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  • >> Hi, good afternoon.

  • We would like to welcome you all to our update for private sector

  • organizations.

  • on the 2019 coronavirus response or COVID-19.

  • We are grateful for all you are doing to keep your employees and

  • communities safe and we are pleased to have Dr. Jay Butler here to give

  • updates from CDC and thank you all for who submitted questions in

  • advance.

  • We approximately appreciate your engagement.

  • I would like to introduce Dr. Jay Butler.

  • He brings a lot of expertise.

  • You probably heard him from previous phone calls as well.

  • He is the deputy director for infectious diseases.

  • he provides leadership to the three infectious disease centers and hopes

  • to -- and he brings experience, 30 years of experience both in the field

  • and here at CDC so has a lot of great perspective.

  • I will turn it over to him to provide an update on where we are at with

  • the coronavirus

  • >> Good afternoon and good morning to those on the west coast.

  • Today is March 30th.

  • It's interesting to think it was December 31 that the world was first

  • notified of the cluster of.

  • pneumonia cases that occurred in but, China -- but- Wuhan China.

  • We are here to talk about a pandemic caused by a virus and disease that

  • we didn't know existed only three months ago.

  • It's both humbling and fairly stunning to think how much the world can

  • change.

  • in only three months.

  • Of course, as of today, the virus has spread pretty much around the

  • world.

  • There are laboratory confirmed cases in over 200 countries now.

  • There is almost certainly some bias in that depending where testing

  • capacity is, but the virus has now been documented for several weeks on

  • all the -- all of the inhabited continents of the earth.

  • The majority of cases right now are being reported in Europe, but also

  • every jurisdiction in the Americas is involved now.

  • The United States actually has the most laboratory confirmed cases of

  • any country.

  • including more than were confirmed in China as well.

  • Here in the United States, there have been over 140,000 confirmed cases,

  • probably closer to 150,000 by now.

  • Unfortunately there have been over 2400 deaths.

  • Every state has seen cases.

  • Some more than others.

  • There are certainly hot spots.

  • New York City, the chief among them.

  • Also seeing some fairly dramatic increase in the activity in the Boston

  • area New Orleans and in other areas around the country.

  • I recognize that depending where you are at, it may look very different,

  • but there is a slough of information that's available on the status of

  • the epdicking at CDC.gov/COVID-19.

  • And also that page will be getting considerable remake later in the

  • week.

  • We want to provide useful data in a graphically -- in way that

  • graphically.

  • is presented to be able to facilitate communication.

  • Please do keep an eye on that website.

  • We continue to find that the people at highest risk of severe illness

  • and fatal.

  • outcome are those who are older, particularly over age 70 to 80.

  • And that people with underlying heart/lung/kidney disease are at higher

  • risk as well as those with diabetes.

  • There will be a descriptive paper coming out in the MMWR later this

  • week.

  • highlighting some of the risk factors for more severe disease.

  • Now that said, I think it is a couple of paradoxes here that are always

  • tricky in the communications.

  • The vast majority of people who are infected with the SARS COV2 virus

  • will recover completely.

  • We are learning more and more about the mild manifestations in some

  • people and also asichmatic infection.

  • However, younger people are not completely immune to more severe

  • disease.

  • We occasionally learn of unfortunately people in their 30s and even 40s

  • winding up in the ICU with COVID-19.

  • Let me walk through some of the emerging hot topics.

  • One of the issues that I just touched on is what appears to be a more.

  • likely roll of pre-symptomatic transmission, and even asymptomatic

  • transmission where we have data from cohorts of people who have been

  • exposed with testing.

  • We are finding it's not uncommon to have fairly high amounts of virus

  • present in the nose and throat before onset of symptoms.

  • In fact, people who develop symptoms, the highest amount of virus is at

  • the time.

  • of the onset of symptoms with some decline afterwards.

  • It may be a bit of a game changer for us as we look forward in terms of

  • trying to determine what are the best ways to mitigate transmission and

  • to slow the spread of the virus.

  • I think everyone is aware of the goal of flattening the curve.

  • That's become a household term now.

  • The overall goal there is to distribute the impact of the pandemic over

  • as long a period as possible in order to maintain critical

  • infrastructure, and particularly to keep the health care system from

  • becoming overwhelmed.

  • So one of the issues that we are also looking at because of that is

  • whether or not.

  • use of face covering might be of utility in the community to prevent

  • transmission from people who are either not yet symptomatic or

  • asymptomatic.

