Subtitles section Play video Print subtitles >> Good afternoon and thank you for joining us today. My name is Diane Hall and I'm a senior scientist in the CDC director's policy and strategy office. I also serve as CDC's point of contact and coordinator for our rural health bar. As part of our work on this response we have been in regular communication with federal partners such as the federal office of rural health policy, USDA's national institute of food and agriculture, and the VA office of rural health as well as nongovernmental partners as well as the world health information in the world health information. We have had tremendous interest in this briefing and we have received many questions ahead of time. Please note if the question is not within the CDC purview we have shared it with the relevant agency and we will continue to do so. Also note that CMS launched a website on Medicaid gov which includes a new checklist to make it easier for states to receive federal waivers and implement flexibilities in their programs. If you search Medicaid COVID-19 you should be able to find it. If you have additional questions you may continue to send them to rural had that CDC dot gov. I would like to think Scott Miller in my CBC colleagues working on the coronavirus response reporting is breathing together. I would also like to thank CDC's Captain Margo Rick and the federal office of rural health policy and their assistants for curating questions and assisting with talking points. And thank you to our partners to help disseminate the invitation. And I would like to welcome Health and Human Services Deputy Secretary Eric Hargan, hopefully he is on the line. Okay, it sounds like he is not on the line yet. So I would like to turn it over to Dr. Jay Butler it was the Deputy Director of infectious diseases here at CDC and then maybe when the deputy secretary comes on we can pause. >> All right, thank you Diane, and I will certainly yield to the deputy secretary Hargan if needed. So good afternoon to those of you in the East, good morning to fellow Westerners, and thank you for taking time to join this call today. We are in the midst of a global pandemic of a disease, COVID-19, caused by a newly recognized virus. And all evidence is this is a virus that has only recently achieved the ability to infect humans. Coronavirus in general exist in nature, particularly in bats, and certain coronaviruses adapt to infect people. As some of you are aware if you are in poultry science or you manage swine, influenza behaves somewhat like that. While the epidemic first evolved out of China, it has spread globally now and some of the real global hotspots now are in Europe and in the Americas. All around the world nearly 300,000 cases have been confirmed and we are sure that many more cases than that are actually occurring. Unfortunately nearly 13,000 people have lost their lives to COVID-19. It's important to recognize that the experience of people around the world suggest that people who risk complication send death are those who are advanced in age as well as those with chronic heart lung kidney disease as well as those with diabetes. However, I want to stress that younger people also may have more severe disease and while the overall mortality may be very low among younger people, the impact can still be significant. Here in the United States there have been over 33,000 cases and there have been cases reported from all 50 states. While a significant proportion right now are from New York City or from New York State, I want to stress that this is indeed a pandemic that has spread across the country and across Canada as well, so really all of North America. I understand that Deputy Secretary Hargan is on so I am going to pause and Mr. Hardin, would you like to say a few words? >> >> Well, I apologize for the dead air and if the deputy secretary is able to join we will let you know and interrupt again. Nationally here in the United States that have also been deaths as well as severe illnesses, over 390 people have succumbed to COVID-19. A significant proportion of those have been residents of long-term care facilities which I think again highlights the fact that those who are at greatest risk are those who are older and have underlying conditions. The long-term care facility outbreaks have now been reported from 27 different states. We do expect to see a continued increase in the number of cases both as there is increased transmission and increased capacity to test. As of yesterday 91 state and local public health labs basically representing all 50 states plus the District of Columbia and Guam had capacity to do testing. There were also five commercial labs that are performing these tests as well. As we looked at the mix of cases around the country, some are travel related and when I say travel I mean travel from other parts of the United States. Others are community associated, and so it is important to recognize that this is an infection that really is threatening the entire country. One of the challenges in controlling the disease is that it is apparent that some people also have very mild disease associated with infection and it may be possible that people are shedding the virus prior to onset of symptoms, and some people may have no symptoms at all. Just today CDC finalized and put out a report on some of the cruise ship clusters and at least in one of the cruise ships, 18 percent of people who have documented infection never developed any kind of symptoms. Over the past week there has been increasing focus on social distancing and the things that we can do to mitigate spread in our communities. And the reason for that is we want to be able to protect critical infrastructure, especially our health care system, recognizing that there is a small