Emma Ross
Hello, everyone. Thank you so much for joining us today. I’m Emma Ross and I’m a Senior Consulting Fellow at Chatham House, and I have with me today David Heymann, who’s one of our distinguished Fellows, but before we get started I just want to do a couple of housekeeping things. The one thing is this event is on the record, so if you’d like to tweet, please use the #CH, capital C-H, Events, and the other thing is please put your phones on silent for the duration of this. Okay, thank you. So, I’m delighted today to be here with David Heymann. If you’ve been following the news at all on this coronavirus outbreak over the last few months, you are likely to have heard David commenting on the latest developments. He is a world-leading outbreaks expert who, as Infectious Diseases Chief at the WHO, led the global effort that successfully stamped out SARS in 2003. With all the outbreaks that have occurred since then, it’s easy to forget what a significant achievement that really was. I certainly haven’t forgotten. I have very fond memories of the time I spent, as a fly on the wall at WHO headquarters, reporting for the Associated Press from behind the scenes of the SARS campaign that David masterminded, back in the olden days. So, it’s really extra fun for me to be able to grill him again today.
In 2004, just after that outbreak, a profile in the article – a profile article in The Lancet dubbed David ‘WHO’s Public Health Guru,’ but even before that he’d spent much of his career as one of those celebrated, globetrotting disease Detectives that had despatched around the world to fight emerging infectious diseases and stamp out outbreaks. He’s participated in campaigns to stamp out all diseases, from smallpox to polio. He’s investigated the emergence of new ones, from AIDS to Ebola, and he’s battled long-time foes, from tuberculosis and malaria, as well as training scores and scores of next-generation disease Detectives, otherwise known as Epidemiologists, in developing countries all over the world. So, he’s also a superlative risk communicator and champion of the public understanding of science.
He has always been a voice of reason, sobriety and evidence-based opinion and advice on nearly all of the most frightening infectious disease threats humanity has faced over the last few decades. Besides being one of us at Chatham House, he’s also Chair of the World Health Organization’s Strategic and Technical Advisory Group for Infectious Hazards, which has been advising the Director General on this coronavirus outbreak. In fact, David, we’ve just had to snatch him out of a room where he was on the phone briefing the Director General on this committee’s latest findings on the disease. He also advises on infectious disease control in countless other capacities, way too many for me to mention here, and he’s a Professor at the London School of Hygiene & Tropical Medicine and Editor of what many regard as the Bible on infectious diseases, the Control of Communicable Diseases Manual. I’m going to stop there because I think you get the picture, and if I carried on anymore, we’d be sitting here all day with listing his contributions to global health security. But bottom line is you could argue, and I would, that nobody in the world knows more about the emergence and containment of a new coronavirus. So, it’s very exciting to have him here with us. David, thank you for being with us today.
Professor David Heymann CBE
Thank you, Emma, and this is beginning a sparring match that we’ll have after this, because I told you to go light on the introduction.
Emma Ross
And I said, “No way.”
Professor David Heymann CBE
Anyway, thank you very much.
Emma Ross
Okay, so, just, before we start with the questions, I – what I’m going to do is, I’m going to have a conversation with David and then I’ll open it up to everybody, to the floor, to ask some questions. Just to, kind of, situate us, as of last night, where we are with the outbreak. We’re at more than 80,000 cases worldwide, and the deaths are nearly 2,700, 34 countries, and in the last two days, five more countries in the Middle East. So, that seems to be the, kind of, the newest spread areas. So, I wanted to start first with a question that’s likely on everybody’s mind, and that’s about how worried we should be about the virus. You said – a few weeks ago you published an article in The Lancet saying that “The next few weeks will be critical in determining whether containment is going to be feasible and a realistic option.” We’re now a couple of weeks on from that, so here we are, and what’s your assessment now?
Professor David Heymann CBE
Well, those weeks have been very valuable to better understanding of this outbreak. You know, what you don’t see is behind the scenes solidarity of Doctors who are treating patients around the world at these outbreak sites, Epidemiologists who are containing the outbreaks in countries, hoping to delay the onset of major outbreaks in their own countries, and also, Virologists who are looking at the virus, and Modellers who are taking all that information and helping make projections. So, all these things are going on behind the scenes and providing to us a really important understanding of this virus.
What’s always important at the start of an outbreak of a new virus or any infectious agent is not what’s known as much as what’s not known, and what’s known is the destiny of a virus. Will it just cause a few cases, an outbreak, and then disappear into nature, come back again, or will it continue to spread in human populations and become endemic, as has HIV, for example, or other infections? So, we’re right now at a stage where we’re beginning to understand that, how that virus will end up, but we can make really no solid predictions. But the evidence has told us a lot, and this is again, from the solidarity in the world of sharing information.
We know that this outbreak is caused by droplets that contain virus that pass from human-to-human, either through close social contact, a cough or a sneeze in the face or nearby, and also, causes severe risk to health workers who aren’t protected properly. The severe risk is even greater because, unlike for influenza, health workers have no immunity, as none of us do for this new virus, whereas health workers do have immunity for flu, they’ve had vaccinations many times, and they get a less severe form of the disease. So, this new virus is quite vicious in health workers who have a very high inoculation of virus when they’re taking care of patients.
