Saleem Abu-Tayeh: Hello everyone! Thanks for joining us today on our sixth and final episode of our Unwritten Webinar Series, where expert authors are joined by student co-hosts to talk about our COVID changed world. I am your host Saleem Abu-Tayeh, a Pearson Campus Ambassador and a second year at the University of Virginia studying Global Commerce and Biology.
In this episode I am thrilled to have the opportunity to discuss the pandemic from a historical context, where we were, where we are now and what we can expect in the future.
I am joined today by Laura Howe, who is the Vice President of Innovation Communications for Pearson. She will be moderating our live Q&A. Get your questions ready and put them in the chat box. We will get to them in about 15 minutes.
I am also delighted to welcome Dr. Lourdes Norman-McKay, a medical scientist who earned her PhD in Biochemistry and Molecular Biology from Pennsylvania State University College of Medicine. As a postdoctoral fellow she specialized in microbiology and immunology and studied the roles of viruses in cancer. Over the past 17 years as a professor at Florida State College in Jacksonville she has strained thousands of allied health students through courses such as microbiology, biochemistry, virology and anatomy and physiology.
Her Pearson textbook “Microbiology: Basic and Clinical Principles” is used across the globe to teach tomorrow's healthcare team, many of whom are now frontline workers in the current COVID crisis.
We want to begin each of these conversations by turning it over to our expert authors for a two-minute hot take on the most important thing we should know about our COVID changed world.
Dr. Norman-McKay, give us your hot take.
Dr. Lourdes Norman-McKay: Thanks so much Saleem and Laura and welcome to our viewers! The hot take is pandemics are not new and they aren’t going away. If anything, we can expect an increase in their frequency. We must have well developed and globally cooperative plans to fight these inevitable challenges because our global economy won’t confine newly emerging pathogens to a single nation.
In just the past 50 years we have seen an unprecedented increase in the number of dangerous and newly emerging viruses infecting humans. Some examples include mosquito-borne viruses like Zika and chikungunya, hemorrhagic viruses like Ebola, hantaviruses, Lassa fever and Marburg virus, influenza viruses like avian influenza and swine flu. And the shockingly infectious and deadly coronaviruses such as SARS and MERS and of course we are now seeing the effects of SARS-CoV-2, which causes the disease COVID-19.
This is not politics. This is Mother Nature. We must improve our processes to fight emerging infectious agents rather than laying blame on a specific government or nation. If we managed a hurricane or an earthquake by blaming another country or political party, it would be outrageous or at the very least nonproductive. Similarly, we must depolarize other acts of nature like pandemics to include the current one and get to the important work of effectively managing them or better yet at preventing them.
Saleem Abu-Tayeh: Thanks Dr. Norman-McKay! I think you made some vital points about uniting the country. Now let’s get into some questions.
One of the common rebuttals to current stay at home orders in the US is why are we so concerned, the flu kills 60,000 people on average a year and we haven’t had to do this, why is COVID-19 so different?
Dr. Lourdes Norman-McKay: Saleem, that’s a really important question to address. It’s essential for people to understand that SARS-CoV-2, which causes COVID-19, is more dangerous than the currently circulating seasonal flu. It’s true that the typical seasonal flu kills about 60,000 Americans per year, but in under six months, and despite dramatic public health measures over 84,000 Americans have died from COVID-19. Let that sink in. That’s 40% more deaths in half the time and the virus hasn’t yet run its course.
For some perspective, when we look at the monthly average for the top 15 causes of death in the US, we see that COVID-19 is ranked number one. It’s way ahead of flu, which is eighth. And it's even higher than deaths from heart disease or cancer, which are second and third, respectively. I would hate to imagine how COVID-19 deaths would have looked had we treated it like a run-of-the-mill flu.
So why is SARS-CoV-2 worse than seasonal influenza? That answer has two parts; the number of susceptible hosts in the population, that is the number of people who can catch the virus and how the virus attacks the body.
Let’s start by considering susceptible hosts. Most people are susceptible to SARS-CoV-2 infection and certainly more so than are susceptible to the currently circulating influenza virus strains. Why is that? Well, we have vaccines against influenza and that reduces the number of susceptible hosts. And secondly, influenza strains roll through the population on a regular basis, so there is some carry over resistance across the population.
