Amid the growing number of cases of COVID-19 in Iran, South Korea, and Italy, VP and Team Lead of GLG’s Healthcare Content Team, Michael Weissman, spoke with Dr. Stephen Ostroff, who served as the Deputy Director of the CDC’s National Center for Infectious Diseases during the SARS outbreak and later served as Acting Commissioner of the FDA, to learn more about the state of COVID-19 and what we should be concerned about. The Q&A below, which took place on February 25, has been edited for length and clarity.
GLG: How serious is the situation in Iran, where the deputy health minister contracted COVID-19, and the broader Middle East?
Dr. Ostroff: The latest numbers that I’ve seen for Iran indicate there are 95 confirmed cases, with 34 of them occurring in the last 24 hours. The country has reported three further fatalities in the last 24 hours to raise their total to 15. The high fatality rate coupled with the number of cases seen in other countries among travelers from Iran indicate the extent of the outbreak is being significantly understated or under-detected in Iran. The situation is very concerning, especially as transmission is now appearing in other Middle East countries. I anticipate that the problem within Iran will continue to grow.
GLG: In Italy, the total is now 300 cases and 10 deaths. There have now been confirmed cases in Switzerland, Croatia, Austria, Spain, Germany, Finland, and Sweden. How should we view the situation in Western Europe?
Dr. Ostroff: Based on the strong interconnectedness of the European Union and how freely people move around, it’s inevitable that you would see the virus move around with them into different countries. The problem is that the cases that are being detected now are individuals that, because of the incubation period, were exposed two to 14 days earlier and already could have started chains of transmission in other locations.
On the plus side, Europe has a strong public health infrastructure, so they can bring a lot of resources to bear to try to contain the virus, especially with contact tracing and follow-up with individuals that may have been exposed, as was done in Germany with the one incident of the woman from China who traveled to the business meeting outside of Munich and transmitted the virus to others.
GLG: The WHO recently had a mission to China, and the leader of that mission said that they didn’t find evidence of many undetected mild cases. Can you help us understand what that means?
Dr. Ostroff: I find it hard to believe that you could have only cases that are severe enough to be diagnosed or be completely asymptomatic with nothing in between. It sort of defies logic to think that there isn’t a spectrum of illness ranging from asymptomatic infection all the way to severe and fatal disease.
The information that came out from the WHO suggested that the mortality rate in Wuhan in Hubei province among confirmed cases of coronavirus was 2.7% and that outside of Hubei and the rest of China, it was 0.7%. The question becomes, what’s the explanation for such a significant difference? The likeliest explanation – other than ascertainment bias, meaning cases aren’t being detected and counted in the same way in the two locations – is the difference in availability of healthcare.
The healthcare infrastructure in Hubei was completely overwhelmed by this event. They didn’t have sufficient resources to be able to care for a lot of these patients in healthcare facilities that meet any type of standard. They were basically just housing patients in a lot of places that wouldn’t be considered typical hospitals. In those circumstances, you shouldn’t be surprised that the outcomes aren’t going to be so good. The ability to provide quality care is considerably different if you’re in Shanghai and there’s only 300 to 400 cases versus if you’re in Wuhan and there’s 75,000 cases.
GLG: Is there any way to understand the overall progression of the disease?
Dr. Ostroff: The overall numbers still suggest that the mortality rate associated with this virus is somewhere between 1% to 2%, but if the virus starts spreading and causes large numbers of cases in many different parts of the world, that can translate to a lot of bad outcomes. It’s highly dependent upon where you get sick. I have little doubt that unless the situation totally gets out of hand, most individuals that become infected in Western Europe are going to get good healthcare, but the same isn’t true in Yemen or Syria. The physical infrastructure, healthcare personnel, and availability of other types of interventions are going to play a significant role in the mortality rate and what the severe outcomes of the disease are going to be. In certain parts of the world, you have people with poor nutritional status. There are many reasons there can be variable mortality in different parts of the world that have nothing to do with the virus.
GLG: South Korea has tested more than 30,000 individuals already, and plans to test the entirety of the religious sect – hundreds of thousands of people – where there was a large amount of community transmission. How can South Korea do all this testing?
Dr. Ostroff: I don’t know where South Korea is getting all those diagnostic tests. We also don’t know the quality of the test. Especially if they’re ramping up production of the test kits, we have to wonder how rigorous the quality control is for those tests and how many false results they may get. Even in the best of situations, it will take many days to run through 200,000 tests. Even if the test had good specificity and sensitivity, they’ll still be missing a fair number of cases and they’ll be inappropriately diagnosing some infections.
GLG: What’s the process in the United States for getting an approved test and being able to test widely for COVID-19 more specifically?
Dr. Ostroff: Given the problems with the CDC test and the fact that it didn’t initially perform like it was supposed to, CDC is now the choke point for laboratory testing in the United States. You need approval from the FDA to be able to distribute a test for use in other laboratories. In an emergency there is the option for the FDA commissioner to issue an Emergency Use Authorization. This allows a test that’s not been approved formally to be used without having to go through the hoops of getting informed consent from the individual to be tested.
Something’s going to have to give one way or the other. Any laboratory can essentially develop its own test and be the only one to use it. That is called a home brew. FDA has always used what’s referred to as enforcement discretion for laboratory-derived tests and my guess is that there are a number of advanced, academic medical centers that have already or are in the process of developing their own assay to be able to test people who show up in their institutions.