So, we know the way it’s transmitted, we understand a little bit about the seriousness that’s been skewed because initially, all that was reported were serious infections. But now it’s beginning to become clear that maybe up to 80 or 85% of infections are very mild, like a common cold, and others require some extent of hospitalisation, been very few, fortunately, go on to death, and this is mainly in people who have comorbidities, pneumonia, diabetes, and heart disease, other comorbidities, and especially for the elderly. So, we’re beginning to understand a lot about the disease, but what we don’t yet understand completely is what’s called the reproductive number or the transmissibility. How easily does this virus spread from human-to-human? So far, from the data in China, it looks about 80 to 85% of all cases in China were in family clusters, close family contact. So, the question is, is this going to spread elsewhere and how will it spread in the future?
Emma Ross
And globally, is containment still on the table? Are we still gunning for that, or should we, kind of, adapt our expectations now?
Professor David Heymann CBE
Well, containment to delay the onset is very important. Wherever there are outbreaks, it can be contained, because if you can stop the chains of transmission in those individual outbreaks, you change – you decrease the chance that that virus will cede other outbreaks in the country to almost zero. So, containment activity, such as have been done in Germany, being done here in the UK and other countries, do interrupt transmission and the chains of transmission from people coming into the country, and hopefully, they delay the onset if that virus is destined to become widely spread.
Emma Ross
Okay, I want to talk about the P word. That’s the word on everyone’s lips this week, pandemic, and I know you’ve said that getting hung up on the terminology is really a distraction, and that view’s been echoed by experts at WHO. But nonetheless, there’s a lot of interest on whether this should now be called a pandemic, how close we are to that. There seems to be a few opinions bubbling up as to why, now that we have these worrying outbreaks in Italy, Iran and South Korea that it’s not been called a pandemic yet. I wanted to ask you, how close do you think we are, and is it inevitable, and what the criteria are for a pandemic?
Professor David Heymann CBE
Well, if it had been declared a pandemic, we would be doing nothing differently. The idea is to stop outbreaks if you can, discrete outbreaks, and interrupt transmission, those chains of transmission from an infected person to another, and at the same time, prepare, using pandemic influenzas preparedness plans and others, in the event that this does spread more widely. Some countries are already using some of those strategies. China has shutdown major events. There was an event that was shut down between – and a sports event between UK and Italy that was shut down. Countries are beginning to use some of those strategies that are called mitigation strategies, and at the same time, they’re preparing hospitals for the massive influx of patients that could occur, should there be an outbreak that’s generalised in – within a country. So, there is a lot going on now, which is both strategies for outbreaks and for more widespread. I will continue to say that pandemic is a distraction because people are waiting to hear the word, but don’t know what it means, and I don’t really know what it means either, but I do know that countries must continue to do what they can, and it’s based on a national risk assessment, as is being done here in the UK on a regular basis.
Emma Ross
So, that actually was going to be my next question, is if it does step over the threshold – so, is there a criteria, first of all? Is there a moment where there’s a threshold where now we’re in pandemic, or what is that based on? ‘Cause we could be asking this question again and again and again and everyone could be sidestepping it, saying, “Don’t worry about that,” but is there a time when it would be?
Professor David Heymann CBE
Well, nobody is saying not to worry just because this is not called a pandemic. It’s been called a public health emergency of international concern by the World Health Organization, and that means that we should all be very, very concerned about what should happen. But that concern must be self-empowerment to understand what to do should you be in an outbreak that spreads throughout a community, or should you be in contact with a person who you think has infection, and that’s basic hygiene principles. Wash your hands, make sure that you stay at a respectable distance from a person who you feel might be sick, and make sure that they’re able to call into the number that’s required here in the UK, that’s been given out in the UK, to report that they might have infection. So, people being empowered to deal with their own health is what’s most important, and at the same time, an understanding that we’re all in this together and that we have to protect others if we can, so that if we ourselves become sick, we make sure we protect our families and others by staying at a distance from them and making sure that we notify the health authorities.
Emma Ross
Okay, one last bit on the pandemic question and how worried should we be if it’s suddenly called a pandemic? I’m thinking about the H1N1 flu pandemic in 2009. The death rate was less severe than we see in normal flu, and it stuck around, but nobody seems to be too panicked or worried about H1N1. It’s still with us, it’s past the pandemic. Is it just a word, pandemic? Does it mean that if it’s gone pandemic that it’s here with us to stay and it becomes one of those normal human coronaviruses, like the other four that cause common cold?
Professor David Heymann CBE
Yeah, the word ‘pandemic’ might not really be appropriate in the 21st Century. You know, this is a word that’s been used in the past to describe when waves of cholera came through the world from the – many times from Asia, into the rest of the world, and when the plague came into Europe and other places. These were called pandemics, and they were – they have a historical place. Today we’re in a world that’s entirely different. Countries don’t wait to be told there’s a certain pandemic or whatever, they do their risk assessments daily, with information that’s available on the internet, that’s available throughout the world instantaneously. And so, it’s really now a matter of countries doing their own risk assessment, based on what the World Health Organization and others tell these countries, that they can give the information that they give, and at the same time, to model their response based on good epidemiological principles, outbreak containment and widespread mitigation, if necessary.
Emma Ross
Okay. We’ve heard a lot about the lessons that have been learned from SARS and other outbreaks have been brought in that we see at work here. Can you tell me a bit about the lessons that we learned from other outbreaks that are not being applied here?