but significant portion of people who will become seriously ill and we want to make sure that they are able to get the care they need. You may see different actions taken in different states and in different communities, and actually that makes sense because even though the virus is present around the country, in some states the transition rates are higher than in others. Here at the CDC we are working with all of our federal partners across the department and also with FEMA, and our particular role is to collect and analyze data, to be able to provide technical advice to states, counties, and other partners to make good decisions. This is truly a learning curve and it's very humbling to recognize how despite the best science sometimes what happens in nature can outsmart us, and in some ways a viruslike this is like a tornado or a hailstorm. There is not much that we can do other than be as prepared as possible and then be ready to mitigate the impact as much as we can. Of course as I mentioned we work closely with state, local, and tribal leaders who are also organizing the local responses. We also work with the private sector, particularly focused on ways we can help support development of drugs that are effective for treatment, develop new ways to make the diagnosis, and ultimately to have a safe and protective vaccine. So all of this involves us working together. We recognize that there are particular challenges in rural areas. There is a lot of dependence right now on things like the Internet for communications, whether it is with family or for teleworking, and in our rural areas as well as especially in frontier areas, broadband and Internet access can be quite limited. We also know that providers are oftentimes already overtaxed in our rural areas and we want to do everything we can to help support them. Also some of the things that are true when it is sunny and 70 degrees are true now in a pandemic such as how difficult it can be to transport patients that are in need of a higher level of care. So with that maybe I will pause. I can try to pause one more time to see if Deputy Secretary Hargan has been able to join us in an unmuted fashion and if you would like to say a few words. Otherwise I will turn it back to you, Diane, and we can begin taking some questions. >> Great, it sounds like we are having some techie issues, the deputy secretary is on the line but he is muted and we will wait to see if we can get that taken care of. Do we want to start with checkbox or take questions on the phone? >> Sure, we can go ahead with the chat box. What is the current trajectory and Outlook for patient search around the country? >> It is quite variable depending on where you are at in the country. In some areas hospitals are approaching maximum capacity already, but I mentioned earlier New York City seems to be particularly impacted and there has been a focus on being able to provide emergency additional rooms, particularly for people who are only mildly ill but still needing hospital care. It's also a chance to point out that most people who become ill can isolate at home and don't need to be in the hospital. So again it is important to understand the vast majority of people who become sick will have relatively mild illness and can self manage at home. However, because we are talking about a virus that may be able to infect everybody even if the risk of the overall proportion who develop severe illnesses relatively small, we may be talking about a significant number of people. So we want to make sure that we can provide care for those who are more severely ill, and he gets back to the discussion a little earlier about the role of social distancing and community mitigation. We are trying to flatten that curve and I think now everybody has heard that term, it's a household word now, but to put it another way, if you are, say, running a hospital and you need to admit 100 patients over a one week period, that might overwhelm the system. But if it is 100 patients over a two month period, that might be something that can be handled very, very well. >> Thank you. Another question, that asks do we know what the aftereffects are for those who are infected? Is this like the flu, once it is over or do we have lasting effects? >> Well, that's a great question and it's a great question because that is one of the ones we are exploring also. The context of our discussion today, it is important to keep in mind that we are talking about a disease and a virus that was unknown to us only three months ago. We were all getting ready for the holidays and COVID-19 was not in our vocabulary. Those of us in health care new of coronaviruses but we only knew of six and now we have 1/7 that we have had to learn about very quickly. So at this point in time we don't have a lot of information. What information we have is mostly what has come out of China which has seen the most cases occurring the longest time back. So far it appears that many people do recover completely, although some may have persistent cough primarily. So again not everyone who develops the infection costs, but some who do and develop more severe respiratory tract symptoms sometimes have a persistent cough afterwards. >> Will there be any guidance from the CDC provided to states regarding limitations to travel across states? >> Yes, that's also a very good question because it sounds like that is somebody who has looked at the CDC travel alert page which traditionally focuses on international travel. Currently the recommendations are very broad with an increasing number of countries to which we recommend all nonessential travel be deferred. Really globally we recommend anyone who is at higher risk of infection to further travel until a later date. And the third thing that I want to