GLG: There have also been questions about the number of masks that are available. HHS Secretary Alex Azar told senators that the administration has 30 million stockpiled masks, but would need at least 300 million for healthcare workers if COVID-19 spread widely through the U.S. Is this a worrisome statistic for you?
GLG: It depends on what type of masks you’re talking about and what the setting is. There are the surgical masks, which you see people in China and other parts of the world wearing, and N95 masks, which have a much higher degree of filtration capability, and so are much more protective than surgical masks are.
If most of the transmission is droplet transmission, then surgical masks are likely to have some benefit. It’s dependent on how well you wear them, and you can’t wear them for very long for several reasons. Studies that were done during SARS suggested that they look like they were beneficial in healthcare settings. There was less information about how valuable they were in the general community.
But in circumstances where there’s concern about aerosol transmission possibilities, especially in healthcare settings, N95 respirators are more appropriate to use. The problem with N95 respirators is they must be fit tested. That’s not easy to do. In terms of the national stockpile, I don’t know what proportion of those are regular surgical masks versus N95.
Surgical masks are probably not as important from a public health perspective as some other control measures, such as social distancing measures and travel restrictions, which in China seem to have had a big impact on the spread of this virus.
GLG: Are there any updated statistics or studies about the incubation period? Are there any reasons to believe that the incubation period could be over two weeks?
Dr. Ostroff: They all still tend to settle on an average of five to six days, with a range of two to 14 days. There have been some reports of outliers who had longer incubation periods. That happens with virtually any outbreak. Even the incubation period that was used for Ebola was up to 21 days, even though there wasn’t good evidence there were many people that took that long to start manifesting symptoms. But the number of people that would likely have an incubation period that long is probably incredibly small and unlikely to cause outbreaks.
There have also been reports of some individuals, that even after they’ve recovered from illness, seem to continue to carry the virus. The question is whether they have an actual viable virus that could infect somebody else.
GLG: A member of CDC leadership said in an interview that Americans need to prepare for the likelihood of COVID-19 spreading to the U.S. Other members of the administration who aren’t healthcare officials have said it’s contained. How should we be thinking about these diverging messages?
GLG: It would be helpful if there was more diagnostic testing going on in the United States right now, so that you could identify if there were individuals from places other than China that were bringing the virus into the country. But based on what we’ve seen over the past few days, it seems inevitable that we’ll see problems get to North America. The only question is when that will occur and how much transmission and illness might result. Nobody can predict that right now.
GLG: Given how much the world is connected, how concerned should people be about flying to these major areas where we’ve seen outbreaks already?
Dr. Ostroff: That’s a difficult question to answer. Inevitably, at this time of year there are people sitting by airport gates or several rows around you on the plane that are coughing. It’s respiratory disease season. If it’s a flight that’s going or coming from an area that has significant coronavirus activity, your level of concern certainly goes up that someone may be infected with the coronavirus. You’d hope there would continue to be some screening mechanisms in place to keep people who look like they’re not well from getting on an airplane.
The overall risk in general is still quite small, but you must factor in how important your travel is. The CDC has recommended, just as they did with China, that U.S. citizens should not travel to South Korea unless essential. Several countries have taken similar actions now against Iran. I suspect that other countries will do the same things. The problem is that there’s only so many times that you can do that before there simply isn’t any travel, so it becomes a moot point because nobody is moving through these places anyway. These types of measures will possibly slow the spread of the virus, but at this point, unless you really want to significantly impact global travel, they will only slow it down. They will not stop it.
GLG: What’s the process to potentially get tested within the United States?
Dr. Ostroff: There’s two options. One of them is you let your healthcare provider know that you have symptoms and that you were in an area that appears to have community transmission of COVID-19, and you’re concerned that you may be infected. Don’t just go to an emergency room or your doctor’s office. It would be best to call ahead and let them know, so that they could take precautions in their facility to minimize the possibility that you will expose other people. If for some reason you don’t want to call your healthcare provider, call your local health department, give the same information, and let them arrange for specimens to be collected and tested if they think it’s appropriate to do so.
GLG: From your time back at CDC during SARS, are there any steps to take to watch out for ourselves and our own safety?
Dr. Ostroff: Well, number one, wash your hands. Two, use respiratory etiquette if you sneeze or cough. And three, watch around you for people who you think may be ill and try to minimize your direct contact with them. Those are the appropriate things to be doing at this point.
About Stephen Ostroff, MD:
Dr. Stephen Ostroff is currently employed at S Ostroff Consulting, since January 2019, where he holds the title of Public Health and Regulatory Consultant. He was previously Acting Commissioner, Food and Drug Administration. Dr. Ostroff was the Deputy Director of the National Center for Infectious Diseases during the SARS outbreak of 2002-2003.
About Michael Weissman:
Michael Weissman is VP and Team Lead of GLG’s Healthcare Content Team and has served in this role since 2018. He has worked at GLG for over 7 years, helping to manage and grow healthcare client relationships across GLG’s hedge fund, private equity, and equity research business. Michael has a BA in Physics from Brown University.
This article is adapted from the GLG Teleconference COVID-19 Transmission – Live Update. If you would like access to this teleconference or would like to speak with Dr. Ostroff, or any of our more than 700,000 experts, contact us.
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