Of course that could change if the flu mutated into a more dangerous strain and that’s always a distinct possibility which is why we have aggressive flu monitoring programs in place. I imagine a longer-term change in public health will be that we add novel coronaviruses to the monitoring program.
The second consideration relates to how SARS-CoV-2 affects the body. When thinking about how our bodies respond to viruses, it’s helpful to envision the immune responses being like a controlled burn that keeps forests healthy.
Like a controlled burn our immune system normally applies just the right level of fire, or in this case, protective immune response to clear a virus. In a controlled burn situation, the patient may get sick and feel terrible, but they are less likely to develop life threatening complications. They are likely to recover. Again, that’s the typical healthy response.
On the flip side, the elderly and those with underlying medical conditions have a less effective immune response. They can’t keep the controlled burn going, so they struggle to clear the invading virus. Therefore, without an effective way to reduce viral loads, the patient is more likely to die.
It’s worth noting that to date the only viral infection that we can actually cure with medications is hepatitis C. All of our other available antiviral drugs only reduce infection severity. They don’t technically cure a patient. This fact holds for the potential COVID-19 therapies that are being investigated too. They won’t cure the disease. They will just make it more manageable
and push the odds in favor of recovery. Ultimately, the immune system is the final force that’s going to have to clear a viral infection and if your immune system is shot, that’s more difficult.
In COVID-19 -- well, in COVID-19, we see a third scenario that stands separate from the other two, and in that third scenario the virus triggers a forest fire versus a controlled burn and in such a case the patient’s immune system goes haywire and generates what we call a cytokine storm.
And if you doubt the deadliness of the immune system when it goes rogue, consider an anaphylactic reaction that some people may have to an allergen like peanuts. In that situation the immune system can turn on a patient and kill them in a matter of minutes. It's worth noting your individual genetics, your underlying health decide which of those three scenarios your immune system is going to follow. The viral load that you are dealing with also can have effect. In other words, every case is a coin toss.
And then just one more thing adding to this is how the virus infects cells. It binds to ACE2 receptors in our lungs and can trigger a domino effect of complications, such as events in our blood vessels or what we call vascular events. These can include thrombotic or clotting events. Blood clots not only block those fine capillaries that allow for oxygen to move from the lungs into the blood, but those clots can also migrate through the body and lodge in places like the brain, in which case the patient suffers a stroke.
So, all of these things are really good reasons for us to treat COVID-19 differently from the run-of-the-mill flu. It's just not the seasonal flu. I wish it were.
Saleem Abu-Tayeh: Thank you for shedding light on the difference between the seasonal flu and COVID-19. I think a lot of questions on many people’s mind is what has happened in past pandemics when we have lifted restrictions and what can we learn from those past pandemics?
Dr. Lourdes Norman-McKay: That’s a great question. For an apples-to-apples comparison, it makes sense to look at the Spanish flu pandemic from 1918. It's similar to the current pandemic because it hit the US hard. It involved a respiratory transmitted virus and we didn’t have a vaccine.
The Spanish flu was managed similarly to what we are doing now. Public gatherings were barred. Schools and theaters closed. Religious services were suspended. Businesses were shuttered. Public transit reduced passenger loads to promote social distancing and in some places even closed elevators in buildings that were under six stories high. In many communities, mask wearing became mandatory. While some people accepted those measures, others loudly and actively protested in the streets.
There were also attempts at vaccination.
I think one of the most interesting and useful accounts to consider from the Spanish flu is what happened in San Francisco in the fall of 1918. San Francisco started locking down around October 18th that year and within a week San Franciscans really went nuts over masks. They were super strict about making people, including children, wear them. They imposed fines on people who were caught out and about without wearing one and repeat offenders were even jailed.
About a month after the lockdown the city was declared safe and ready to reopen. And so, in celebration, the people of San Francisco literally threw their masks into the streets. This shows us that people were really anxious for those month-long restrictions to end and the San Francisco Chronicle actually called that a torturous month and it's not too different from how many of us might feel now, at least we have Netflix.
Saleem Abu-Tayeh: That is very true.
Dr. Lourdes Norman-McKay: By January 10th, which is about two months after reopening, officials realized they have made a terrible mistake, the flu was not gone. San Franciscans were ordered to put their masks back on. However, they were so confident that the masks had saved them the first time around that they were really lax about social distancing.
