
But from some really interesting and probably ethically questionable studies that they've done in humans where they intentionally infect quote unquote volunteers. When were these studies from the eighties and early two thousands.
Uh, okay, that's yeah, that's yeah.
Anyways, what we do know from these studies is that these four human coronaviruses colonize the upper respiratory tract, so your nose and throat in general, okay, And we know that they invade and replicate in your respiratory epithelium, so the sort of first cells lining your respiratory tract. So in the case of these four common coronaviruses, that's pretty
much where they seem to stop. They're not super infectious in these human studies, up to like a third of people that they inoculated didn't actually even get infected with the virus, and most of those that did had very mild or maybe moderate colds. So we all know what the common cold looks like, right, Aaron, what kinds of symptoms do you have?
Running nose? Hmmm, sneezing, coughing.
There you go, exactly, yeah, So these are very mild upper respiratory symptoms. Cough, runny nose, stuffy nose. Maybe you get a headache, maybe rarely you'd spike a fever, but in general you're not all that sick. The way that common cold viruses like coronavirus are generally transmitted is by respiratory droplets. So since they make you cough and sneeze, when you cough and sneeze, you cough and sneeze out liquid droplets full of virus, and that's how the next
person gets infected. So it's not like something like measles that we talked about that can hang out airborne in the room for many, many hours in the air. These are viruses that are contained in water droplets that you cough and sneeze out. It is also possible that these droplets can land on surfaces and the virus can then live on these surfaces and be transmitted from say a doorknob to your mouth if you touch a doorknob and then touch your mouth. That makes sense, yes, Okay, So
that's the four common coronaviruses. They don't cause a lot of morbidity or illness, They don't cause a lot of mortality except in very, very very rare cases. And it's estimated that anywhere from ten to thirty percent of all common colds around the world are caused by one of
these four coronaviruses. Huh yeah, so there's really common. Yeah, And I think that's important to keep in mind because even when Stars first came on the scene, while we'll see that it was very novel in the type of disease and this verity of disease it caused, it wasn't a completely unknown alien invasion virus, right, and neither is this new novel coronavirus that's circulating today. Okay, So let's get into the more serious things, and that starts with SARS.
SARS stands for severe acute respiratory syndrome. What was novel about SARS when it first came on the scene in two thousand and two is that it caused a very serious illness in people. It caused an illness that was so severe, especially compared to what coronaviruses normally cause, which was like a cough and runny nose, that we didn't
recognize it as a coronavirus for a long time. And there's a number of reasons for that, many of which I'm sure Aaron you'll get into, right, okay, But at least in part, it's because we're we didn't expect before SARS that coronaviruses could cause the kind of disease we saw with SARS, right, So why did we see more
severe infection? And the answer is that while SARS still mostly affects the respiratory tract, unlike the other coronaviruses, SARS is able to extend its infection to the lower respiratory tract, so not just your nose and throat, but actually colonize your lungs and cause disease in your lungs itself.
What allows the sarskv to do that, Like, what is stopping the other four endemic milder coronaviruses from invading your lungs?
Good question, and This was one of my I put a little asterisk next to this because I thought you might ask it, so let's talk about it. So, remember that viruses can't replicate on their own right. They have to enter our cells in order to replicate and then use our cellular machinery in order to replicate and make
new viruses. So in order to do that, they have to get into our cells, and the first step in doing that is to bind to some receptors on our cells and use those receptors to get into our cells. Different viruses use different proteins and bind to different proteins in our cells. And what proteins they bind to and where in our body those proteins are found, like what cell types have those proteins determines what's called the tropism of the virus, what organs in our body the virus tends to invade.
Oh, like where it goes? Okay, yeah, exactly.
And so in the case of SARS, we found out later we know now that SARS binds to a protein called ACE two angiotensin converting enzyme. This protein is expressed in very high concentrations in our lungs and also in our small intestine and some other organs too, kidneys, et cetera. Because this is the protein that SARS uses to bind, it was able to then invade our lungs because our
lung tissue has a lot of ACE on its. I didn't look up exactly what proteins the other four coronaviruses used to invade, because there's four of them and that would be too long of an episode. But it's not generally ACE, right, So the other coronaviruses use different receptors that they recognize that are located more in the upper respiratory tract.
It seems like knowing the proteins that these viruses bind to would be great targets for treatment.
Absolutely.
Yeah.
So there's been some ideas because we have oh, this is probably getting too much, Aaron, but we have drugs that actually target ACE because it's an important component of how your body manages blood pressure.
Whoa, oh my gosh. Yeah.
So we have things called ACE inhibitors. So there's this thought that like, oh, could maybe you use these to treat SARS. We don't, as far as I know, there isn't actually good evidence that that works, but it's like, yeah, cool idea, Yeah, let's do some research on it, but yeah, knowing how viruses get into our body is often a good place to try at least try to target for treatments. I'll just say we don't have any though at this
point for SARS, ormers or the novel coronavirus. Just thrown that out.
There, Okay, there we go.
So, yeah, so SARS gets into your lungs and is able to cause a lung infection. Lung infection means pneumonia, so this is a virus causing viral pneumonia. So the symptoms of SARS, because it's a more extensive disease, tend to start more systemically. So fever is the number one
symptom of SARS. Actually, Okay, fever, chills, mayalgias like you described in the first hand account, these muscle aches can get really really severe, and then you do still get some upper respiratory symptoms, but a lot of the symptoms are more lower respiratory, so you'll get a cough, but less of the runny nose type symptoms that we see
with other coronaviruses. And then as this disease progresses and more damage is caused to the lungs themselves, you'll get other more serious symptoms like shortness of breath to kipnia, which means a really fast breathing rate, plurisy, which is like pain in your chest and lungs when you breathe, and then depending on how late in the course of disease people present to the hospital. Because this is a very serious illness, most people will present to the hospital
almost everyone. When you take an X ray of their chest, it will look like what we call ground glass opacifications.
Oh my gosh, that sounds terrible.
It is terrible. So if you've ever seen an X ray of a normal chest, a not ill chest X ray, you know that the lungs are filled with air, so they're mostly black because air is black on X ray, So you can see the outlines of ribs, and then you can see sort of black in between the ribs with maybe little bits where you can see like blood vessels and things like that. That's a normal, not sick chest X ray with stars. It looks like you're looking through like a bathroom. You know the glass they put
on bathroom windows. Yeah, I have some of that on my bathroom window exactly. So it looks like that. So it's not so opaque that you can't still see like the shadow of your heart and your ribs. You can still see that it's not completely whited out like it might be with a bacterial pneumonia, oh.
Because the bacteria has colonized. Whereas this is just inflammation.
Well, bacteria still produce a lot of inflammation, but it'll be localized to one spot and it'll be so much in like one corner of the lung that it's totally whited out, okay, Whereas this is bilateral often throughout your whole lung fields, top and bottom. Often it's all just kind of murky looking.
That sounds terrible.
Yeah, it's bad, it's not good. And then this can sort of just progress. So about one third of people with SARS will get better on their own, but twenty to thirty percent end up needing mechanical ventilation because their lungs are just so inflamed that they're not able to get enough oxygen in on their own. And I want to point out that this kind of supportive treatment is the only treatment that we have since we don't have
any antivirals for SARS. And overall, what we saw from the SARS outbreak was a case fatality rate of just under ten percent, So about ten percent of people who were infected with SARS ended up dying from SARS or SARS complications.
That's a very high mortality rate.
It is, and it varied a lot based on demographic factors. So in people older than sixty five, the mortality rate was over fifty percent.
Wow, I didn't realize it was that high.
Yeah, it was really high. So that's kind of what the disease looked like for SARS. We learned a lot about it after the outbreak because, as you can probably see with what's going on with a new outbreak right now, it's really hard to get good information while the outbreak is going on right because you're just kind of dealing with like trying to keep people alive well.
And also there's steps to publishing reliable information has to have asolute, pure review process, and some of those things are are lifted right now and people are getting early drafts out. But it's then you know what information is reliable. Sample sizes tend to be small, et cetera, et cetera.