Professor David Heymann CBE
Well, you know, what’s good about this outbreak, if there’s anything good, is that this outbreak has even gone a step further than the collaboration that’s been done in the past, for example, with the SARS outbreak. After the SARS outbreak, there was much concern, for example, that Academics withheld data, did not publish that data until they were ready to publish it and could get the credits they needed in academia. Today, all the major medical journals are providing rapid peer review, online access, open access in front of the paywall for any articles that are being proposed and accepted. So, everybody has the access at no cost to the current medical literature on this current outbreak. That did not occur in the SARS outbreak. It was started, but the medical journals have gotten together and decided, yes, that they will do that. At the same time, after the Ebola outbreaks in West Africa, there was a group here called CEPI, the Coalition for Epidemic Preparedness Innovations, which is an organisation, which is based here in London and also in Oslo, and which is attempting to develop vaccine platforms for vaccines that might be – for a disease that might be caused by emerging viruses.
This CEPI has invested some in development of vaccines for coronaviruses. At present, is investing even more, and that funding will remain available, even if this outbreak stops, is declared over, and the funding dries up in the private sector. This public-private partnership will continue to fund research, and that’s been a major problem, drying up of funds after outbreaks have occurred.
Emma Ross
Okay, but going back to the question, which was what is not being applied, lessons that we should’ve learned. For inst – I mean, one I was thinking about is, have we really applied anything we’ve learned about the way we interact with wildlife? For instance, this culture of wet markets, where live and dead animals, including wildlife mingle and are sold for food. I mean, that seemed to have been an important lesson from SARS, but it seems to be a difficult issue to tackle. I mean, how…?
Professor David Heymann CBE
Yeah, yeah, and I think you’ve really hit that, the nail on the head, because what happened, during the SARS outbreak, was that there was a lot of research going on to determine whether or not coronaviruses were being spread in live animal markets in China. Funding was available, antibody evidence of infection of less severe coronaviruses were found to be greater in workers in live animal markets than in the general population. And at the end of the research, at the end of the outbreak, when it was declared over, the research funding dried up, and so we weren’t able to see a continuation of that research, which could’ve provided understanding of how to prevent these infections at the source, instead of having to jump on them with costly outbreak response mechanisms. So, yes, there were lessons learned that weren’t followed.
Emma Ross
Okay and on – just zeroing in on the wet markets, wet markets are coming under a lot of, shall we say, blame or suspicion. Are you convinced that wet markets must be shutdown, must be regulated, that they’re the problem, or is there still some question as to proving that?
Professor David Heymann CBE
You know, our political leaders like to regulate, and they like to regulate and say, “The problem is over once it’s regulated.” In a country like the UK, it’s possible because there’s an enforcement agency that can make sure that regulations are followed. There are enforcement for many different sectors. In many developing countries, making a regulation without enforcement or where there’s corruption and enforcement isn’t done properly, can be more of a risk than a benefit. And there’s evidence, after the SARS outbreak, that when markets were shutdown, live animals markets were shutdown, people knew exactly where to get those live markets at other places, in black market. It was out of view of the officials and out of view of regulators, and it just continued to spread, as we see now. So, regulation is fine, regulation without enforcement is a risk.
Emma Ross
Okay. This – so, I just wanted to bring up something that came up last night. I’m not sure how up on it you are. The WHO-led team that came back from China investigating how – what China’s doing, what impact it’s having and what the next steps are reported last night some of the highlights of their findings, and there’s been a lot of talk about what’s going on in China may be shambolic or too authoritarian. A lot of speculating, of assessing how China’s been handling this, but the upshot of this report from the visit, which I must say had international members really, really impressive backgrounds, an independent group, and the upshot that they came up with was that China’s pretty much used a lot of classic public health interventions, old-fashioned classic interventions that a lot of people weren’t sure could work on this scale. But at the same time it was technologically powered, science driven and very agile response at a phenomenal scale.
I mean, they did the case finding and the contact tracing in a really extraordinary way, with extraordinary rigour and discipline, and very tailored, incredible collective action, and they repurposed the whole government machinery to make this work. And the opinion was that after 30 years of doing this kind of work, Bruce Aylward, who led this mission, said he’d never seen anything like it, and he wasn’t sure it would work, but he seems to think it is working. Not it’s worked ‘cause it’s not finished yet, but it is working, and he concluded that they’ve probably averted hundreds of thousands of cases, in taking this approach, and that the impact has been striking on the epidemic curve. And he basically said that what China demonstrates is that where this is going is within the control of our decisions to apply this kind of rigour and approach to this disease and its outbreak, and I just wondered, do you agree, and if so, do you see that that would be replicable in other places and other contexts?
Professor David Heymann CBE
Yeah, well, China has a very unusual situation in SARS and also in this outbreak. It’s been an all-government approach, it’s been really an all-government approach. It hasn’t been health, it hasn’t been animal health, it’s been all of government, and the same that they did in SARS, they pulled out their civil society, their civil societies, their cells and – of workers in various places and others to really take this on as a mission that the Chinese people must do, in order to protect each other. And this is the word that they’ve spread throughout China, that this is to do – to protect each other, as well as to stop this outbreak if possible. Of course, the outbreak – the final outcome will not be known for quite a while. What’s known is that outside of the Hubei province they have been able to contain fully some outbreak situations, but at the same time, they’re seeing cases pop up where they didn’t expect them. That’s what the team reported. At the same time, they’ve treated the whole epicentre of this outbreak as one cluster. So, they’ve surrounded it with a wall of isolation and quarantine, and they’ve had citizens assume this as a responsible measure in their own country to help each other.