make sure is very clear, we also recommend that no one should go on cruises right now. The industry is actually in the process of suspending cruises although there are still a couple of dozen ships that are at sea with people on board, including Americans. In terms of domestic travel, our recommendation right now is primarily where we talk about how to stay well if you are at higher risk, and those of the people who are older, have underlying conditions, and we recommend that as much as possible you stay home. Limit your interaction with other people, and that would also certainly apply to getting on an airplane which can oftentimes be a crowded situation and flying to another part of the country. Is also very important to know what other recommendations and sometimes even regulations that have been passed on an emergency basis at your point of destination. A number of jurisdictions are now requiring people who come in from other parts of the country to self quarantine at home for a period of 14 days and not return just straight back to work. >> Will you please discuss current and future testing capacity? >> Yes, testing capacity is an area where there has been progress. I mentioned earlier the number of state public health labs that are now up and running with the CDC test, into many of those actually have been able to clear backlogs and are turning around test results fairly rapidly. We really appreciate the volume of tests that the commercial labs are able to do. That is a big heavy lift that is helping in this response. They are using some other methodologies but as far as we know these are going to be good results. There is a bit of the backlog in some of the commercial labs, so we are hearing of instances where the test results from commercial labs are taking a few days to return. We have also been told that that backlog should be cleared fairly soon. The other areas regarding diagnostic testing where CDC has been involved is making the virus isolate available to people in the commercial sector to be able to develop new tests, and I think the ultimate goal is to move past the PCR-based technology which is fairly high tech and is harder to perform in smaller and more remote locations, and I think the ultimate goal would be a test that might function more like a rapid flu test that could be in your health care provider's office. We are not there yet but I know there are many people who recognize that that is a very high priority. One of the challenges, though, and I think this is impacting all of us is that after some of the initial challenges we had with re reagents at CDC we next moved into the next age of complications when many of the reagents as well as the supplies to run the tests began to become in short supply as the global supply chain has been limited. So I know that is frustrating for all of us and there was a lot of smart people thinking about how do we best address these problems so that the diagnosis can be confirmed. And I think that is particularly important in areas that have not had widespread transmission of the virus yet. In some places you have probably seen in the paper, particularly in urban areas where there has been a number of cases, oftentimes providers and public health are moving more to a syndrome surveillance where cases are identified based on the symptoms. The caveat and that is I will say we I still learning what some of the symptoms of this infection are. >> Could you explain more thoroughly the term and shedding the virus? Do particles remain airborne for long? >> Another great question. So shedding basically means that the virus is in secretions and are potentially infectious. The way we can assess that are a couple of different ways. One is using the diagnostic PCR, but the caution I would offer there is the PCR, polymerase chain reaction, detects the viral RNA. It does not tell us whether or not the virus is actually capable of infecting another person. What is probably more predictive of the risk of transmission is actually recovery of the virus through viral cultures. That is more labor-intensive and actually takes a lot longer to get the results back, but it suggests that the peak level based on the data we have so far, the peak infectiousness is probably very early in the course of the illness, and then we also have concerns that there may be a period of infectiousness prior to the onset of symptoms which makes the control of the infection through diagnosis and quick isolation or quarantine much more challenging. And this may account in part for how we have seen a fairly rapid spread of this virus around the globe. In terms of survival in the environment, there is two lines of evidence. One is what can we do in the laboratory under ideal conditions, and then what are we seeing in real-world conditions. In the laboratory we can make the virus survive on surfaces if the temperature is just right and the humidity is just right and the surface is just right. We can aerosolize it into the air if the conditions are just right, but the primary mode of transition is probably respiratory droplets meaning when I cost or sneeze I make a spray which has the virus in it and be able to pass on to somebody was near me, generally within a range of about six feet. It also suggests that I could contaminate surfaces, and it seems reasonable based on what we would observe so far as well as experience with other coronaviruses to say that these contaminated surfaces may play a role as well. That's why when we talk about control measures there is such a focus on if you are sick, stay home, wash your hands for 20 seconds with soap and water or use an alcohol-based hand cleaner with at least 60 percent alcohol, cover costs and sneezes and wipe down surfaces with commonly available household disinfectants. One