Yeah, But so things that we know now looking back at Stars since the outbreak has passed, is we know that with SARS, subclinical infection, so like asymptomatic infection, was really rare. So in looking at zero prevalent studies of people in areas where there were high rates of SARS, there's very little evidence of infection in people who didn't have symptoms of SARS.
Interesting, okay, Yeah.
So we know that in the case of SARS, infection almost always led to symptoms, and in general, those symptoms were very severe. And the other thing that we learned about SARS was that the viral load, so how much virus you had in your body, was a really driving
factor of infectivity, okay. And so in the case of SARS, the incubation period, so the time from when you first got infected to showed symptoms, was usually about four to seven days, and viral load actually increased slowly over that time, so people were most infectious about ten days after first getting infected. And so that means that people STARS were really only infectious if and when they showed symptoms, which made SARS relatively easy to screen for and to help contain.
So that's pretty much SARS, okay, So let's let's move on. The next most famous coronavirus was merz Middle East respiratory syndrome. So was MURRZ just the same thing as SARS, but in a different part of the world. No, not really. It was another novel coronavirus that was discovered in twenty twelve after an outbreak in I believe Saudi Arabia was the first identified cases. Is that right, Aaron?
So it was first isolated from an outbreak in Saudi Arabia, but retrospective testing showed that it actually the first cases seemed to be in Jordan earlier that year.
That's right, That's right.
Okay.
So symptomatically, MERHS present very similarly to SARS in a lot of ways. It started off with fever, mayalgia's muscle pain was really common. Oh, I forgot to mention this, but a really common symptom for SARS was actually diarrhea and in some cases nausea and vomiting. So you often, in addition to this viral pneumonia had pretty extensive GI symptoms. You also saw this in MRS, and then like with SARS,
you would get a really rapidly progressive viral pneumonia. You'd have similar findings on chest X ray, those ground glass opacities, and it could lead to respiratory failure and potentially death. We know that MRS also had a similar incubation period a similar time to symptoms as SARS.
Does it also bind to the ACE two protein?
Oh, I'm so glad that you asked, Aaron.
No.
Really, it turns out MURRHS binds to a different protein called DPP four dipeptidl peptidase. This is another protein. It's similar to ACE. Okay, but it's expressed in high levels in the lungs and the kidney. So can you guess another very common symptom of MERS that's different from SARS renal failure? Renal failure absolutely, so ACE is also expressed
in the kidney. So you can still get renal failure with SARS, but it's more common in MURRS because I think DPP four is expressed at very high levels in the kidney.
Right.
Oh, how fun? Okay unless you have MERS. So let's talk about some of the differences between MRS and SARS. First off, MRS way more deadly, yes, okay. So in looking at the outbreaks of MURRS, the case fatality rate is close to forty percent, about thirty six percent.
That's very, very, very high.
It's very high. For SAR, it was just under ten percent, right, So a case fatality rate of forty percent sounds very terrifying. So let's calm ourselves down for a minute and not freak out too much about MRS. Here's a few reasons why. Number one, it turns out that MURS is not nearly as infectious as SARS, so person to person transmission is not very efficient for MRS.
Why is that?
You know, that's a really good question that we don't fully understand the answer to. What we do know is that when we compare the R NOTS, so the average number of cases from a primary case to a secondary case for SARS, it was probably around two to three I think, is that right?
Yeah?
For MRS it's er point seven.
Okay. Do you think it has something to do with the tropism of the virus? Is it in the lungs as much? Is the infectious dose different between STARS and MRS.
It could be the infectious dose, absolutely, I think that probably has a lot to do with it.
It could be the.
Tropism, although you know DPP four like it causes just as bad of a viral pneumonia, if not worse. But here's another important part about MRS, and this I think helps at least I think this makes more sense as to why it maybe doesn't transmit as well. The vast majority of cases of MERS, not even just the deaths, but the people who were infected with MRS, seventy five percent of them had some kind of underlying disease, Okay,
some kind of comorbidity. So it seems like maybe MURHS requires that a person is already a little sick, so they have diabetes or some kind of underlying lung disease or heart disease, something that makes their immune system not work as effectively. That allows for MURZ to colonize, infect them and then make them very, very sick, gotcha. Whereas with SARS, you know, healthy people got infected, sick people got infected. SARS just infected pretty much anyone. Does that make sense?
Yes?
So overall, that's the good news about MRS. It's a lot less transmissible. Almost every outbreak or group of cases had at least some documented spillover events, and it's thought that there were many many individual spillovers that happened with MRS. Whereas SARS, you'll probably talk more about, was one big outbreak right right, and MURRS the vast majority of people who have been shown to be infected had at least
some underlying comorbidities. Okay, so that's MURRS and SARS saved a special one for last, a special one for last. So those two novel coronaviruses, as a recap are different than the other four coronaviruses that circulate because they cause more serious illness by infecting the lower respiratory tract. So that brings us to today, twenty nineteen n Covy, the
newest coronavirus on the block. I don't have all the answers for you about what is this virus and what's the fatality rate and et cetera, et cetera, not only because we're not the experts on this topic, but because this is such a new virus and an ongoing outbreak that we can't answer all of these questions. We can make estimates based on the fact that we've seen stars
and merhs in the past. We can guess that in a lot of ways, this novel coronavirus likely operates very similarly to SARS and MERS and honestly the other coronaviruses. So how do we think it's transmitted Most likely respiratory droplets, right, That's how all coronaviruses tend to be transmitted. It's certainly possible that fomites or surfaces can be an important part
of transmission. So we don't know how long this particular coronavirus can survive on say a door knob or your cell phone, but we know it can probably live for at least a period of time since other coronaviruses can survive for many hours. And what it appears based on the number of people who have had severe symptoms, is that this novel coronavirus is also able to infect our lungs and cause serious viral pneumonia, So this is a more severe coronavirus than the four typical coronaviruses.
We don't know anything about the protein that it binds to.
So there has been at least one study that has shown that it likely actually uses ACE two as well, at least potentially, but that study was it's very preliminary, and it wasn't you using a live virus. They like conjugated it to a herpes virus and it was just in cell culture. So no, we don't know for sure what protein this novel coronavirus is using. It might be the same one as SARS, it might not be. Okay, we also don't quite know what the r not is,
so the basic reproductive value. There have been a lot of people trying to make estimates. It seems at this point on February second, like it's likely between two and two and a half maybe Okay, the estimates that I've seen so probably similar to SARS, maybe not quite as infectious, although we've seen numbers go up a lot more rapidly than with SARS. And one thing that I think is really really important is that we cannot estimate a case
fatality rate until this outbreak is over. Yeah, period. And I think that there's a lot of people on the internet right now saying, well, the mortality rate is this and the case fatality rate is that we can't estimate
either of those numbers right now at all. We can calculate a proportion of you know, total deaths from this disease so far, but because so okay, February twod at ten am, there are currently fourteen thousand, six hundred total cases that we know, about three hundred and forty eight of those have recovered, and three hundred and five of them have died thus far. Okay, so if you use those numbers, then it would look like a proportionate mortality
of around two percent. But this is not a fixed number. Fourteen thousand, two hundred of those fourteen thousand, six hundred are still sick, and we don't know how severe their illness is going to be and whether they're going to end up in the recover group or the death group. And there are thousands more tests that haven't been run, so we really don't know at all what the case fatality rate is going to be at this point, makes sense, yeah,
but otherwise this likely operates. It seems similarly to SARS. So it's estimated that the incubation period is likely no more than fourteen days. That's like the max that we've seen in both SARS and MERS. So if you're two weeks out from being say next to someone with this novel coronavirus, and you haven't gotten sick, you're probably not
gonna get sick. And then there's a lot of other questions about like when exactly are you infectious, how many asymptomatic or subclinical infections might there be, and at this point it's looking like it's more likely than with SARS that there might be kind of low level illness rather than only serious severe cases.
Right, which might be part of the reason and why the number of infected has surpassed SARS already.
Exactly right, Yeah, But we don't have a ton of answers, and so later in this episode we'll talk more about what we know about this outbreak overall and what's being done about this outbreak with some experts on the topic, people who know a lot more than we do. Yes, But first, Aaron, can you help us to understand where these coronaviruses came from and how we got through the stars and MRS outbreaks and kind of the lay of the land.