  • We don't know what role asymptomatic infection might play, but as we

  • look at some of the experience around the world in areas where face

  • masks are oftentimes worn more often for the wearer's protection, there

  • may be a benefit because of source control with this particular virus.

  • So we are looking hard at the possibility of using face covering or non-

  • medical masks as a method to basically as an environmental control, if

  • you will.

  • Again, not something that necessarily protects the wearer, but something

  • that would be an additional tool in the toolbox of community mitigation

  • measures in addition to what's been done already for social distancing.

  • I imagine everyone is aware, speaking of social distancing that

  • guidelines coming from the White House task force have been extended

  • through the month of April.

  • As we look around the country, I think there are 17 states now that have

  • had some type of stay at home order statewide.

  • 49 states that have closed schools statewide.

  • 9 only state that hasn't -- the only state is -- 99% of the schools have

  • closed based on decisions made at the local level.

  • These community mitigation measures are part of what we do -- an

  • important part of what we do to flatten the curve until we know more

  • about the status of any chemo prophylactic agents.

  • right now there are basically none.

  • There are therapeutic agents that are under study.

  • we certainly can talk more about that if you would like.

  • A vaccine that's probably at best 12 to 18 months down the road before

  • that would be available for more widespread use.

  • I was talking about face covering.

  • It's important to recognize the importance of maintaining personal

  • protective equipment for health care workers.

  • There has been a lot of work done and the response that's now led out of

  • FEMA and the national response coordination center to be able to tap

  • into the strategic national stockpile and also to be able to receive

  • donations of PPE and other equipment such as surgical masks to be able

  • to get them out into the communities where they are needed by health

  • care providers.

  • Another real hot spot of concern is the long-term care facilities.

  • I was mentioning earlier, the persons at highest risk of severe illness

  • are older persons and persons with chronic underlying conditions.

  • Many people in long-term care facilities are both older and have under

  • lying conditions.

  • Some of the worse situations we've seen in terms of outbreaks have been

  • in long-term.

  • care facilities.

  • As of now we are aware of over 400 long-term care facilities.

  • that have had cases in a large number of states.

  • It's an area where we are doing everything we can to provide technical

  • assistance to our partners at the state and local level.

  • Regarding testing, testing using the PCR and other nucleic acid assays

  • continues to become more available there are 20 platforms that have

  • emergency use auto sx granted by the FDA.

  • The number of tests that the test results that have come back are over

  • 400,000 so far.

  • There is a lot -- the capacity in the commercial labs is greater than in

  • the public health labs.

  • So far about a third of all of the tests that have been completed have

  • been in the public health labs.

  • So I really want to acknowledge the important role that commercial labs

  • have played in terms of meeting the demand for testing.

  • There are in addition to more than just traditional PCR, I was

  • mentioning nucleic acid assays, this is helping us move toward being

  • able to push testing as far out into the health care system as possible.

  • And also get a faster turnaround on results.

  • The latest EUA granted is for a nucleic acid assay that can be performed

  • in many laboratories that are present in larger community centers, and

  • perhaps in the larger specialty clinics and can return a result in as

  • little as 15 minutes.

  • Ultimately the goal will to be have some sort of true point of care test

  • that would be performed by a provider and have a result back before the

  • patient leaves either the emergency department or the clinic.

  • There is a lot of work that is occurring now to move us in that

  • direction.

  • Of course, that is normally how influenza is usually diagnosed in this

  • country.

  • Also, HIV and hepatitis C testing is performed that way also.

  • We also have a lot of interest in serlogical testing.

  • Here at CDC we have an ELISA assay developed and serology is not going

  • to be.

  • very useful in terms of diagnosing acute infections.

  • It will be more useful for epidemiological assessments that answer the

  • questions about how often sub clinical or asymptomatic infection occurs

  • and to be able to assess population based immunity levels as the

  • pandemic continues to spread.

  • There are some -- there is some interest in the commercial sector to be

  • developing serlogical assays as well.

  • I would have to defer to FDA to discuss any saitous of emergency use

  • authorization applications.

  • I know there has been some development of rapid serlogical tests that

  • have been marketed in other countries.

  • A question we often get, are they any good?

  • At this point we don't have a lot of data or assessment on those.

  • It's a very pressing issue we know, and we are very much involved in

  • being able to evaluate the utility of serologic assays as well.

  • So at this point in time, maybe this is a good chance for me to stop

  • talking and start going through some of the questions.