question we get quite a bit is what about things like mail or products that are sent around the world. Even though in the laboratory virus can be detected on things like paper and cardboard, we are not seeing a lot of evidence of that from the real world. Otherwise I think we would've seen a lot more instances of the infection popping up in remote areas far away from China back in January, whereas when the infection was primarily in China we were mostly seeing cases that occurred in travelers coming out of China or in their household contacts, people who had fairly intensive exposure with people who returned home and subsequently became sick. That's why early in the response we had so much focus on travelers and restricting travel to be able to slow the entry of the virus into the US and around the world. >> What can we do to support and help our farmers who are actively engaged in spring planting? >> Yes, in terms of the actual act of spring planting I think that is actually a very good example of a work activity, as I think back on number of years ago now when I was working on a farm when I was an undergraduate student on Monday, Wednesday, Friday, and Saturday I mostly spent my time on a tractor hauling hay. That is the kind of activity that should be able to continue because it is not so hard to social distance as it might be in an office. Clearly it is also an activity where teleworking is not going to put the seed in the ground. The measures that can be taken is to avoid a lot of interpersonal contact when you come back and off the field. And also do everything you can to make hand hygiene possible ideally with water and soap, but if that is not available an alcohol-based hand cleaner. >> We are hearing a lot in the news about shortages of supplies and rural providers and hospitals, clinics, FQHCs often having even more of a shortage in terms of workforce and actual supplies that are needed. Can you speak to more rural specific suggestions? >> Yes, and I think toilet paper is in short supply everywhere, urban or rural. But the issue of shortages of critical supplies such as medications, such as personal protective equipment for health care settings, and particularly for our FH QCs, the federally qualified health centers is an area of concern. This is where the national response I think is going to be very helpful in terms of the work that is going on at FEMA in partnership with HHS, the Department of Health and Human Services, to be able to look at alternative supply chains to get some of that personal protective equipment out, and also us working with HRSA to be able to do everything we can to support the FQHCs to not only have supplies but also be able to manage the potential increase in patients as well as apply good infection control practices particularly when PPE may come into short supply. CDC's particular role in terms of PPE is addressing the demand side of the equation. What are the things we can do to help preserve PPE. We've got a couple of tools online that I think can be useful to clinics and hospitals, whether they are rural or urban, to be able to assess the PPE burn rate and to be able to project what their needs are going to be down the road. The response through the assistant secretary of preparedness and response is focused more on the supply side and ways to supplement what is available including being able to provide what provisions are available through the strategic National stockpile. >> Great, thank you. What should rural hospitals and clinics be doing to prepare for research? >> Preparedness is a very important part of all of this now that we are actually in response mode. Almost all hospitals have done some type of pandemic influenza planning exercise and they actually have a plan that is written out. Of course they say plans are no good if they just sit on the shelf, so I hope everybody who is running these hospitals has had a chance to pull their plans, pulldown their plans and think about what they learned during pre-pandemic tabletop exercises, and then how they will do with some of the unique aspects of this particular pandemic. Some of those unique aspects include health care workers who are unable to come to work because of school closures and lack of child care for their families, and then of course the concern that health care workers themselves can become ill and not only do we want to make sure that health care workers are healthy and able to keep working, but also that they don't then become a mode of transmission to high-risk patients. >> Thank you. How come Nutella difference between flu, COVID-19, and allergies because allergies are still active in a lot of areas. >> Yes, there is a lot of overlap. Let me start with that and of course with COVID-19 it is a brand-new disease so we are still learning a lot about it. Flu and COVID-19 probably have the most overlap because fever, cough, muscle aching, headache, can be prominent parts of both. Allergies generally don't cause fever but I have also talked to a number of patients who had very little fever with COVID-19, or it was not the first symptom. So it's I think virtually impossible to anybody who walks in the door complaining of a runny nose to say for sure which is allergy, which is influenza, which is COVID-19, but we continue to learn more about it. I know there is some reports now about things like altered sense of smell or a funny taste in the mouth being more common with COVID-19. I think at this point in time those are really anecdotal reports and they are intriguing and certainly merit more study, but we have no idea how predictive those types of symptoms might be for COVID-19. >> Thank you. Since we are more rural and spreadout are we at less risk? >> That's a very good question and it depends on more on