I think I can help out with that a little bit. Let's take a quick break first. All right, are you ready for this?
Oh?
I'm so ready. It's a big one, okay, And there's a ton of info here, so I try to organize it into discrete units just like you did. So I'm going to start with talking about the ecology and origins of coronaviruses in general, and then I'm going to focus on the two thousand and two to two thousand and three SARS epidemic, and then I'll talk a little bit about MRS. And finally we'll go into what's done on everyone's mind, which is the twenty nineteen novel Coronavirus.
Awesome, all right.
Let's go As you mentioned Aaron, SARS and MRS and this twenty nineteen novel. Coronavirus are all types of coronaviruses, and as a subfamily, they're pretty diverse. So, like you said, they can be found all over the world different animal species, in wildlife, in domestic animals, and humans, and they can
cause different degrees of illness in all these animals. It's difficult to know exactly how long coronaviruses have been infecting humans, but it's likely that it goes way back, particularly for those mild endemic strains. And it's also possible, of course, that there have been historical epidemics of more deadly coronaviruses
like SARS and MRS and so on. But the first one that we are that we were aware of is the one from the SARS outbreak two thousand and two to two thousand and three, and then MRS popped up in twenty twelve, and then finally this one in twenty nineteen. The common thread among these more virulent or deadly coronaviruses is that they all seem to have their origins in bats. So with SARS CoV it was likely a spillover event from bats to civets to humans, and with Murrs covy,
the in between animals were camels. We're not exactly sure yet how the twenty nineteen novel coronavirus spilled over into humans, but according to two papers, one of which I want to point out is not pure reviewed. It's just a draft of an early paper. Bats have been implicated as the source as well. Makes sense SARS mers twenty nineteen novel coronavirus. These viruses are novel to humans, but the
way that the outbreaks occurred is not. And before I get into the nitty gritty on each of these coronavirus outbreaks, I wanted to talk more generally about emerging infectious diseases. Yeah because yeah, because these coronavirus outbreaks won't be the last. And if we want to be able to control or predict these spillover events, we have to understand the factors driving them. The incidence of emerging infectious disease events has risen significantly over time, and the majority of these have
their origins in wildlife. And the term emerging infectious disease can also be used to describe something that has evolved, like in antibiotic resistance strained bacteria, or something that's been with humans for a long time but has recently increased in incidents like lime disease, but it also can mean pathogens that are branded to humans and with this last category, the so called emerging disease hotspots, so the places around the globe where spillover events are most likely to occur
based on what we've already seen, these tend to be concentrated in the tropics, so like in low latitude areas and subtropics, that's also happens to be where animal and pathogen diversity is high, and also in resource limited countries,
particularly those with high population densities. As our human population grows, as we continue to build and spread into natural areas as urbanization increases, as the climate changes, humans and domestic animals become more likely to interact with wild life and with pathogens from wildlife, and we've seen this time after time with Ebola, with Marbourg, with hendra, with Nepa, with
bird flu, and with many more. Detection or surveillance of novel pathogens in these areas is challenging, mostly because the
funds just aren't there, both nationally and internationally. And if we want to reduce the likelihood of another outbreak like this, or be better at controlling it from the start, we need to channel more resources into early detection and surveillance both in humans and wildlife, conservation of natural areas, and especially interdisciplinary collaboration like we see in a one health approach with ecologists, epidemiologist, physicians, et cetera all working together
get it arin. There should also be a push towards the free and open exchange of information, which is actually something great that I've noticed with this twenty nineteen novel coronavirus. So there are several scientific journals that are saying, we're putting all of these articles, We're taking these from behind the paywall, We're making them free to the public, open access,
publish early with like you know. Note that it was a draft or whatever, But there are still so many journals and journal articles that are behind a paywall, and this current outbreak of twenty nineteen novel Coronavirus. It's probably not going to be the thing to wipe out the human race, but the next one could be unless we make certain changes and we work really hard on the prevention and surveillance aspect of this. Okay, now, are you
all scared? Stars. The earliest signs of the SARS epidemic began in November two thousand and two in Guangdong Province in China. In Guangdong Province, as well as many other places throughout the country, open air markets and restaurants featured animals of all different species, often held in tiny enclosures, with their poop and breath and blood all mingling constantly.
Poop and breath yea.
There were many restaurants that offered any part of any species you could possibly want, and to ensure that the meat was fresh, the animals on the menu were often held in cages in alleys behind the restaurant. It was at these restaurants and markets that the first cases of SARS would emerge. On November sixteenth, two thousand and two, an official on the village committee was admitted to a hospital in Foshan, Guangdong Province, complaining of respiratory symptoms. His
family also came down with the illness. Over the course of the next month, case numbers of this mysterious atypical pneumonia steadily rose. By December twenty fifth, two thousand and two, thirty five people were infected and eight had died. And this is important to note it was a retrospective count for they but deaths were apparent. And so with these number of deaths from a mysterious respiratory ailment, some public health officials were growing suspicious and a little bit concerned.
Rumors started to circulate of an influenza epidemic, possibly avian influenza, and since the outbreak of avian influenza in Hong Kong in nineteen ninety seven, there was constant vigilance for the virus because it is extremely deadly and if person a person transmission was established that could be a real problem.
But other people doubted that it was avian influenza. This was, after all, the winter season when it seemed like everyone had a respiratory complaint of one kind or another, and rumors circulated every year about a mysterious hemorrhagic fever or a wild skin disease. These rumors were different though. For one these rumors all focused on the respiratory ailment and were pretty consistent, at least as far as rumors go. Cloudy chest exs rays, burning fevers, and high prevalence owning
medical personnel. The first official public statement about the SARS epidemic was released on January third, two thousand and three, a little over a month since the beginning of the outbreak. At this point, there were forty eight people infected and nine dead another retrospective count. This statement was published on the front page of the Heywan Daily. It read, quote, there is no epidemic in Haywan. There is no need
for people to panic. Regarding the rumor of ongoing epidemic in the city, Health department officials announced at one thirty am this morning, there is no epidemic in Haywan. The official pointed out that people don't need to panic and there is no need to buy preventative drugs end quote. Despite this incredibly reassuring statement, people panicked. They rushed to the pharmacy, buying all the accedo, minifin and antibiotics that
they could get their hands on. Because antibiotics are available over the counter without a prescription.
There and they're very useful viruses.
Not they're They're not useful at all.
They are not, they're not.
Public health officials were dispatched to the Hewan Number one Hospital to conduct an investigation into the mysterious pneumonia. Some suspected a species of chlamydia, which can cause pneumonia, but the infection didn't respond to broad spectrum antibiotics. Others thought maybe it was caused by a virus, possibly influenza, or possibly a virus not yet described. They also interviewed patients
and medical staff about their experiences. Disturbingly, they found that several patients had been to multiple hospitals, moving either by their own choice or being transferred. Oh yeah. By the end of January, rumors were soon swirling yet again, this time in Jangshan about the atypical pneumonia, which was now circulating in multiple hospitals in the city, as well as popping up outside of hospitals. By this time, it had earned the nickname breathtaker or breath stalker, which is where
we got our quarantine name. And whereas in Hewuan the disease was largely confined to one hospital. What was going on in Jiangshan appeared to be the first community outbreak of the mysterious disease, and it would later be determined that the first known super spreader of SARS, nicknamed the Poison King, was transferred from Jiangshan, where he had infected six medical personnel, to Guangzhou, where he would continue to infect people. And these super spreaders, it's no fault of
their own. People didn't know how to control the infection at this point or how infectious it was, but these super spreaders would be a hallmark of the SARS outbreak where a lot of the infections originated from one source like that. Okay, So by late January, medical officials were pretty certain that it was caused by an extremely infectious
virus transmitted through respiratory droplets. But getting that information out there was a different story, because it was standard practice among the Chinese government to keep this information top secret and classified, to not share it among anyone less than the top most ranking public health officials, not the public,
and certainly not to the outside world. So the rest of the world finally caught wind of a mysterious and deadly outbreak in China on February tenth, two thousand and three, at which point an estimated three hundred and ninety three people were infected and forty had died retrospective count somebody posted a report on ProMED ProMED all right, you ready quote there's like also there's this is like a quote within a quote, So just keep that in mind as
I'm trying to say it. Okay, this morning I received this email and then searched your archives and found nothing that pertained to it. Does anyone know about this problem? And then here's the email another quote, have you heard of an epidemic in Guangzhao? An acquaintance of mind from a teacher's chat room lives there and reports that the hospitals have been closed and people are dying and double quotes.