Singapore has taken a very similar approach, but it’s been a more open approach, and as you know, in general, Asians are very polite when they have infections and when they are infected with something that they, you know, are afraid they’ll pass onto others, and they many times wear masks to protect themselves from coughing or sneezing on anyone. That’s very ingrained in many Chinese and Asian cultures, and Singapore has played on that and made the citizens responsible for each other, and that is the current slogan in Singapore, that people are responsible for each other’s health, and they’re working together in a similar way of quarantine and isolating, but in a different context.
So, the answer would be that is China doing right? China is doing what it can do best in its own context based on its risk assessment. Singapore is doing what it can do within its civil society and its context, and the UK is doing the same. So, you know, rather than try to criticise a country, what we need to do is build on what they’re doing that’s positive, as WHO attempted to do last evening, and, you know, in situations some – such as this, it’s a very difficult decision to determine what’s more important, individual or collective protections. And, you know, we all have our own opinions as to what countries are doing and who does it right and who does it wrong, but at this point in time, we hope that China has begun to decrease and maybe eliminate transmission, but if it hasn’t, they’ve at least delayed that second wave from coming out and spreading further.
Emma Ross
Okay. Can I move onto this concept of global preparedness? There’s been a lot of talk and saying that the world is ill-prepared. So, after H1N1 in 2009, a seminal report said the world is ill-prepared for a pandemic or something of significant, you know, equal thing, and a couple of years later the same is said, and we hear this during this outbreak, that the world is ill-prepared. Is that – first of all, is that even a realistic target, the whole word prepared? It seems to be very national, as you’ve just described, a very tailored approach per nation, depending on their risk assessment, to say – are we ever going to get to a point where we say, “Okay, tick, now the world is prepared?” Are we ever going to get there? Is that realistic? Is that a useful framing for this?
Professor David Heymann CBE
You know, we’ve all fallen into this way of working that says, “We will do this for you. We will stop outbreaks for you.” If we really want to have health protection and global health security, what we need to do is turn that around to say, “We will help you strengthen your capacity, so you can detect and respond and prevent outbreaks from spreading,” and that’s a whole change in our mentality. Right now, more funding is going into global mechanisms to help the global community respond to outbreaks in developing countries, and very little of that resource is going to developing countries and to get their governments engaged in preparing by developing the public health capacities they need to detect and respond when and where outbreaks occur. So, we need to really begin to understand that it’s not we who will do it for you, it’s we will do it together by strengthening your capacities to do it better.
Emma Ross
Okay. Dr Tedros, the WHO Director General, has repeatedly said that “This outbreak is a test of solidarity, political, financial, scientific.” Why is that so important, and how much solidarity do you see going on in these three areas in this outbreak?
Professor David Heymann CBE
Well, certainly, technical solidarity has been quite impressive. As I said earlier, we have answers to most of the questions because people are working together: Doctors treating patients, Epidemiologists fighting the outbreaks and Virologists looking at the virus, and the Modellers, who are helping us to better understand the dynamics of outbreaks. So, we’re having great support, technical solidarity. Hopefully, financial solidarity will come behind that, that permits not only countries to begin to contain outbreaks where they’re occurring, the developing countries that don’t have that capacity, but that also will remain available after the outbreaks are over, so the countries can continue to develop their capacities.
Emma Ross
Okay. I wanted to move on possibly for the last question on the global health security architecture. There’s been a bit of criticism, as there’s always criticism in these things, of WHO in not declaring this a global emergency, officially called a public health emergency of international concern, earlier, and the accusation was that this was due to politics with China. The same was levelled at WHO during Ebola. This is not a new accusation. This, kind of, maybe raises questions of how well is this system of declaring public health emergencies working? Is it really fit for purpose? Is it serving us well, this system?
Professor David Heymann CBE
Well, the system was developed in a treaty context by 194 member countries of the World Health Organization. This is what they felt would be useful. There have been a couple – it would be useful to declare a public health emergency of international concern, through the Director General’s consultation with an emergency committee and many other groups. The gift of declaring a public health emergency of international concern is to the Director General alone. So, member countries have asked WHO to do things this way and to declare a public health emergency when it occurs.
The emergency committees are always made up of experts from countries in the six different regions of WHO, and it’s made of people who are on rosters in those countries, who have been named by their governments. Those experts, a different group each outbreak is called together, and they make a decision as to whether or not to recommend to the Director General if this is a public health emergency of international concern. If they recommend that, what this means is not what most people think it means. What it means is that that committee feels that there’s a threat that this outbreak will continue to spread internationally and could impact on travel and trade. So, that’s what the fate says, that this is an outbreak that could impact on travel and trade, and it was decided at the second committee meeting. But that alone isn’t what countries always follow, because that’s what governments understand, that this is a public health emergency of international concern, and that you should not, at this point, make recommendations of avoiding travel.
That’s what the regulations have said, the emergency committee said, the Director General has said, but airlines, private companies make their decisions, based on individual rather than collective benefits. Airlines, many times decide not to fly to an area because their insurance might not cover people on their staff who become infected and have to return home, or because their worker rights, their workers’ health programmes don’t permit them to do that. So, their decisions, industry in general, are made on an entirely different set of principles than on public health principles, which are to collect – to protect the collective population. So, there’s always going to be difference, and we’re always going to see those differences, and the question is, does the public health emergency of international concern really convey what it was meant to convey? And this, of course, has been deliberated. Brian McCloskey, who’s an Associate Fellow here at Chatham House, has been on an expert committee, along with Louis Lillywhite, who’s also an Associate Fellow here. They were at WHO, after the Ebola outbreak, and they’d made recommendations about possible changes to the mechanism that supports the public health emergency of international concern. There will be more after this outbreak, and eventually, member countries will make decisions whether or not this or something else is more appropriate.