your local environment then say your county environment. So if you are in a county with only two people per every square mile, that's a good start, but if you were in a household that has say 20 people in it, your risk may be similar to what it might be in a more urban area. I think in general we will see slower entry into particularly the frontier areas because of lower volumes of traffic, but it's important to look at history and what we have learned from that. When we consider the flu pandemic of 1918, before we even had air travel, that was an infection that spread far and wide and by November 1918, after the virus first was fairly prominent on the East Coast of the United States in September, it had spread even as far as the Seward Peninsula in far western Alaska. So I think it is reasonable to assume that while the entry into rural areas may be lower and it may be easier to do some social distancing because of the lower population, we should not assume that any part of the country is going to be spared. >> Thank you. Do we think this will go away during the summer, during warmer temperatures? >> The question about seasonality is one that I think we always -- we would like to think it's going to go away, but it's important that -- we can hope for the best but we have to be prepared for the worst. It gets back to our opening discussion about this is a brand-new disease and a virus, and while most respiratory viruses are less common in the summer, we don't know just how this one will behave. >> Thank you. So for rural providers should they be keeping well-child appointments, physicals, etc. ? >> The decision of keeping -- I will call them elective visits -- it really depends on the local situation. And it's concerning because we know that there are women who are pregnant now, they are still going to deliver. We know there are people with high blood pressure who still need to have their blood pressure checked, we know there are people with diabetes who still need to have their diabetes managed, and we know also that we want to keep our kids healthy. So being able to have those well-child checks and get on time immunizations is critically important. So it really is a decision that will ultimately be decided locally. Just very broadly our recommendation from the CDC is to consider deferring nonemergent procedures or elective surgeries or visits to a provider, but just when to do that depends on the local situation because we don't want to do think so early that then things that are not emergent become emergent by the time we are seeing a lot of spread of the virus locally. >> Thank you. How should providers, hospitals, and clinics respond if patients called and reporting exposure or symptoms? >> First of all that's what you want to have happen, have people call ahead rather than show up and maybe sit in the waiting room for a little while and they come back and say they have been coughing and have fever and particularly if they have been around someone known to have COVID-19. So that call ahead is important. For clinics and hospitals, they need to have a plan for how will you assess those people and also make a determination of whether or not they need to come in at all. There is a tool available that CDC has provided online that allows someone to check their symptoms and determine whether or not it is important that they get into see a provider right away. But of course someone who is severely ill, short of breath, chest pain, blue lips, these are symptoms of potentially a very serious condition which might be COVID-19. That's a situation where a phone call is nice but the phone call that needs to be made is really to 911. >> Thank you. There were some questions about language clarification around isolation versus quarantine, what does it mean to self isolate versus a Florentine and what should people be doing and not doing when they either self isolate herself quarantine. >> Okay, let's start with the definitions. I know this is confusing because many people use these terms interchangeably and they actually have technical meanings and there is a reason why they are different words. Quarantine means you are removing people who have been exposed to an infection from those who have not been exposed. So both groups are not ill. Isolation is when you have someone who is known to be infected and you are separating them from people who are not known to be infected. So usually in the hospital that is very common, whether it be actually an infectious disease or even just something that is grown out in culture. Quarantine is much less common. In fact the COVID-19 outbreak is the first time there have been federal quarantine orders signed in over 50 years. So we really are in a very unusual situation. In terms of do's and don'ts, I think do as much as possible but you have been asked to do. In both instances you need to try and minimize your contact with other people, particularly in situations of isolation because those other situations where we can be quite confident that there is a high likelihood of infectiousness for someone who has documented COVID-19 and who has symptoms. Some of the other things that can be done is making sure that people have enough food, that they have other medications, the things they need to continue life until either they have recovered or are through the 14 day quarantine period. This is an example of how we have to be together as much as possible even though it may be done at a distance. So if you have a neighbor, check on them by phone ideally, or just a knock on the door and take a few steps back from the door to see how they are doing. It's also an opportunity for particularly supporting older people are particularly people in isolation that we don't really want them to be going out to the grocery