So around this time, the WHO got an email describing panic in Guangdong as the death toll from a mysterious pneumonia was climbing, but official word from the Chinese government
was still lacking. But once other countries started reporting on this disease, speculating with what little information they had, panic and anxieties set in anyway, and the Chinese government was forced to hold a press conference on the disease in Guangdong, and this press conference, held on February eleventh, which was one day after the ProMED announcement, was full of assurances
that this disease wasn't anything to be concerned about. They said there were only three hundred and five people infected and it was already under control. Meanwhile, in Hong Kong, a doctor from Guangzhou arrived at a hotel where he was staying for a wedding. This would be the next super spreader. He started to feel worse and worse and eventually sought medical care, but it was too late to
stop the spread of the virus. Also at this hotel was a woman from Toronto, a Chinese American businessman, and a Hong Kong local who went to the hotel to visit a friend. All of these left the hotel to continue on their travels or to return home, unknowingly bringing with them this hitchhiking virus. And this marked the start the real start of the global spread of the virus. Hong Kong, Toronto, Hanoi, Singapore, Beijing, These would be the
next hotspots of infection. On February twenty eight, two thousand and three, parasitologist Carlo Urbani, based in Vietnam, alerted the WHO about a highly contagious, atypical pneumonia after treating the Chinese American businessman who had stayed in that Hot Zone hotel in Hong Kong and several healthcare workers who had also come down with this pneumonia. After treating this person
back in Toronto, a similar scene was unfolding. So the woman who was infected in Hong Kong died in a hospital back in Toronto, and five of her family members were found to be infected as well. On March fifteenth, the WHO was notified of a possible SARS infected doctor traveling from New York back home to Singapore with a
stopover in Frankfurt. Mid flight, the doctor, his wife, and his mother in law were all cordoned off and then as soon as the plane landed in Frankfurt, they were placed in isolation.
That's one of the few moments that I really do remember from the SARS outbreak.
When it was like there's a person traveling in.
The yeah, and like on the plane and then they like quarantined them when they landed in Germany. Like I don't know why that's one of the moments. I wasn't that into disease at the time. I was in high school, but I remember that.
You should read his account. It's really interesting because he talks about the depression of isolation and how much insight it gave him as a physician to know what his patients had been going through. So this doctor, his wife, and his mother in law, all three of them developed SARS. I don't know if they infected anyone else, actually I don't remember, but regardless, these signs of a global spread or potential global spread prompted the WHO to declare a
travel advisory and to come up with a name. And as we said, locations were out, but acronyms can be catchy, so someone suggested SARS, and it's stuck. But what no one realized at the time was that SARS was very similar to what China called Hong Kong Special Administrative Region sar OH. In a way, it was it placed a lot of stigma on Hong Kong as like who had already experienced stigma about the Avian influenza outbreak in nineteen ninety seven and subsequent outbreaks, and then it sort of
further stigmatized Hong Kong, Okay. At the hospitals where the people with atypical pneumonia were being treated, the pattern that emerged was that healthcare workers were becoming infected by the dozens. There weren't enough beds to put all of the sick people, and there were too few people left to help care
for them, so hospitals were beginning to crash. Some emergency hospitals were being built, and one practice that developed was to form dirty teams, which were composed of medical staff that had volunteered to treat the infected people, and they would live at the hospital in isolation, and those who were not on the dirty team would not be permitted to go near the patients, and so this would reduce the number of medical staff that was potentially exposed. And
filling out the dirty team was never a problem. More people volunteered than there were places. Wow. Always yeah and the Star's epidemic, like this coronavirus epidemic and other epidemics, is filled with these stories of selfless people, especially healthcare workers, many of whom lost their lives to the illness. And one of these was the parasitologists that I mentioned earlier.
Carlo Orbani, who just before he died, asked to have his lung tissue sent to the CDC so they could use it for research.
That's who in the movie Contagion. That's who Kate Win's it's character is based off of.
I didn't realize that. That's cool.
Yep.
Wow. On March twenty first, researchers at Hong Kong University announced they had found that the pathogen causing this atypical pneumonia was a coronavirus, beating the CDC by a couple
of days. And up to this point, a coronavirus, as we have said, had never been known to cause such severe disease, and it was kind of low on the list of potential agents because of that, right, and also there was a couple cases of H five N one avian influenza that had shown up in Hong Kong, and so it was kind of thought, maybe this is just a mutated strain and for some reason, we're not detecting
it in these samples, and so on. Anyway, on March twenty first, there it was coronavirus, and that allowed people to test whether people were infected or not, which was a great help in terms of understanding the extent of
the epidemic. At this time, though, the Chinese government was still refusing to give up any information on the disease holding firm with its February eleventh totals of three hundred and five people sick, the real numbers as of March eighteenth, two thousand and three, another retrospective count were around fourteen hundred infected and one hundred and thirty seven dead. Wow. Those are global totals, okay, and those numbers would continue to climb as the nature of transmission changed a bit.
Earlier in the epidemic, transmission mostly seemed to be happening within hospitals, which is why there was such a high proportion of those infected being healthcare workers. But then there was a bit of a shift to community outbreaks, notably in Hong Kong. At the end of March, several people showed up to the Prince of Wales Hospital in Hong Kong with symptoms of stars. But they had no obvious connection to or contact with other infected people. So what
was making them sick? Turns out they all happened to be residents of a housing complex called Amoy Gardens. Pretty soon After this discovery, the housing complex was put under strict isolation, no one in, no one out, and this went on for weeks. But what if that wasn't enough? They had to find out how this had spread in the housing complex before it started doing the same in other parts of the city. Elevators, Eh, maybe, but air and water were both tested and found to be clean.
Rats may have contributed, but they alone couldn't account for the infection pattern that had been observed. And around this time researchers realized that the virus could be spread in fecal matter from infected people, and so their new hypothesis became that fecal matter containing viruses was being aerosolized. Every time a toilet was flushed. The contaminated droplets were spread to other apartments via a dried up U trap, which is that thing under the sink, and so when they're
standing water, that water acts as a barrier. But a lot of the U traps had dried up, and so it was effectively spraying poopy virus particles. Dude, Yeah, And it is like it's important to note that that is still a little bit debated whether it was that or the rats or some combination of multiple things, but regardless, it was like a sequence of really unfortunate events. The
isolation seemed to work though of a moi gardens. Those cases there seemed to mark the peak of the epidemic in Hong Kong, and by April it was largely over there. Part of this was because in crease precautions at hospitals in terms of personal protective equipment, the formation of these dirty teams. Part of it was because contact tracing an esar's database were proving effective at identifying potentially exposed people and isolating them. And part was that community outbreaks died
out as people changed their daily routine. Hong Kong became a virtual ghost town during the epidemic, as people who could leave did so and others stockpiled food and dared not go outside. Okay April, moving on to April.
Okay April first, two thousand and three and estimated twenty three hundred people infected, two hundred and fifty five dead globally.
Globally Okay.
