Placeholder Image

Subtitles section Play video

  • >> 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.

>> Good afternoon and thank you for joining us today.

Subtitles and vocabulary

Click the word to look it up Click the word to find further inforamtion about it