  • >> Great.

  • Thank you.

  • I would like to remind folks this call is intended for partners in the

  • private sector if you are media, we won't be answering media questions

  • and you get questions that should be sent to the media @CDC.gov

  • >> A very clever web address

  • >> So I have some questions here about mail and incoming packages.

  • Are they safe?

  • Should business being doing anything particular in those

  • >> Excellent question.

  • So people may be aware that there was a paper published by both CDC and

  • NIH a couple of weeks ago looking at what are the maximal survival times

  • for the SARS COV virus in the environment on various surfaces at various

  • temperatures on different materials.

  • And it's important to recognize that this paper really looked at

  • maximizing the opportunity for the virus to survive.

  • So it's an important paper, but also has to be interpreted in light of

  • the real world situation.

  • In that paper it was possible tounder the right conditions could get

  • virus that could be recovered from cardboard or paper.

  • The epidemiology of COVID-19 doesn't point to rapid dissemination.

  • of the virus through the mail.

  • Given the amount of mail and various produced goods that come out of

  • China in particularly out of the province where Wuhan is located, if

  • this were an important mode of transmission, I think we would have seen

  • earlier popping up of, if you will, metastatic foci of transmgs around

  • the world.

  • what we saw during January and the first half of February was spread

  • outside of China primarily by way of travelers who had become infected

  • in China and who had traveled while asymptomatic but developed symptoms

  • after return.

  • In the cases that occurred secondary to those travelers were mostly

  • among.

  • household contacts.

  • So this points away from really widespread transmission through

  • contaminated goods that were sent around the world.

  • Currently the bulk of the evidence still points towards respiratory

  • droplets as primary mode of transmission.

  • These droplets are generated, of course, during coughing and sneezing.

  • Even as I sit here coughing, I'm producing a small amount of respiratory

  • droplets as well.

  • So this is of concern as we begin to learn more about the amount of

  • virus that may be present in the Naso pharynx prior to onset of symptoms

  • the other possible mode of transmission that I have touched on already

  • is contamination of surfaces, and I think for at least a month now

  • everybody has become very familiar with the concept of hand hygiene.

  • Knowing that hands are an important mode of transmission for a number.

  • of respiratory viruses and we would expect it's likely for the SARS CoV2

  • virus as well and decontamination of surfaces particularly high touch

  • surfaces such as doorknobs touch pads.

  • I've notice in a restaurant that's takeout service they have a whole jar

  • of pins.

  • for people to sign their credit card notices and move it over to the

  • dirty pile and then there is someone who goes through about once an hour

  • or so and wipes down the pens with an alcohol wipe and moves them back

  • to the clean side again.

  • These are some of the kinds of things that are being done to be able to

  • reduce the risk of transmission by fomites.

  • Another question is whether or not airborne transmission is occurring.

  • The difference between airborne and respiratory droplets is airben is

  • more -- is like what occurs with tuberculosis or the measles virus.

  • It's not just a matter of droplets that fly through the air until

  • gravity takes over and they fall to the ground.

  • It actually becomes a airborne particle that potentially infectious and

  • can float around the room.

  • It can be entrained into the ventilation system and spread through that

  • route.

  • There is not a lot of evidence for that at this point in time.

  • Again, the caveat in all of this is that we are talking about a virus

  • and a disease that we did not know exist three months ago.

  • The emerging epidemiology still does not support a prominent role for

  • airborne transmission.

  • That said, we do recommend particularly in health care environments

  • especially when there is a possibility of Airosol producing procedures

  • being performed that airborne precautions be takennen by health care

  • workers

  • >> We have questions about asymptomatic and pre-symptomatic.

  • and if we know anything when a person might be most infectious.

  • >> That's a good question and one of the things that over the past

  • couple.

  • of weeks as we have more experience with this new disease where the SARS

  • CoV virus may behave sirchly than the SARS coronavirus.

  • In SARS, the peak level of virus.

  • and peak level of infecttivity, the peak of illness several days after

  • onset for for SARS CoV, the highest amount of virus in Naso financial

  • appears to be at -- Naso fir reasonings at symptom on set.

  • In those people we have samples upon symptom onset.

  • the viral load can be fairly high.

  • Exactly when does someone become infectious is not entirely clear,.

  • but I think it's entirely plausible that it could even be as early as a

  • couple of days before onset.

  • This is fairly unusual for respiratory viruses.

  • We know that flu sometimes starts being shed a few hours before onset of

  • symptoms.