Even though the epidemic in Hong Kong seemed to be waning, it spread in other places. Was a concern to the who who was still getting the same numbers from government officials in China on changed for about two months, so the WHO resorted to making surprise visits to hospitals in Beijing,
where the official numbers were twelve infected, three dead. At at least one of these hospitals, minutes before the WHO were due to arrive, a fleet of ambulances pulled up and the hospital director ordered all thirty one stars infected healthcare workers to get into the ambulances, where they were driven around until the WHO left. The WHO showed up to the hospital to the promising site of an outbreak
nearly over. Regardless, they still amended their estimates of those infected in Beijing to like one to two hundred people. In reality, it was much higher than that. And I want to note that among healthcare workers and among people in the community, there was ample communication. People were trying to get the word from one hospital to another, from one city to another, to get some sort of idea of the scope of the outbreak, how to protect your self,
what was being done, et cetera. But communicating that info to press outside of China could have serious repercussions because it was sharing. It would be the sharing of state secrets. What was needed was a whistleblower, and what we got
was a whistleblower. And this whistleblower was named doctor Jiang Yan Yung, and Jiang, who had treated many of the students injured in the Tanneman Square massacre, became aware of the extent of the SARS crisis in Beijing when he called a hospital to check on a friend of his who had lung cancer, and the doctors that he had talked to, who were respiratory specialists, sounded panicked as they described how at least sixty people were infected with SARS,
many of them healthcare workers, and that this was happening in hospitals all over the city. Remember the official numbers were still twelve total infected in Beijing at this point.
Oh yeah.
Jiong did a bit more calling around and made tallies of the number of estimated SARS cases in different hospitals across Beijing, and he sent those numbers in a note to a couple of Chinese TV stations, But unfortunately his note was ignored, but it was eventually picked up by
Time magazine, which made it into international news. That there was an epidemic could no longer be denied, and on April sixteenth, an official announcement was made by the Chinese government saying that the tsar's situation is quote extremely grave. The numbers were revised from twelve to three hundred and thirty nine infected in Beijing, with hundreds more suspected. And it wasn't just three hundred and five people infected in all of China, which is the number that the government
had been sticking to since early February. It was over twenty two hundred, wow, with again many more suspected. And then the government did a remarkable thing. They canceled the week long Spring holiday and admitted that they were wrong. After the announcement, the number of cases went up tremendously and continued to grow. But was that because people now felt they could report accurate numbers. Was the epidemic actually growing?
But with this sudden shift to finally acknowledging that SARS was a big freaking deal, the propaganda around it changed. There was now twenty four hour coverage of the epidemic, whereas previously there had been almost none in China specifically. And then, whereas before sharing information about SARS meant betraying state secrets, the government now threatened the death penalty to anyone spreading misinformation or hiding aspects of infection.
Ooh yes, oh, swing one pendulum to the other. Yes.
The Chinese Ministry of Health finally put into place some preventative measures, foremost among them being thermal scanning for fevers. So these scanners were put into place at train stations, bank's office buildings, everywhere, and if you were found to have a fever, you would be rushed off in an ambulance and placed under quarantine for up to twenty one days.
Wow.
And even though this method was perhaps crude, it was probably pretty effective because a person was found to be most infectious, as you mentioned, between ten and twenty one days after infection, and during that period they would almost certainly have a fever. This quality of stars made it
easier to control, as we've talked about. And the authoritarian aspect of China was a double edged sword because on one hand it restricted the flow of information that would end up fueling the outbreak, but on the other hand, once the epidemic had been acknowledged, it could mobilize people and put into effect practices some that are questionable in terms of civil liberties, that might have been more delay in a more democratic society.
This is where public health becomes difficult, man.
This is where public health becomes difficult because these are civil liberties that are being trampled on. But that's why I say, you know, it's been called this double edged sword. All Right, We're almost done with the SARS outbreak. Okay. Throughout May and into June, the epidemic began to wind down as Vietnam, Singapore, Hong Kong, and Beijing are all declared free of SARS. First case was in November. Now it's May.
Okay, it's like half a year. Okay.
Yeah.
In July, Toronto and Taiwan see no new cases, and it's been announced by the WHO that SARS has been contained worldwide.
Awesome.
The final tally of infected and dead is eight ninety eight people infected, seven hundred and seventy four people dead. The economic costs of an outbreak like stars are extreme. People lost jobs, personal bankruptcies went through the roof. Tourism and travel revenue fell tremendously. The economies crashed in many of the affected areas. But I think what is often
not as highly considered is the personal impact. Many people lost their lives, and those lucky enough to survive the infection often experience long term health consequences, and many also experienced PTSD or depression and were highly stigmatized for a
period after. So the cost of an epidemic like this are far ranging, and some costs are more easily quantified than others, and I think that's important to keep in mind as we talk about the twenty nineteen novel coronavirus outbreak, and as we'll get into also a little bit of the issue of stigma and xenophobia that are surrounding things like this, and and how travel bans restricting people from entering certain countries does not seem to be effective and
is actually a way of disguising xenophobia and racism.
Yeah, we can. We can look back at times when we've instituted travel bands in past outbreaks and see that they in general cause a lot more harm than good. So I think that's really important to keep in mind, considering that they've already been put in place supposedly during this outbreak.
Yep, So okay, let's move on to Merz. What all right? This is going to be really fast, I.
Promise, cool, cool, cool, cool, cool all right.
So MRS most cases have an association with dromedary camels. An analysis of past samples show that the virus may have been circulating in camels at least since the early nineteen eighties, which is thirty years before the first known human case. And this also suggests a long history association
between camels and the virus. And I also want to note though that MURRS related viruses have been found in bat species on five continents, so it suggested, Yeah, there are like clusters of you know, MURZ related coronaviruses, SARS related coronaviruses that are found in bat populations or animal populations that don't have the ability to infect humans or don't appear to. But it does show that this is a very diverse and wide ranging group of viruses.
Yeah, yeah, yeah, Okay.
So Murr's covey was first isolated in June twenty twelve from a sixty year old man from Saudi Arabia who died of pneumonia and renal failure. And as I mentioned earlier, this wasn't the first case of MERS. So retrospective testing show that there was a cluster of cases in a family in Jordan a few months earlier to this, with
likely human to human transmission occurring. Since then, there have been a handful of murr's outbreaks as large as SARS or as the twenty nineteen coronavirus is turning out to be. Most of these outbreaks or clusters seem to be regional, with limited spread outside of the hospital setting, and with most infected people being close contexts of the index case.
Since its first appearance in twenty twelve, it has caused outbreaks in Saudi Arabia, the United Arab Emirates, South Korea, and many many other countries have had isolated cases or very small outbreaks clusters. Some outbreaks have been larger than others, and as of December twenty ninth, twenty nineteen, there have been two four hundred and ninety nine lab diagnosed cases and eight hundred and sixty one deaths, and eighty four
percent of these cases were reported from Saudi Arabia. Yep okay novel coronavirus twenty nineteen novel coronavirus.
This is that everyone had to wait an hour and a half to get to this point.
We're sorry, not sorry.
These are important things to understand the context of this outbreak, absolutely I agree.
I mean, I think that there's a really important lessons to be learned from SARS in particular, but just from the way that these outbreaks occur and how they progress, and you know, we learn something new every single time, so as I as I you know, hammered on over and over again in the SARS history, the Chinese government seemed very reticent in keeping the rest of the world updated on how the outbreak was progressing, and that does not seem to be the case so far with the
twenty nineteen novel Coronavirus, and I think that's a really important thing to consider. There's been a huge push towards the free and open exchange of information, as we mentioned, with these early articles being published in certain journals. The sequence of the virus has already been published like this is pretty incredible and very encouraging.
I think we are getting information so incredibly rapidly in this outbreak, more than we ever could have seen in the past, which is incredible. But I think also in some ways people are now freaking out about it because there's a lot of triple exclamation mark all caps going on that maybe isn't always valid, and so I think trying to understand this outbreak what's really going on in context, is really important.
Yes, absolutely, so what is going on? Yeah, Well, in December twenty nineteen, a bunch of people became sick with atypical pneumonia after visiting the Wuhan Juanan seafood wholesale market, which also sells non aquatic animals such as birds and rabbits. This cluster of twenty seven pneumonia cases, seven of them severe, was reported by the Wuhan Municipal Health Commission on December
thirty first, twenty nineteen. On January ninth, it was an that a novel beta coronavirus, which is just a subtype of coronavirus.
That's the same subtype as SARS and mers.
Yes. The next day, January tenth, the genome sequence of the virus was announced was published. This is incredible.
We're talking in less than like two weeks.