Emma Ross
Okay. My last question, before I open it up, is actually on now, WHO said that besides fighting these outbreaks, it’s fighting an infodemic. The rumours, conspiracy theories and other fake news that’s whipping up fear, and rumours and misinformation have been a feature in epidemics throughout history, but this has been called the first true social media infodemic, and I wanted to – I mean, WHO is trying to address this, they’re partnering with Twitter and Facebook, they’re doing all sorts of things and trying to push the search terms in Google up to the top, so that they come out first. But can you tell me a little bit about the impact this kind of infodemic can have on the ability to snuff out an outbreak, but also, why do we repeatedly face this problem every time there’s an epidemic? We know this, it happens, it’s always happened. Is it something we just have to accept as a companion to outbreaks, and do you think it’s going to get even worse now?
Professor David Heymann CBE
Yeah. I expect it will continue to be a problem, but, you know, the social media picks up messages from many different sources, and what’s very important is responsible journalism. It is not reporting ahead of the evidence, because if there are responsible Journalists and responsible publications that are providing the correct information, the evidence-based information, social media will pick up those messages as well as the messages that are not so valid and are picked up by others. And sometimes there is deliberate attempt to sabotage messages and to make people think that things are different than they are, and, you know, there are many groups studying all about social media and finding where the rumours are and even where they originate. But there isn’t yet a technology or an ability to control what’s going on in the social media, and I don’t know the answer.
Emma Ross
But is this one of the lessons that we just haven’t applied and haven’t learned? Because, I mean, going back to ancient Rome, this was an issue, and why are we still grappling with this and not got on top of it?
Professor David Heymann CBE
I guess we have to live with it, but we have to learn how to deal with it in a better way than we are now, and I don’t know what the answer is. You would know better than me, being a Journalist, so let me turn the question back to you.
Emma Ross
Well, I mean, the thing is, it’s not – I think it’s interesting that you say, you know, if Journalists are responsible then that’ll make things, but I think the field is that it’s a little bit, you know, the people making the inputs, sort of, a lot wider now. It seems like a very tough thing. I don’t have the answers to that either.
Okay, so I’m going to open it up now to the floor. So, if you could please wait for the microphone, just a couple of more housekeeping, keep your hand raised up high, so that the people with the microphone can see it, and just to remind you, the question should end with a question mark, so please don’t use this as an opportunity for a speech. So, where are the microphones? Okay, can we have one there right by you? Yes, over there. Thank you. Oh, okay, well, David wants to take two or three at a time, so why don’t you have your first question?
Alexandra
Yeah. Hi, Alexandra from…
Emma Ross
And if you could just say who you are and affiliation, if you could.
Alexandra
Hi, Alexandra, I’m a Journalist at Yahoo. The Sun have published a memo they’ve seen put together by the National Security Communications Team. It’s called ‘COVID-19: Reasonable Worst-Case Scenario.’ They’re saying up to 80% of the population of the UK could be infected, of which two to 3% could be fatal. So, I don’t know what that’s based on, probably estimations of the reproduction number, but how plausible does that seem to you, up to 80%, apparently from an official document?
Emma Ross
Thank you, next – other questions. This gentleman here in the front. We’ll take two to start with.
John Wilson-Nurse
John Wilson-Nurse, also a Journalist and a Member of Chatham House. What is the cure? What is the treatment? And are any existing antibiotics effective?
Emma Ross
Thank you. Do you want to go ahead and in any order? Oh, okay, we can take one more. Not another Journalist for now. Just here. So, then I’ll go to the back next time, remember – yes, thank you.
Maria Tjader
Sorry. Hi, I’m Maria, I’m a Consultant with Flint Global. I’m a bit interested in what effect you think this virus could have on blood supply, as in, in terms of infected and contaminated blood?
Professor David Heymann CBE
Okay, let me start then, with the question about whether or not the projection that’s done by Epidemiological Modellers, probably the group at Imperial, I would think, or at London School, whether or not this 80% is a figure to trust. Well, certainly, in preparing for an outbreak, you want to take the most dramatic figure, and certainly, that’s a dramatic figure and the country needs to get prepared to deal with an outbreak should that occur. But that’s a – I’m sure that on the modelling that was the worst-case scenario, and that’s what governments should pick up and work on. But Journalists, many times don’t understand what those figures mean, they don’t even think that there might – and I’m not talking about you in particular, I’m just saying in general, Journalists look for the most high figure, rather than the figure that might occur, should the reproductive rate and the transmissibility be much, much less. So, Journalists have a real important role to play. If they take this 80% figure, they should say what it is and what the context was, in which it was developed, and it’s purely an epidemiological model, it’s based on current evidence today that will change daily as more evidence comes in.