  • This is particularly concerning with coV19 there is a period of days of

  • infectiousness.

  • The other difference of COVID-19 and influenza, is the onset can be

  • fairly subtle.

  • In fact so many people the disease can be very subtle.

  • I chatted with one gentleman in his 40s that had a documented infection.

  • He actually never had any cough at all.

  • He felt a little off.

  • The next day he felt more off.

  • Had a little bit of a headache.

  • Muscle ache.

  • Thought he might have had the flu.

  • Took his temperature and he had a low grade fever.

  • And then he thought about some of the international travel that had

  • involved Europe at that time.

  • He became concerned that he might have COVID-19.

  • And was tested here in the United States where he was at and was found

  • to be positive.

  • He recovered after about four days.

  • And never really had cough or shortness of breath.

  • A little bit of runny nose he was unsure if that was attributable to

  • COVID-19 or not.

  • So it's one of the challenges with control of this virus.

  • It actually is a challenge to some of our initial approach of test and

  • isolate to know that the virus may spread.

  • from people that are not yet symptomatic.

  • The reason why community mitigation, social distancing and some of these

  • things that we have been instituting and have been talking about over

  • the last 20 minutes may be so important.

  • So you mentioned in your comments perhaps face coverings for either

  • essential work force.

  • non-health care workers or the general public.

  • And it seems like clarification on who that might be protecting.

  • Can you comment on that?

  • Sure.

  • Actually has been some discussion nor at least a week or two -- for at

  • least a week or two now for people who have been exposed who are part of

  • the critical infrastructure work force being able to monitor for

  • symptoms but continue to work while wearing face cover.

  • That was more just because the symptom onset can seem to be -- fairly

  • subtle sometimes.

  • With the newer data suggesting that there the potential for transmission

  • prior to symptom onset and possibly even from asymptomatic people, it

  • does raise the question about what role face covering would play more

  • broadly.

  • One other observation its comparing the U.S. to the experience in South

  • Korea where there was some very aggressive test and isolate procedures,

  • but there has been widespread use of masks.

  • I think many of us have looked at the rates of infection that are

  • confirmed in South Korea, particularly over the past week or so with a

  • great deal of envy because it did seem to plateau off very well.

  • Many people were attributing that to test and isolate which certainly

  • did play.

  • a role, but it also raises the question about the frequency of mask use

  • in communities in South Korea.

  • Which in some of the communities where there were high rates of disease

  • were even mandatory.

  • And so it does raise the question of whether or not face masks even

  • whatever reason they were being worn, might have played a role in

  • mitigating basically source control.

  • So to summarize that, I think putting the lift of observations together,

  • it does begin to raise the question of the utility of using masks as

  • source control to be able to limit spread from people who are infectious

  • knowing that we may not be able to have good clinical markers for who is

  • infectious.

  • I think this is an extension of something that we commonly do when

  • someone is symptomatic and even with COVID-19 has been recommended all

  • along.

  • If someone is coughing and sneezing and needs to be in public or going

  • into the health care system, they should have a mask on to be able to

  • limit the spread of those respiratory droplets.

  • that may very well be something that we need to be expanding to a

  • broader swath of the community.

  • I think there are questions that we are trying to sort through very

  • quickly in terms of what are the thresholds to make that recommendation?

  • When should it be worn?

  • And what are the measures to decide when it's no longer needed?

  • There are some questions both on-line and received in advance about

  • close contact and how is that defined and what's prolong and how is it

  • defined

  • >> Yeah, I feel like I've seen this concept of the six feet develop over

  • the past 20 years.

  • starting with SARS and maybe a little before that.

  • And I'm sure many people on this call are aware that if you are in the

  • EU they will say two meters.

  • It's not a magic number of 72 inches is not good, and 73 is a problem.

  • So it's getting back to that concept of how respiratory droplets are

  • spread as they come out of the source person they fall to the ground.

  • So the closer, the greater likelihood exposure, the more time you spend

  • in that close proximity the greater likelihood there is of an infectious

  • exposure.

  • In terms of what's a minimum time, the data are such that it's a

  • continuum.

  • I think I would be hesitant to break it out too much, but in general the

  • way we've looked at it is comparing a quick passage of tbreetings being

  • low -- greetings being low risk whereas sitting next to one another at

  • dinner would be a moderate risk.

  • It really is a continuum of the variable of how close you are, whether

  • or not the source person is coughing or sneezing.