store to be able to get food and basic supplies to them. This is a role that I have observed that many faith-based organizations have taken on in terms of how they can do leg ministry, particularly with her younger people who are at lower risk, and taking appropriate steps to prevent the risk of transmission of infection but also making sure that people who are in quarantine or isolation are getting what they need. >> Great, thank you. Many rural communities have seen the hospital's close or decrease the number of services or amount of services they are able to provide. What are your suggestions for those communities were out of a hospital has closed are they not providing a full range of services? >> This actually points out a larger issue of the things that were challenging for us in rural and frontier areas when it is sunny and 70 degrees have not gone away, and things like hospital closures and lack of access to care are only worse during a time like this. So this is where planning, if you are not get impacted in terms of how people might be transported or how they might get care is critically important. Sometimes if the hospital is cut back or even if it has closed, if the building can still be occupied there may be opportunities to reopen to at least provide low levels of care. If there is a volunteer staff that could be made available. I don't know of rural examples of that yet but that actually did happen in Chicago where a hospital that had closed a number of months the back was actually able to reopen to provide care for people who were relatively mildly ill but unable to take care of themselves at home. >> What are your suggestions for rural communities regarding setting up isolation and quarantine spaces? >> The thoughts on isolation and quarantine is ideally to be able to do it at home, particularly people who are infectious or potentially infectious can be separated from those at higher risk. Beyond that it comes down to what resources you have in terms of where people can be housed. The issue of mass housing is I think always problematic in a situation like this, while after a tornado or an earthquake people might be housed in a gymnasium and fairly close together, that's not a good option during a pandemic, particularly for isolation of people who are actually actively ill. So it's going to depend on what is available locally. >> Great. We have a bunch of questions about testing. Where would providers, hospitals, or health clinics in rural areas get testing kits. >> The providers would not get testing kits, and I think this is where the term kit is misleading. Going back to when we started using it in describing what was being provided to state health departments. The current PCR technology, when we were using the term kits, it was basically a package of reagents and certain supplies that could test anywhere from 400 up to 1000 people. So it's not like a home pregnancy test kit or a rapid flu test, something that can be done in anybody's office. It's actually a fairly high tech procedure. As the FDA has worked to approve a broader range of the nucleic acid amplification tests and things like PCR, that has helped to push it out further, but still in general these are going to be tests that are mainly available either in state public health labs, large commercial labs, larger hospitals, and sometimes in larger clinics. So that's why earlier I was saying that I think what we are all really hoping for as soon as possible is something more like that rapid assay that can be done in the provider's office. Right now providers have a couple of options. One is to work through the local or state health department to get specimens to the state lab, or to work with the commercial providers that they work with who also many of them are now running the assays as well. >> Can anyone get tested if they want to or should we be prioritizing certain groups for testing? >> The CDC has put out some guidelines for prioritization recognizing that the global supply of some of the reagents and equipment are in fairly short supply. The people that we would recommend prioritizing our people at higher risk of severe illness, people who are hospitalized so appropriate infection control procedures can be in place, and then also health care providers because we want to make sure that no one who is sick and potentially infectious is taking care of patients and potentially exposing larger numbers of people. In general if the test -- in some areas the testing is more available than in others, but we do recommend it be limited to people who are actually experiencing symptoms of infection because we really don't know what the meaning of a test is in someone without symptoms. A negative test in particular doesn't tell us anything and we would be concerned that someone might feel an unreasonable sense of safety because they may still be in the incubation period and the results of that negative test in the face of limited resources for testing may not be very helpful. >> You have talked about rapid testing. What's involved in actually getting tested and when are the results available at this point? >> We have changed those guidelines as we have learned more about the results that we are getting with the assays. Now it is a single swab, it is what we called a nasopharyngeal swab or and NG swab which involves passing the swab back through the nose, literally almost as far back as it will go although we are getting more and more data that it can also go back just an inch or two and we might be able to get good results as well. It's actually a very safe procedure. I once did over 500 of them in a rural Alaskan village in one day, so it's not very time-consuming and the testing -- the swab goes into a viral transport media or some type of vial and