Cure and treatment. Certainly, antibiotics might be useful in people who have had a severe pneumonia and have a bacterial infection on top of that pneumonia. Many have recommended pneumococcal vaccine for the elderly, as they do for influenza. So, elderly might need to get a pneumococcal vaccine to protect them because they’re at the greatest risk. So, vaccines – pneumococcal vaccine and antibiotics may have a role to play. The most important, from what’s understood from all these Clinicians working with patients now, is to sustain people in life long enough for their immune system to take over and develop the antibodies, which will cure the infection. That includes various types of oxygenation, a nasal canula or all the way through to extra-corporal oxygenation of blood, a whole series of things that might be required. But the fact remains that people who are elderly and who have comorbidities, as I said earlier, are the ones at greatest risk, and so nursing homes and groups where elderly people, who might have comorbidities congregate, must be doubly aware of the possibility that there could be serious infection. And as far as drugs, antiviral drugs, on the Chinese register there are over 200 trials going on, with various antiviral drugs, including traditional treatments and others, and on the international record, when I last was aware of this, which was about four or five days ago, there were 72 clinical trials on record. So, there are lots of clinical trials going on for drugs in China, and I understand that recently, you’ve probably heard the same thing, not verified, that there might be an oral vaccine, which is being tried, also in China, which would be quite a rapid development of a vaccine, if indeed, that’s what’s occurring.
Finally…
Emma Ross
Okay.
Professor David Heymann CBE
…blood supply…
Emma Ross
Oh, yeah, blood supply.
Professor David Heymann CBE
…of course, blood supplies are always at risk, and if this does become a generalised infection, throughout the country, then there will be a need to screen blood for virus. The problem, though, is that we have very few diagnostic tests at our hands today. There’s really no serology yet, which can be used to determine whether people have had infection and recovered and no longer have the virus. The only test available is the PCR test looking for nucleic acid, which would be appropriate for screening in blood banks, because it would find virus in blood, but it’s very costly, and would have to be done.
Emma Ross
Thank you. Another round of questions. We’ll go to the back, far back corner there. Thank you.
Juliet Samuel
Juliet Samuel, The Telegraph. You just mentioned cost, and I wondered how you view the trade-off between containment and health outcomes and very dramatic economic impacts, which can also have knock-on effects, maybe on health, mass quarantines and things like that, and what the approach should be there?
Emma Ross
In the middle here, the lady with the white top.
Caroline Voûte
Hello, I’m Caroline Voûte from Médecins Sans Frontières, from Doctors Without Borders. My question was also about the use of quarantine when that often has negative effects on outbreak control, but I’d add to that as well how WHO is encouraging best practices from lessons learned of previous epidemics and particularly, in terms of not directing all attention, resources towards the epidemic, when they are equally needed in other health needs.
Emma Ross
Okay, one more in the middle here, the guy with the grey shirt. Thanks.
James Holmes
James Holmes, Staffordshire University. I was just wondering, how do you think the global community can best come together to find a solution to any future global outbreak?
Emma Ross
Okay.
Professor David Heymann CBE
Okay. Quarantine, well, it’s first about cost of approaches. You know, the cost of the approach depends on the feasibility of that cost within a country, and that’s how decisions are made, unfortunately or fortunately. So, the decision made in Cambodia, based on its risk assessment will be entirely different than the decision made in the United Kingdom. I know that in the United Kingdom and I know in many countries cost is a major concern for all outbreaks, including this one, and there’s a constant look at that to see when the balance might shift to needing to spend more time on mitigation strategies, which improve hospital availabilities and get the hospitals ready, rather than on the approaches that are currently being used. But, you know, in hu – in saving human lives and in protecting populations, it’s very seldom that at the start of an outbreak people think about cost. They put in what they can, which is only normal to do, and then, as they begin to understand the cost effectiveness and cost benefit of what they’re doing based on their own risk assessment, they modify as necessary. So, that’s the best answer I can give you on that.
Regarding the MSF question on quarantine and best practice, well, you know, epidemics don’t always affect only people who are involved in the epidemic, as you know, best of all. They occur – they affect also people who are trying to get healthcare and can’t get into the hospital or the health facility. In the Ebola outbreaks in West Africa, childhood deaths from measles and malaria were greater than the deaths from Ebola because patients couldn’t get to the hospitals or vaccination service couldn’t complete – be completed. So, you know, that has to be weighed. Maintaining a health service open has to be weighed with the cost of quarantining and do other – doing other activities, and again, it’s a national risk assessment procedure. WHO recommends that countries do its own risk assessment, that they determine, and I believe they will say this if they haven’t, our report from the committee yesterday will say this, that they have to be looking at what’s of more value at present – at the present situation, individual or collective protection, and as they go through the outbreak they’ll make those decisions. Does that answer your question, or do you want to ask more? Well, no, what – ask more if you want to, because I’d like to answer it.
Caroline Voûte
It does answer the question, but also, I think history has told us over and over again that quarantine, as a control measure, has usually negative knock-on effects, including distrust of government and health authorities, as well as social unrest, yet it’s been used very widely here. Now, so far it seems like that has not yet been a by-product, but it could be on the horizon. What thoughts are – or what’s being discussed so far around this?
Professor David Heymann CBE
Well, WHO just today on a discussion that I had, one of the major emphases was on helping people understand that it’s their responsibility to protect each other, and if they understand that and they – their government does decide on quarantine, then they will understand why they’re being quarantined. That doesn’t say the negative impacts of quarantine will not weigh on them, because they will, but clearly, if it’s considered a social responsibility to do what your government says, and if you trust your government, then you can do it. If you don’t trust your government, then you have a situation such as occurred in West Africa in the Ebola outbreaks, where there was no trust in what government was saying about how they could best stop the outbreaks. And, you know, there are many issues, the same as is it right for groups like MSF to continue responding, rather than to strengthen infrastructure? I know that’s a common discussion with MSF, and these are all discussions that we need to bring out in the open and finally make decisions about.