  • And then the amount of time together as well as the susceptibility of

  • the person who is exposed.

  • >> There are some questions in here if you are a business that's open.

  • and maybe have an employee who is sick.

  • What kind of things should you do, put into place?

  • The most important is someone is at work and becomes symptomatic is they

  • should be isolated away from other employees.

  • and customers.

  • This is one of the areas where we have recommended use of face covering.

  • in the community for quite sometime now.

  • It does not have to be a surgical mask or an N95.

  • Preserve those.

  • We would recommend against it.

  • Again, basically just trying to cover the nose and the mouth to limit

  • generation of respiratory droplets.

  • You want to be able to get the employee either home to self-isolate or

  • if they are ill to a place to be evaluated, to determine whether or not

  • hospital care is needed.

  • In terms of other employees, notification within the appropriate

  • parameters of representing privacy is important.

  • And I encourage everybody, particularly with larger corporations that

  • have HR legal support to review what are your corporate policies as well

  • as any state or local regulations that may apply in this situation.

  • In terms of the environment, ideally I think this is an area where the

  • ground is shifting some as we learn.

  • more about COVID-19.

  • We have guidelines on the website about cleaning and able to

  • decontaminate.

  • areas and I think those those will continue to be updated as we continue

  • through the experience with the pandemic.

  • I think with our newer learning it raises the question about how much

  • already.

  • people in any public area may be infected with COVID-19.

  • I know the practices that I just observed is that a number of stores

  • that remain open such as grocery stores which are critical to maintain

  • food supply, many are cutting back on hours so they can have more time

  • invested in being able to do very thorough cleanings to keep the work

  • space as well as the customer areas as safe as possible.

  • >> I feel like you answered in some ways when you were talking about

  • before about mail and packaging but I think it would benefit.

  • So the question we got is can I catch it from food?

  • That's a great question.

  • In the traditional sense of what is a foodborne pathogen that appears to

  • be very unlikely.

  • So catching it from food is probably going to be more in the situation

  • where you're eating with somebody and there are respiratory droplets

  • that fall on food as you are eating it.

  • Right now there is not evidence that there is contamination of food that

  • goes through.

  • the food distribution system.

  • So I think the bottom line is that it's not known to be a route of

  • transmission for COVID-19 so it's certainly something to consider.

  • I think the basic rules for food safety, hot food is 409, cold food

  • is -- hot food is hot and cold food is cold.

  • Just because we are in the middle of a COVID-19 pandemic doesn't mean we

  • are protected from Salmonella norovirus or any of the traditionally

  • thought of foodborne pathogens.

  • >> These are music to my ears.

  • We have a series of questions.

  • But sort of in the same spirit like, how do we know if the curve is

  • flattening?

  • When do we know if this pause is working or not?

  • When can we wake up again?

  • >> Those are great questions.

  • It seems like modelers, the new dinner guests you have as soon as you

  • can have dinner guests again.

  • They play a critical role.

  • If we look at case counts and laboratory confirmed cases, it becomes

  • challenging because ideally we want to put the resources that are

  • available in the spot that are transmission is occurring or about to

  • start occurring.

  • When cases -- case counts are going up, it's important to recognize that

  • alone as a measure is basically reflecting transmission that occurred

  • ten to 14 days ago.

  • Why do I say that?

  • It's important to recognize that this is -- while this is an acute

  • infection, it has an incubation period.

  • The range is two to 14 days.

  • The probably the peak is around five days, six days.

  • The onset can be subtle.

  • So people may not seek care or testing until after three or four days

  • into the illness.

  • Although it looks like turnaround times are on average down to about a

  • day or two particularly as that initial surge that hit the commercial

  • labs is being addressed.

  • It still adds up to a number of days.

  • So this is where modelers come into play and will be helpful not only in

  • identifying what are the areas that are on the upsurge, but also when

  • things begin to wind down again.

  • So unfortunately in many ways this is different from influenza where we

  • know basically most all of the influenza viruses behave similarly and we

  • would be more confident in that type of projections.

  • We are always learning new things about the SARS CoV2.

  • So it will be a learning process as we go forward that's determined.

  • optimal ways to give the -- I'm not going to say the all safe.

  • it's probably a more scale back of the interventions.

  • For instance, when is it appropriate to re-open schools?

  • When is it appropriate to loosen up and have more businesses open?

  • , particularly to be able to keep the economy going?