then goes to a laboratory. The turnaround time after that depends on a couple of factors such as shipping time and whether or not the lab has caught up on any backlogs. Here at CDC we can do the extractions in about 4 to 6 hours and usually running the assay is just a few hours after that. There are some newer high throughput technologies that can provide more rapid results as well, so I think there was a lot of progress made in terms of being able to increase the throughput and get more timely results, but it's still not all the way out in the providers' hands. >> Great, thank you. There is some questions about when people if they are sick with COVID-19, or they have been exposed, whenever they no longer contagious, when can they go back to work. >> Yes, we are still learning a bit about that and this gets back to the earlier question about viral shedding. The PCR will remain or can remain positive in some people even after recovery. The data on actual recovery of the virus suggests that it's much lower than that. Currently the guidelines provide two options. One is to get two swabs 24 hours apart that are negative, and again this is after a positive test, this is not just any nose that walked in off the street. Some of the challenges in getting tested is that it would be at least three days after recovery of symptoms, particularly fever, and at least seven days after onset of illness. The one provision in all of that is if someone is a health care provider, because it is possible they would still be shedding virus although less since they would not be coughing or sneezing, they should wear a mask when they return to work. In that situation the mask is not to protect person wearing it but rather to protect the people they are in contact with. And for any health care providers who were listening, it is now more than ever hand hygiene is important, so 20 minutes -- sorry, 20 seconds with soap and water or using an alcohol-based gel. I de-recognize if you are seeing patients all day, soap and water that many times can be pretty hard on the hands and lead to a lot of chapping, so fortunately there are a lot of products out there that will help protect your skin and also do an appropriate disinfection. >> Can people be reinfected if they have been exposed or been ill or do we think that they would be immune? >> Again it is a brand-new disease and virus and so we are still learning. What we know about the common coronaviruses, and this is a family of about four coronaviruses that causes cold symptoms, there is an immune response for a period of time but there is a risk of reinfection down the road, usually a period of years and not weeks. At this point in time we are learning about the immune response to infection. There is an antibody response and that also opens up some doors for how we might assess better how this infection spreads and what is the spectrum of illness that it causes, but we really don't know for sure if people can become reinfected or when that risk of reinfection may occur. At this point in time we really don't have documented instances of reinfection. There have been reports of people who are PCR positive and then PCR negative, PCR positive again. But we really don't know exactly what that means because as we were talking about earlier, the PCR detects the RNA, the genetic material of the virus, and does not necessarily tell us what is present is infectious virus itself. >> You mentioned masks, should hospitals and clinics be stocking up on mask and should people be using masks? >> Hospital situations are different and to be very blunt, if you can get it it's a good idea to get it. But a lot of the PPE is a very short supply right now, so it's important that whenever PPE is available that it is managed very carefully because we know again getting back to some of these global supply chain issues it can be depleted and then we are going to have to be talking about what are some of the next best options to be able to protect our health care workers. In a health care setting the focus has primarily been on filtration masks, things like the N 95 and that is particularly important with something that will ever so lies the virus, like a procedure that involves respiratory secretion, probably even suctioning a patient on a ventilator. In terms of what might be useful in the community, in general CDC has no firm guidelines on that one way or the other. There is not a lot of evidence that wearing a mask in the community provides any additional protection over just basic hand hygiene, and I don't think I have mentioned trying to keep your hands away from your face but that is part of how you get back if your hands are infected that can be part of how the virus gets into your body and causes the infection. There may be a role for people who are exposed or who are in recovery to wear masks, again not to protect themselves but to protect those around them. And that is an area where we are doing some very active research and there may be newer guidelines coming out. Having said that I think even though we have touched on this a few times, it's important to recognize this is a new disease. We are learning as we go. It's very humbling as we recognize that sometimes what we learned two weeks ago, we learn something new and the recommendations may need to change. So I really encourage you as much as possible, keep an eye on what is coming out either from your state health department website or at CDC dot gov COVID-19. >> The next question is about treatment or management. Does [can't understand] help as treatment or prophylaxis for frontline health care providers per Jeff let me start with a very broad statement. Currently there are no proven medications that will treat COVID-19 and that have documented improvement in