Yes, first cases, It's incredible. Yeah. So genomic analysis suggests that the virus likely originated from a bat, as I mentioned before, and then maybe jumped into an animal that was at that market. This is yet to be determined. I'm sure that in the upcoming months more will be discovered about the origins and the exact nature of that initial spillover event. The numbers of infected and dead have
continued to grow since that first cluster was announced. So Aaron, how about we check in on how the current epidemic is progressing.
Let's would you want to take a break first?
Let's take a break, all right?
Erin. It is ten fifty one am now on February TEWOD twenty twenty.
This is a long episode.
We're sorry, it's fine. Listen. I am on the Johns Hopkins map that they've created. We'll put a link to this on our website and in the show notes. That is updating very rapidly with confirmed cases, so as of right now, this will change by the time you listen. There have been fourteen thousand, six hundred and twenty eight confirmed cases of novel coronavirus. The vast majority of these fourteen thousand, four hundred and fifty one have been in mainland China. The rest have been in a number of
countries across the globe. There have been three hundred and five total deaths confirmed from this novel coronavirus, only one of which has taken place outside of China, and that was in the Philippines. There have been three hundred and forty eight people that are confirmed to have recovered from this infection thus far.
Cool. Cool, cool.
So that's the details that we have. That's about it, Aaron. There's a lot of questions that remain right and like we've hopefully informed you all, we are not experts on this topic. So to give you guys a better sense of what is being done, what can be done, and kind of what the differences are that we've seen so
far between stars and mehrs and this novel coronavirus. We had the fortune of interviewing four people who are much better experienced in outbreaks and infectious disease and coronaviruses than we are. So let's talk to them about what's going on, shall we.
Let's do that.
Hello, my name is de Niche Meta. I am an infectious disease physician at Emory University. I specialize in infectious disease care of oncology so cancer patients and solid organ transplant patients. And I am also a member of the Emory Serious Communical Diseases Unit, which is our biocontainment unit at Emory University Hospital.
My name is Colin Kraft. I'm an infectious disease physician at Emory University Hospital. I'm also trained in medical microbiology, and so I sort of enjoy my role in bridging those two worlds between diagnostics and also seeing patients. I love being on both sides of that of the computer screen, if you will. I've been at Emory Hospital since twenty ten.
So my name is Carlos del Rio.
I am a professor of Medicine and Global Health a federal university. I have been involved in infectial disease for many, many years. Say it's almost finished. My fellowship in nineteen eighty eight.
Eighty nine, so I've been doing this for thirty plus years.
Most of my work is around at HIV, but I've been involved also in effectious ease and generally and particularly in global aspects of effect disease. I was very involved with Mexico during the two thousand and nine a swine flu pandemic, and I worked closely with CDC and with
Mexico in working on that outbreak and in controlling that outbreak. Also, I am a COPI of the recently funded Emory Vaccine Treatment and Evaluation unit, so I work a lot also in vaccinology and in the user vaccines to prevent infection diseases.
My name is Marshall Lyon. I am an MD, and I am an infectious disease physician at Emory University Hospital in Atlanta, Georgia. My day job, if there is such a thing, is the Director of Transplant Infectious Diseases, and that is the bulk of my clinical care is taking care of patients who have had a transplant or are being considered for transplant and get an infection. So we deal a lot with viruses, both latent viruses and community
acquired viruses. One of my other roles is as a physician in Emory's Serious Communicable Diseases in it as one of the high level biocontainment units.
In the States.
When novel coronavirus broken wu on and started to become more of an issue, you know, we started to pay attention and started thinking that potentially a case might come our way. And so we've certainly been paying attention to the outbreak of it's unfolded in China and what and the measures that the Public Health US is putting in place to try to keep the public safe.
So we'd love for you to talk about this new coronavirus that's been making headlines. This isn't the first time that we've seen a coronavirus causing a disease outbreak, but this virus is new, So can you tell us a little bit about this twenty nineteen En Covey.
So, the first sort of novel coronavirus we saw was STARS, and then more recently we saw the Middle Eastern respiratory syndrome coronavirus or otherwise called mrs kV. And we've learned a lot a lot from those novel viruses that have developed, which I think have us a little bit better prepared now for what we're seeing, and that's this novel twenty nineteen coronavirus.
So this is actually an interesting outbreak because when it first started, the majority of patients seem to have had contact with this wet market or the seafood market in Wulan, and so it looked like it was more a point source outbreak or a zoonautic outbreak. And so when we think of those, we think that people who get sick all had a common exposure and that if you weren't exposed to whatever that agent is or that location, in this case the market, then you probably didn't have risk
of getting infected or getting disease. It was only later when it appeared so that when the second wave of facial and began to come in, but it became evident that there was now person to person transmission of what we now know is novel coronavirus twenty nineteen. And so now it starts to take the epidemic or the outbreak takes on a different characteristic where you have to think about how do we limit contact with sick individuals?
Right? Quick question about viral or about pneumonia caused by viruses, What is the mechanism by which that occurs? Why does that look different than one caused by bacteria.
One of the things we should think about is when viruses caused pneumonia, that is when we become fearful sort of as clinicians. And so that's a lot of what happened.
We think in nineteen eighteen is that we believe that some of those deaths that were so dramatic probably came from influenza virus pneumonia, which I think is a lot different than how we think about pneumonia's today, which are typically bacterial, and so I think for me when this started, when it was kind of announced in December thirty first, our first question is how frequently does this cause a viral pneumonia versus you know, kind of a bronchitis or
even an upper respiratory tract, which is what we usually think about coronaviruses.
The things that really worry me about a viral pneumonia as opposed to a typical bacterial pneumonia is that when we have a bacterial pneumonia, we generally, though not universally,
see that pneumonia in one region of the lung. One of the things that often concerns me about patients with a viral pneumonia, it's usually affecting multiple regions of the lung, potentially all of the regions of the lung, and in that situation, there's so much inflammation produced that the ability for the lungs to extract oxygen out of the air gets minimized very rapidly, and you see patients develop something we call acute respiratory distress syndrome where they can not
exchange oxygen and require a lot of ventillary and oxygen support to keep all the systems of the body running, and also in that inflammatory condition that you can develop a bacterial pneumonia on top of the viral pneumonia's inflammation, and that can compound the issue and further cause not only damage to the lung, but further developed problems in
oxygenating the body. And finally, the other concerning issue that goes on with viral pneumonias is the fact that we have very limited therapies, unlike bacterial pneumonias and antibiotics to address these. There are some anti virals that are out there, but most of them do not have any ability to treat the viral pneumonias that we are seeing nowadays.
I know that it's sort of early stages in this outbreak, and there's still a lot that we don't know about this virus and how it behaves. Particularly I was trying to get a handle on the infectious period and how that overlaps with a period during which symptoms are apparent, and so I know that that's sort of now more in the gray zone. But correct me if I'm wrong about that. But based on how we've seen this virus spread so far, and what also we have seen in
past coronavirus outbreaks. What do you think we might be able to expect in the next few weeks or months as this outbreak progresses.
Yeah, so you're right, we are in a gray zone about our understanding of this, but I think there are a few things that we do know. So the incubation period seems to be somewhere around five days as sort of the median or the mode of the incubation period, and there is variation probably anywhere from two to the longest being fourteen days. We're pretty comfortable, bullet fourteen days is kind of the outside limit. And what we are starting to learn from what's happening in China is there
may be an infectious prodrum before someone gets sick. And so a prodram is a period of time where someone can actually transmit the virus to somebody else, but they don't have any symptoms of illness and they don't know that they're about to get sick. They feel normal, and so unfortunately, what that means is identifying people once they're
sick won't absolutely terminate this epidemic. And this is slightly different than SARS because SARS was really transmitted by sick individuals, and that most of the outbreaks could all be traced back to someone who had developed illness but was not in medical isolation.
So, in terms of the looking at this outbreak so far, how does it seem that this virus might differ from say, the Stars coronavirus or the Mers coronavirus, both in terms of the disease that it seems to cause and also how the outbreak is actually progressing.
So I'm currently at an ASM Biothreats meeting where I got to hear Tony Fauci this morning from NIAID talk about this virus, and I think one of the things that he really talked about that we're noticing is the total number of cases from Stars. You know, we've almost succeeded and we're only like, you know, a couple of weeks in. So I think the main question that remains to be answered is really how severe is this?