  • I think it's very likely that for sometime for businesses that allow

  • teleworking they are able to maintain productivity.

  • That is going to be something that will continue.

  • And then finally, mass gatherings are important early in this pandemic

  • there is an important role of travel and mass gatherings.

  • That's ongoing work that's determined when it's best to determine those

  • recommendations as well.

  • Can you say anything about the three things that are going on right now.

  • Allergies and flu and coronavirus?

  • >> Yeah.

  • That's a great chance to talk about some of the challenges just in terms

  • of identifying when someone has COVID-19.

  • I mean, particularly many of us who are working long hours these days we

  • generally don't feel ourselves to begin with, but then add that in to

  • the pollen season which we are into down here in the south.

  • As well as the fact that we still have influenza activity around the

  • United States.

  • 2 makes it very hard to -- it makes it very hard to know just based on

  • symptoms of respiratory illness whether or not it's COVID-19 or not.

  • This is one of the reasons why we have keen interests in not only being

  • able to increase the availabilities of diagnostic testing.

  • using the platforms that exist now, but also being able to support the

  • availability of more rapid and widely available testing.

  • I know there has been talk about home testing.

  • That's ongoing research as well.

  • If those tests are validated, it could be a good way for people to have

  • a little more guidance of when to self-isolate and when it will be

  • critical to stay home from work.

  • And maybe one last thought along those lines.

  • And maybe harkening back to the earlier question about and reinterpret

  • that question when is this all over?

  • We look at influenza pandemics in the past, particularly 1918, you know

  • it went on for about two years before it tailed down and then that H1N1

  • virus was the predominant flu strain circulating causing seasonal flu

  • until shortly after World War II, in 1947, when there was a shift in the

  • H1N1 type.

  • So it will not be over in a few weeks, but what we hope we can be able

  • to do is loosen some of the community mitigation so that we can hit that

  • sweet spot of doing the things it takes to be able to save lives and to

  • reduce transmission, but also not have the untoward effects of people

  • not being able to have the appropriate care of their chronic conditions

  • or their additional emerging health conditions as well as the impact on

  • the economy and our educational system.

  • it really is an ongoing process of balancing the cost and the benefits.

  • I'm going over a series of questions about PPE.

  • Some sort of thing they might need or where can they be accessed.

  • I wonder where you can comment.

  • The availability of PPE is being run now under the associate -- the

  • assistant secretary for.

  • preparedness and response, who had responsibility for the strategic

  • national stockpile since about mid-2018 now.

  • And then that is part of the overall FEMA response as well.

  • So those requests probably need to go through the state emergency

  • response coordinator.

  • to direct them up to the people that are best suited to be able to

  • respond and provide advice

  • >> We are just about at time.

  • I'm wondering if there is any key messages or anything you would like to

  • leave.

  • our private sector business partners

  • >> Sure.

  • First of all, thank you for your partnership.

  • These are difficult times and I know that's just not a statement from a

  • health care provider and public health professional perspective, but for

  • all of us and the world will never be the same again as we continue to

  • learn not only about what we have been learning over the last couple of

  • decades about emergence of the diseases that adapt to infect humans and

  • the potential for global spread of new viruses we've learned about the

  • global supply chain and how during a pandemic response it's much broader

  • than just the health issues that are impacted.

  • It also goes the other way.

  • I think many of us in health are aware that economy has an important

  • influence on the health of the population.

  • Are seeing that in ways that are very real and painful that we've never

  • seen before.

  • So I hope that out of all of this, we will learn that we are all in this

  • together, and that through the relationships and the planning that

  • involve both health and the private sector-- the private sector un

  • related to health care will be more prepared for the next event like

  • this that happens.

  • And not to end on a sour note, but we have seen the influenza pandemics

  • before.

  • We will see them again.

  • I would not be surprised if we don't see more events with 9 pandemic

  • disease.

  • caused by other viruses.

  • This one -- viruses.

  • This one seems particularly bad one.

  • Let's all stay in it together because I think together we can address

  • this although, of course, standing together six feet apart.

  • Thank you for the chance to talk with you.

  • I hope everyone is well.

  • And so I wish you well

  • >> Thank you Dr. Butter and thank you all for joining us today.

  • This concludes our call.

  • We will continue to update guidance as we continue working on this issue

  • and we will also continue having calls.

  • Your input and questions if not answered today are informing our future

  • works and understanding if there are gaps in our guidance.

  • So thank you again and have a great day.

>> Hi, good afternoon.

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