outcomes. Let me start actually with hydroxychloroquine, the generic name, there are some mostly uncontrolled data coming out that are encouraging. The nice thing about hydroxychloroquine is it actually is FDA approved for other purposes, mostly treating different types of autoimmune or rheumatic diseases such as psoriasis. So it is available. There is not a lot of really hard data for treatment yet and we are working very closely with NIH to develop guidelines and be able to gather whatever data is available, particularly from China where there has been more experience with this. Chloroquinoline is another drug that is fairly readily available. Last data as well. There is an antiviral drug called [can't understand] which is not approved for any purpose right now but is in randomized clinical trials right now particularly for treatment of more severe infections. And we hope to have data on that soon because some of those trial started in China nearly 2 months ago. There has been at least one fairly large trial completed and mostly data that is coming out of China again about some of the protease inhibitors, the class of drugs used for treating HIV, Le Pen of fear and ritonavir combination. Unfortunately they are fairly disappointing in terms of documenting there was improvement in symptoms or outcome and actually there was no evidence that it reduced viral shedding. So I think this is an area where we have to monitor the science closely and hopefully we will know more soon, but at this point in time there is no proven treatment that's going to make outcomes better. The question about prophylaxis is a very good one because I think many of us are familiar with that with where we were at in 2009 with the influenza pandemic. We had time of year and antiviral drug that was useful for treating exposures or critical infrastructure individuals prior to the onset of symptoms to prevent infection, there is basically no data on that with COVID-19 at this time. >> To cyber profit exacerbate symptoms of COVID-19? >> Think for asking that question too because I know that is come up based on some reports that came out of France. Those were really anecdotal reports and have not been observed as much elsewhere. So at this point in time we have no recommendations against the use of ibuprofen or other nonsteroidal anti-inflammatory drugs. >> We have received several questions about smoking and tobacco use. So either sharing of tobacco products increasing risk of transmission, people who are trying to quit are becoming potentially more anxious and maybe smoking more or relapsing -- what recommendations would you have for somebody has quit to stay in that status. >> Let's start with the question about sharing cigarettes or whatever. In general sharing anything that goes into your mouth is probably not a great idea, but it's an even worse idea right now. It certainly could be a way that COVID-19 is transmitted. In terms of a question that I think many of us are looking at the data very closely about is whether or not cigarette smoking itself is a risk factor for more severe infection. What's really intriguing is the epidemiology from China where the death rates among older individuals are much higher, but they are much higher among men than among women. And the smoking rates among men in China are quite high, whereas among women they are much lower. And so certainly one of the hypotheses is that there may be a very particular role that cigarette smoking is playing in increasing the risk of severe COVID-19. So I think the bottom line there is maybe more for providers is we need to do everything we can to be able to support people who have ceased smoking, to be able to prevent restarting smoking. And this also I think highlights that these are stressful times and there are ways other than using tobacco that can be useful to manage stress. >> We have a couple of minutes but we still have a couple of questions on prevention. What can community members do, churches, restaurants, civic leaders, people in the community, what can they be doing right now? A couple of areas. First of all we have talked about social distancing, that is very important. To be able to as I say stand together but at least six feet apart because it's going to take a community response to be able to address this. Being able to limit or postpone gatherings is important. I saw kind of an amusing picture of a wedding that was held outdoors and there was actually a grid on the ground where all of the participants stood at least six feet apart. I think the groom did get to kiss the bride, but other than that no one was in contact with anyone else. Although in general it is probably better to postpone any kind of gathering like that. The impact on small businesses and restaurants cannot be underestimated. If you are able to support your restaurants that are providing take out services, a number of them actually now have donations, ways to be able to help their employees that may currently not be getting paid. That's important. And I think as we were discussing earlier, know your neighbor and find out if they have particular needs because there's a lot we can do remotely and even with minimal face to face contact to be able to help one another through these difficult times. >> Great. Thank you so much, Dr. Butler. We at CDC hope that this information has been helpful to our rural partners and stakeholders. You can continue to send questions to rural health at CDC dot gov, that is a mailbox that we monitor regularly. And with that we will close this call. Thank you. >> Thank you everyone.
B1 rural covid cdc people health infection Update for Rural Partners and Communities on the Coronavirus Disease 2019 (COVID-19) Response 5 0 林宜悉 posted on 2020/04/07 More Share Save Report Video vocabulary