Yeah, I believe what we're seeing with this current novel Corona outbreak is quite concerning as far as the tenor of infection and spread goes. Initially I thought it was similar to Sarus, which is quite concerning in itself, but the number of cases that we've just had in the past week alone and now exceeding the total number of cases of STARS that we had previously. Is concerning not only for China and the population there, but given them out of travel that occurs from China to China, the
ability for this virus to spread. The other concerning thing that I think is out there is lessons that we learned from STARS was that hospitals and healthcare systems clinics can sort of be incubators for the spread of these type of coronaviruses, and that's something that really was harkened by SARS, and we've learned a lot of lessons from that.
But I think still there's a lot of vulnerability in our healthcare systems or the virus to spread within healthcare systems and therefore create broader outbreaks that can spread throughout the community.
So as with SARS, it seems that there's a decent proportion of cases with this novel coronavirus that are healthcare workers who are likely exposed while treating someone who is infected. Does there seem to be any other pattern in the people who develop maybe severe disease or more negative outcomes.
So certainly, like with many respiratory viruses, you know, it seems that people were older or have other chronic illnesses are more likely to have severe disease and have worse outcome. So the first seventy some odd cases that were reported out of China, of the patients that died, I think the average age was seventy five years old, and so that it's a similar pattern to what we see with the viruses that we're familiar with.
Could you elaborate a bit on the first steps that are normally taken when an outbreak like this occurs and you think, okay, we might need to be prepared if somebody happens to be infected and comes to the US.
What US Public Health has done is first, for over a week now, they've been screening passengers who are coming in from China looking for anyone who might be ill or might have fever, so that if they are sick, they're can be identified quickly and then contact tracing could be done of everyone who was on the airplane with them. So early identification is one of the keys in terms of limiting then subsequent contact to that sick individual. So the other sort of measure that is then put in
place is social distancing. So if you have something that's passed from person to person, especially a coronavirus which uses the droplet method of transmission, if you can distance the infected individual more than two meters from anyone else, then in theory, they would not be passing that virus on
to someone else. And so if you cover your mouth, wear a mask, et cetera, all those things can sort of decrease the amount of drop of production that a sick individual will make and therefore reduce the amount of droplets that are in the environment which someone else could be exposed to. So those are sort of the early measures that the public health is using right now to try to prevent an outbreak in the United States.
The interconnectedness of everything and sort of this decreasing barrier between humans and wildlife has really seemed to be the pattern that's emerged behind all of these recent outbreaks of novel diseases. So what do you think in terms of prevention that can be done to prevent the spillover from these animal hosts to humans.
The first thing is we need to invest more more in global health security, and we haven't done enough in investing in global health security at the level we should And I quote and Dolly Parton when you said, you know, you have no idea how expensive it is to look this cheap. You know, if you think it's the cost of investing in global security is high, wait until you get the bill for what is this outbreak is going
to cost us? So non investing in global security is going to make you spend more money at the end of the day. With climate change, with connectivity like flights that we talked about, with growing population, all those things together are essentially a recipe for more and more outbreaks. They're not going to end, They're just going to be. The question I always have is what's next? Not will we have something?
In speaking more broadly, not just about the twenty nineteen coronavirus, but in any sort of novel outbreak or emerging infectious disease. What are some of the logistical issues in infection control, both maybe at a hospital level and then also with multiple countries working together.
Well, you know, I mean that's where who fits in, right, That's when you need to have international collaboration. You need to have international cooperation. An outbreak in China should be a concern to the US, to England, to know every other country in the world, so we all need to work together. We need to also get away from saying, oh, this is a problem of China. Let China deal with that. This is not our problem, because at the end of
the day, that's not true. So the nationalism has to disappear. Microbes are do not recognize borders, they travel without passports, and therefore we should get away from thinking about countries and think more about the globe.
So one of the I guess challenging things about an outbreak like this today is the role of media and social media and the rapid spread of information, which is sort of this double edged sort. What role do you see social media in particular playing in the spread of information during an outbreak such as this.
Well, I think it's important that all media, whether it's traditional media or social media, presents the facts that surrounds any sort of an outbreak. And I think that because social media and our global information age does allow us to get information so quickly it almost feels as if China is next door, when it's actually halfway around the world.
By the same token, then it also enables people like yourself who are putting together podcasts to reach the masses to put the truth out there and to help people see things in perspective. As of today, which is January thirtieth, China is reporting that they have around seven to eight thousand confirmed cases. This isn't a country of one point five billion people. That's a lot of people, and it still is a very tiny minority of their population, which
has so far been effective. In the United States, we've had five confirmed imported cases, and that's you know, again, in a country of three hundred and thirty million, is a very small n compared to the larger population. And so I think that social media should be trying to put forth the truth and to try to keep the perspective of things that are going on. But by the same token, I think that social media should continue to
examine this and look at it. And I think I'm not sure how big of a part social media played in this, or the fact that social media exists now where it didn't really exist to this extent in two thousand and three. I think that the Chinese government has actually been fairly transparent with this outbreak and with what they're doing as compared to the stars outbreak in two thousand and three. I think Social media has been good because to some extent has kept governments honest.
Some of the media has been great, some of the media not so much. I mean, I think that newspapers sell headlines, right, so talking about the end of the world and is going to kill us all is against people attention. But the reality is we tend to forget about the common things. I mean, for example, right now, CDC estimates that over success and people in the US have died of influence at this epidemic.
And yet we're more concerned about the coronavirus.
And we should be telling people, you know, pet your flu shot and wash your hands and your resptory etiquette because that's going to be more important. That's going to save you from influenza, but it's also probably going to help you with with preventing some other restory viruses.
So I think that the media needs.
To needs to inform, needs to communicate, and more importantly, I think the media needs to rely on reliable sources. I cringe a little bit when you know, meia to start scoring an expert in nutrition as an expert in the diseases. We need to we need to talk to people that know what they're talking about and there are plenty of experts out there.
While I was doing the research for this episode, I came across a bunch of articles that compared this current outbreak of the twenty nineteen coronavirus to things like the nineteen eighteen influenza pandemic and of course SARS, and in many ways, so kind of feels like a bit of a bullet dodged because the control measures that we used, contact tracing and quarantine, these things worked really well. What do you think that says about the current outbreak?
I really liked what you said about the bullet being dodged because I think if you think about us having the most population on Earth that has ever been of human population, some of that is really because we have learned how to do things to prevent ourselves from dying from infectious diseases. So in nineteen eighteen, I cannot only imagine it was so scary to think about you didn't have really anything, I mean, supportive care really was like nothing.
And so when you think about having mechanical ventilations and whole specialties of subspecialties of pulmonary critical care that are dedicated to super sick people with bad lungs. I just think we have made a lot of advancements. And what Anisha and I have said since even Bola virus five years ago and Stars and Mers is this rapid development of bringing in therapeutics into clinical use a lot sooner
than we've ever seen before. And that's because we're getting used to saying, you know, the longer we wait, the less information we have, the less knowledge we have. Even the fact that we've had the sequence of this virus so quickly, it's pretty it's pretty amazing, even from five years ago. And so I really like your dodging the bullet. But I think it's pretty cool to think about all the kind of advancements that we have even in the last decade, not not even since you know, one hundred years.
Ago, less of dodging the bullet and more building the shield.
I guess yeah, I agree.
I like that analogy of building the shield. And you know, one of the great lessons we learned from Stars and Colleen and I really witnessed this during the Bola outbreak was how important it was to keep unicate information about what's going on with patients, what's going on in the public health setting, what's going on immunologically and with the virus very rapidly to healthcare environments and scientists and public health officials around the world, and with this outbreak, we're
seeing exactly the same thing. As soon as there were reports coming up, the sort of the infectious disease community, the public health community, the emergency medicine community throughout the United States was coming together. We're having conference calls, we're having rapid communication, and importantly, our colleagues in China were putting out all this information about what they were seeing.