Emma Ross
And the third question?
Professor David Heymann CBE
And the third question was on the global community – how does the global community…?
Emma Ross
What do they need to do to stop future outbreaks?
Professor David Heymann CBE
Yeah, how does the global community need to come together? Well, they’ve come together already in understanding about the epidemic, and they’re working together, along with the journals and others to get this evidence out to people. What there is in the world is a pandemic emergency fund at the World Bank, which needs to be activated, hopefully will be activated soon, which provides funding to developing countries, to de – if they develop a plan for how they will deal with the outbreak appropriately, and that’s one source of informa – of funding. In addition, WHO and other UN agencies have gone out with a joint appeal, in order to make sure that funding becomes available, but even more importantly is for governments to get engaged and make their responses cross-government, involving funding that goes into other parts of the government, so that they can divert it as necessary to outbreak containment. So, there are a whole series of things that can be done, starting nationally with an all-sector response and then moving upwards to the global situation.
Emma Ross
Okay. Questions here, right at the front. Thank you.
Michael Le Page
I’m Michael Le Page, New Scientist. You were saying earlier that much of the spread seems to be in family clusters. What can people, in that situation, do to avoid infecting housemates or family members?
Emma Ross
Thank you. Do you want to do three?
Professor David Heymann CBE
Yeah, go ahead, no.
Emma Ross
Okay. In the middle there, lady with the beige top, behind you. Thank you.
Megan Harris-Gillard
Hi, my name’s Megan Harris-Gillard, and I’m a Member here at Chatham House. My question is somewhat similar to the one that was just asked, and is essentially, the trans – how is this virus transferred? Despite my best efforts, still not have – I’ve not had a clear answer on that.
Emma Ross
Thank you. One more in this round. Over there I haven’t been for a while, yes, two rows in. Yeah, there we go, thank you.
Guy Taylor
Yeah, good afternoon. Guy Taylor, Treseder & Company. I’m interested in transparency, and I think most people in this room, living in Britain, would be interested to know what is Public Health England telling local authorities at the moment about this and how to prepare for what could happen next?
Professor David Heymann CBE
Okay, family clusters and protection and how is the virus transferred? Information about that is how you – and understanding of that is how families can protect themselves. It’s known how this virus transmits from person-to-person, close social contact. So, members of the family that are dealing with patients, who are touching them, to care for them or doing other things, should have a mask that will protect them from a direct sneeze or cough, and also, the patient that’s being dealt with should wear a mask because that’s double protection, and at the same time, gloves should be worn, if possible, as long as there’s understanding of how to take them off so that contamination doesn’t occur, and then handwashing afterwards. So, the basics of handwashing and protecting yourself from the possibility of having a sneeze is one way.
It’s not yet understood whether the virus passes in body excretion such as faeces, but it’s thought that it can. It’s thought that it probably can, the SARS virus could, and therefore, protection against faecal-oral contamination, against touching a patient that might – who might be infected and then touching yourself anyway where that could be transmitted is another way. So, there – family understanding is how families can – family clusters can protect themselves. At the same time, that – if people understand those things, even in the general public, they can protect themselves, and walking down the street wearing a mask is not protection against anything, except preventing you from sneezing on somebody else directly. It’s not protecting you, it’s protecting others.
Emma Ross
Can you talk a bit about maybe some more detail about how far away does – do you have to be if a droplet thing – is it airborne? One metre, two metre thing?
Professor David Heymann CBE
When you’re speaking and when I’m speaking, we’re probably contaminating each other with our droplets just by speaking because they travel, but droplets travel less – far less distance than do aerosolizations. Aerosolization is when water is fine and remains suspended. So, when I’m speaking, there’s some aerosolization and it’s covering you with aerosol, but there’s also droplets that might be reaching you, and the droplets are what are important in this infection.
Emma Ross
And how far can they go?
Professor David Heymann CBE
Well, I don’t know, but they can certainly go probably as far as you and me, just depends on the force of your speaking or whether you coughed during your speaking or a sneeze. So, stay away.
Emma Ross
Well, can you give me a number? Like…
Professor David Heymann CBE
I can’t give you a number.
Emma Ross
…keep two metres away, three?
Professor David Heymann CBE
Yeah, I think two metres is reasonable, two to three metres, yeah.
Emma Ross
Two metres. Does that answer your question?
Megan Harris-Gillard
Yes and no. In terms of on an aeroplane, for example.
Emma Ross
Yeah, book three rows in front and back.
Professor David Heymann CBE
Okay, yeah, that’s right. What’s been shown from SARS, and that’s the only example we have at present, is that the virus can transmit by close contact, sitting near a person in the waiting room, when you’re waiting to board the aeroplane, and it can also transmit in your row and one row above and one row behind, and that’s about the extent. So, that would cover your distance of maybe two to three metres.
Emma Ross
Doesn’t sound very practical to book the row behind you and the row in front of you.
Professor David Heymann CBE
You shouldn’t travel.
Emma Ross
If someone’s got the money, great, great.
Professor David Heymann CBE
Transparency in Public Health England, I won’t answer that because it’s not my role, and I was Chairman of Public Health England in the past and would not want to have that conflict of interest. But I know Claire Bain and maybe others are here who could maybe speak to that. Claire, could you say a word about that?
Claire Bain
Well, I’m afraid I haven’t got up-to-date sufficient details about that.
Professor David Heymann CBE
Is anyone from PHE that would be able to address that? I know that the government is working hard to be as transparent as it can and, you know, I can’t give any more information than that because it’s not my role to do that.