They put out immediately the sequence of the virus that people could work on diagnostic testing and learn more very rapidly, and I think those are the lessons that we've learned as a global public health community on how to really address these new challenges.
One of the questions that many of our listeners are very concerned with is basically how scared should we be of this? Which is a pretty big and loaded question. So could you maybe talk about something about this virus or this outbreak in particular that is quite concerning to you, and then maybe something that also is reassuring that maybe you know, this isn't the end of the world.
We hope, yes, so I'm pretty sure it's not the end of the world, but one never knows. I would say that that there's always this initial panic about something new, and without being glib, I want to say that this isn't like an alien invasion of something we've never seen. We have dealt with things that are similar, and so it falls within our paradigm to be able to figure out. You know, yes, it may be more severe, but we
understand how these things are transmitted. We also understand how to protect ourselves in terms of what.
Makes me nervous.
I think is the surface aspect of virus transit mission? And so what does that mean? It's kind of what I've already been saying. But if somebody coughs on like a seat that I now sit in, or a surface that I now touch because I'm getting, you know, like a fast food takeout or something, how long does it stay on that surface and how much of that has to be transmitted to me to make me really sick?
And maybe maybe I'll add something, but before I do, I just have to say doctor craft has really taught me to fear my cell phone and make sure I clean it all all the time.
It really like it literally has poot bugs on it. I don't let my children touch my phone, and I lends wipe clean it every day.
I know, I looked down at my cell phone and I was like, oh, dear, I just.
Like kicked it out of the way.
I was like, no, I you know, I every time I talk to doctor Craft, I make sure I don't have my cell phone in my hand. I think every reporter I've talked to in the past seventy two ours is the first question is should we panic? And my answer is there's no reason to panic. There are things
that are worrisome. The thing that I think is worrisome to me is how quickly it's spread and how quickly we found cases in other countries, which means that we really need to institute good controls and screenings to make sure that we don't have continuous spread. I think, just like any novel infection, early on, one of the greatest
fears is what we don't know about it. I think we will learn more about the virus in the coming weeks that will be reassuring to us, but there's still some that's unknown, and how it's transmitted, how severe the disease can get, and who's most susceptible for. But as my colleague doctor Craft mentioned, there are a lot of
things that are reassuring about this. I think, going back to their experience with SARS, what we learned from both the experience in China and our experience with our colleagues in Canada and here in the United States is that once we were able to identify the infection and the signs of the infection, we're actually able to do really good epidem and logic contact tracing and appropriately isolate people, put people who were at risk in appropriate monitoring, and
suddenly the cases started to get to go down very rapidly, and the morbidity and the mortality from SoRs started to go down rapidly. And so I think we have the tools in place to understand how to control infections like this, And it has worked with STARS, it has worked with mers CoV and preventing the spread around the world of mers CoV, and I think it will continue to work. Those lessons will work here with the novel coronavirus.
What scares me, I mean, I'm more scared about driving home this evening and getting killed in an accident that I'm about this virus. But honestly, so you know, I think we all need to put into perspective risk and realize what the risks are.
I think what concerns.
Me is that is that yes, this virus can can continue to is read and can reach places like for example, Africa and other places that are not going to be able to control it as quickly as as as China has.
Been able to.
And again it makes me worry about about the lack of support for international and global health security and the need that we need to have to talk to Congress and talk to others and say, hey, and we have to invest in global health security. We have support WHO and other agencies, and we really need to think about how to make global health security a priority for all of us, because the reality is right now that we're all worried about this, it's the right time to do that.
What do you think our listeners can do on an individual level to try to push that cause forward a bit more, having more investment in global or national health security.
I think you send an email or call it Environment Frontment and say, hey, you know, with this outbreak, I worried that we're not investing enough in global health security and we need to do that, I think we need to have the attention of the people that have the that are the funders, right.
That was so fantastic. Thank you again so much to doctor aniche Metta, doctor Colling Kraft, doctor Carlos Delria, and doctor Marshall Lyon. Those interviews were so wonderful and we really appreciate you taking the time to come and talk to us.
And a huge thank you to Sonia Bell from Emory University who hooked us up for these interviews. We never would have gotten to talk to such experts without you. Thank you so much.
Thank you, Sonya. Before we dive into sources and stuff like that, I feel like there's a couple things that we wanted to say.
Yeah, hugely important things.
One is influenza.
Yeah, okay, listen. Like doctor Kraft especially mentioned in her interview, the ways that we can protect ourselves against this novel coronavirus will also protect us against things that really you should be more concerned about than this novel coronavirus at this point, because you're far more likely to be infected with influenza than you are with this novel coronavirus, even in China, across the entire world. Let's talk about what a toll influenza has taken thus far.
Now, you're not just more likely to be infected, you're also more likely to be hospitalized or die from influenza than you are from the twenty nineteen novel coronavirus. Have you gotten your flu shot this year?
Have you be? Because thus far in the United States alone, it's estimated that there have been in this flu season between one hundred and eighty and three hundred thousand hospitalizations from influenza and upwards of ten thousand deaths do to influenza in the US alone. Just in these few weeks where we have seen fourteen thousand confirmed cases of novel coronavirus, there have been over forty thousand confirmed cases worldwide of influenza.
And that's just the confirmed cases. The vast majority of influenza cases are not reported.
Get your flu shot. If you haven't, protect yourself, protect others please. I think that one of the lessons that we can take away from this outbreak, as with past coronavirus outbreaks and other types of spillover events, is that these epidemics reveal these international wealth disparities o YAH, it can decide who will get the vaccines, who will get the treatments, Who has the financial support for control or
importantly prevention and emergency preparedness. Yeah, as several of our interviewees said, microbes don't know country boundaries, They don't acknowledge them, recognize them. These are not national concerns. This is a
call for international concern. An epidemic in one place is an epidemic globally with the interconnectedness that we have, and I think that, you know, some of the ugly sides of these epidemics are this, you know, pointing fingers and saying, oh, it's it's this country's problem, not mine.
And that's not effective. Right when we have something that's of international concern, what we need is international collaboration and working together. And I think what's great is that we have seen a lot of that in this novel Corona virus outbreak. We see people exchanging information and talking with each other in order to do our best to prevent this outbreak from getting worse.
Exactly, Okay, sources, sources, I have oodles of sources, but I want to shout out a few of them. A couple books that I read that focused on SARS. One is called twenty first Century Plague by Thomas Abraham. Another is called China Syndrome. The True Story of the twenty first centuries First Great Epidemic by Carl Tarol Greenfeld. That's where our first hand account was drawn from. And then
I have a few other articles. A couple I want to shout out are by Qui at All in twenty nineteen Origin and Evolution of Pathogenic Coronaviruses, and by Jones at All in two thousand and eight Global Trends of Emerging Infectious Diseases, and then also by Lee at All two thousand and five. Bats are natural reds of stars, like coronaviruses.
Excellent. I read a great chapter in the book Viral Infections of Humans all about coronaviruses in general, if you're interested in that. Two articles I loved, one was the Severe Acute Respiratory Syndrome in the New England Journal Medicine about SARS, and one called Middle East Respiratory Syndrome in the Lancet. And then if you'd like the most up to date information about the novel coronavirus, which I know
that's what you all are here for. Our experts recommended a few sources that we also have been relying upon. That is the World Health Organization Situation Report. They are updating this daily. Every single day there's a new situation report that's released, so you can get the most up to date information on the number of cases. Oh look, they just updated it. Let's see what it says. Yep, it's a little less up to date than the other up to date source, which is the Johns Hopkins website
of a app that's continuously updating. And finally, the CDC has a great sight on the novel coronavirus. If you're interested in specific things that you can do to help prevent yourself from getting infected, wash your hands and cover your mouth, and we'll post the links to all of these in the show notes and on our website.
Awesome. Thank you again so much to our wonderful, wonderful guests. We really appreciate it.
And thank you to Bloodmobile for providing the music for this episode in all of our episodes.
And thank you to you listeners for allowing us to keep making this podcast. It is our absolute favorite thing to do. And with that, wash, wash, wash your hands.
Our experts had something else to say about this don't panic.
Just wash your hands and wash your.
Cell phone, you filthy animals on um
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