Emma Ross
Okay, we have time for maybe one, maybe two more rounds of questions. Let’s see, where have I not been? Oh, yes, here, right in the middle at the backish.
Xiao
Hello, I’m Xiao, from China. I wish to know what’s your suggestions for co-operation between China and Britain in combatting this coronavirus?
Emma Ross
Thank you. Any more? I know I have to go over there a bit. Okay, are you a Journalist?
Member
Yes.
Emma Ross
Okay, no, what – let’s – red jacket.
Member
I’m not a Journalist.
Emma Rose
Okay, great, not that I have anything, I just want a bit of balance. Next round, definitely, you guys.
Member
Thank you. So, thank you for putting the obligation on us individuals. I, sort of, like and don’t like that. What would your advice be for people who have a cough, who have not been to these countries that are hotspots and when it comes to travelling in public trains, etc? And what would your advice be to us who are travelling right next to them, sandwiched in as sardines, as we often are?
Emma Ross
How many is that? Have we done three?
Professor David Heymann CBE
Two.
Emma Ross
Oh, two? One more, one more. Okay, down here, right at the front, lady in the stripy – and then we’ll have one more round after.
Hannah
Hi, sorry, another Journalist. I’m Hannah from The Guardian. Just, it’s a general question really, but I think people have a real difficulty reconciling advice that this is not necessarily much worse than a cough or a cold if you’re healthy, not elderly and not got any underlying conditions, but then also seeing this, kind of, drastic – these drastic measures to try and contain it and slow it down. Is there an easy way for people to, kind of, get their head around that? Is it because governments aren’t thinking about this in the same way as an individual manages the risk, and they’re trying to, kind of, think about the impact on the whole system and how hospitals are going to deal with a massive influx? I just think it would be really helpful to have a way of, kind of, helping people think about that.
Professor David Heymann CBE
Okay, let me start with the last one first because I think it’s Journalists who have a major role to play in this, and Journalists need to clearly understand the issues and they need to be able to convey these to their readership, and that’s there’s nothing that can replace that honest, evidence-based journalism, providing the facts as they understand them or getting the facts from others if they don’t understand them. So, that’s how public can be empowered, and I’m going to say something, which isn’t going to make you happy, but I’m going to say again, that the public – every individual needs to know what their role is in this and that they’re responsible for their own health and for the health of others in their collective.
So, coming back to the cough in the public, certainly we all know that you don’t put your hand over your mouth today, you put your elbow up and you stop that cough from spreading. That’s responsible behaviour, that’s behaviour that will prevent any cough from spreading, whether it’s coronavirus or not, and how do we know if we have coronavirus? It’s a good question. The only thing I can tell you is that we will all have colds over the next year and we’ll all be worried, “Do we have coronavirus or not?” But good common reasoning, what’s called contact tracing for yourself to see if you were in touch – in contact with somebody who had a cold, who wasn’t – didn’t have coronavirus, or if you can’t find a contact to think back to the public spaces where you were or maybe you are infected. But it’s, again, our responsibility as individuals to do that contact tracing that Epidemiologists do in an outbreak situation every time we develop a cold or any symptom, which we think might come from others. That’s the best I can do on that.
And was there another? Oh, co-operation between the UK and Britain? I can’t really answer that question, but I can look historically at what the UK has been doing with China, and one of the major efforts of the develop – of DFID has been to work with Chinese Epidemiologists and Scientists to make sure that they gain the same international experience and understanding that has been the privilege to obtain here in the UK because of the active work that they’ve done in the past centuries on outbreak response and containment. So, they’re – I know from DFID there’s been an active collaboration with Chinese experts to try to strengthen their capacities, not their capacities as much as their understanding of how they can transfer the great skills and knowledge that they have to others. I can’t talk about other co-operation at present because I don’t know.
Emma Ross
Okay, well, it’s one minute to, so I guess that’s all the time we have for questions, but I did want to slip in one last one for me, which is, Jonathan Quick in his book, 2018, it’s called The End of Epidemics, he said that, “The world reacts to infectious disease outbreaks in a cycle of panic and complacency.” Is that something you agree with, and if you do agree, where are we in that cycle with this outbreak?
Professor David Heymann CBE
Well, I think that what’s been important to date is that there has not been a great amount of panic. In Singapore, for example, there was concern early on and store shelves became empty in some places, grocery stores became empty in some places, but now understanding that there – what’s being done is being effective, they’ve – the concerns in Singapore have calmed down. That was a major source with over 90 cases occurring.
There is concern now in South Korea, in Iran and in other places, and that concern is well founded, but transparency can prevent panic, and, you know, the UK has not had a panic situation, the North America has not had one, most European countries have not had one. Even Italy today is not really having a panic situation because there’s transparency in what’s going on, there’s understanding of what’s being done to attempt to stop this, and as more and more information becomes available, it begins to be more understandable that this is a disease, like others which are occurring in human populations, and it maybe isn’t as severe as originally thought, but it still is a concern because it does cause mortality. So, transparency, and I know John Quick quite well, and I believe that in some countries, panic is the concern, but not in all countries, and panic is directly related to the amount of transparency and information that governments and the Journalists provide to people.
Emma Ross
And are we anywhere in the complacency end of that spectrum?
Professor David Heymann CBE
Not yet.
Emma Ross
Okay, great. Well, that’s it guys. Thank you so much, David, for being with us, and thank you all [applause].