Of course you can imagine where this is going. San Francisco was a catastrophe and they ultimately experienced the greatest death rate of any US city in that second wave. The city leaders and the people had put their faith in masks because they were cheap, allowed the economy to remain open, they were easy, people preferred to wear them versus practicing the harder measure of social distancing. We are starting to see this today; people feel they can simply wear a mask and be safe. It’s a false sense of security.
Now, I want to be very clear, I am not saying that we should forego masks; I am saying we cannot solely bank on them, especially when people are not properly wearing them, they are reusing them and most people aren’t even using medical grade N95 respirators that prevent viral entry.
It’s interesting, if you read some of the original Spanish flu pandemic accounts, it's easy to mistake them for something written last week versus about 100 years ago and the parallels are astonishing from how federal and state responses varied to how people reacted. Some demanded more restrictions while others protested that their liberties were being needlessly violated.
People vehemently argued with each other about possible solutions and those parallels are very likely to apply to reopening our economy today. We can't be surprised when things go the same way as they did under similar circumstances. That is we can expect a resurgence if we act precipitously as people did 100 years ago.
Now, some good news. The good news is despite 675,000 deaths and several spells of opening and reclosing the US did eventually recover. We went on to become a world power. Indeed things were so good that many Americans today didn’t even know that such a terrible pandemic had hit the US until this one brought the Spanish flu back into the news.
So, we are left with four important lessons from the Spanish flu pandemic. Lesson number one, once we lift restrictions it's really hard to re-implement them.
Lesson number two, social distancing worked and saved lives.
Lesson three, expect waves of recurrence.
And lesson four, the pandemic ended without a vaccine.
This idea that we are doomed to stay inside until there is a vaccine is simply not the case and it's a very poor argument for why we should just go ahead and end social distancing and let nature run its course. Models show we could be -- if we could be really strict on social
distancing for just a bit longer, we could snuff this out without the benefit of a vaccine and we could greatly reduce resurgence numbers, and that would mean an overall shorter pandemic and fewer deaths. So, good lessons in history.
Saleem Abu-Tayeh: Thank you for telling us about those lessons, about the problem of lifting restrictions early!
I think one question is what are the events or characteristics we should be looking to dictate when things can go back to normal? I think a lot of us really want to go back to normal, but we are not sure how to kind of get those signs.
Dr. Lourdes Norman-McKay: Yeah, of course! Well, that’s the big question, it's one that many of my friends, family and students have asked me.
Normal is of course a relative term. If your idea of normal is dinner in a restaurant with a few friends, you will be back to normal faster than someone who is a large event enthusiast.
The White House plan has several gated criteria for how states should reopen, but suffice it to say here most do not yet meet that gating criteria to return to normalcy.
So okay, setting aside public health aspects I think, a simple litmus test for the general public is how easy is it to get an N95 mask, bleach, rubbing alcohol and hand sanitizer without along waiting period and a hefty price tag. I say that because if the general public is struggling to get those products, it is because they are being diverted to healthcare facilities which are still not properly stocked. Until those formerly humdrum items are readily available to the general public, it is a clue that things are not normal. And even when we do go back to normal albeit in phases, we can expect pockets of COVID-19 and resurgence and ultimately, our lessons from the Spanish flu, which was similarly dangerous to COVID-19, indicate that a full return to normal will be a way off at least a year. I know that is a hard thing to imagine maybe hard to hear. But problems of this extent and complexity do not suddenly evaporate. They did not back then, and they will not now. It is going to take time and trial and error, but it will pass. We will see the other side of this, but a lot more people will die if we act impulsively. It is certainly not easy to put a price tag on life especially if it is your own or someone you care about and unfortunately, that could be the real price people pay and these are exceedingly difficult choices.
Saleem Abu-Tayeh: Thank you for letting us know. I guess when we might be able to go back to norms and give us some examples. I think you mentioned this a little bit and touched on that a little bit earlier, but what are some challenges we may see with vaccination development and what some things that may be in our favor during this process?
Dr. Lourdes Norman-McKay: Well, an effective vaccine could definitely help things return to normal and reduce resurgence. There are at least a hundred different vaccine development efforts underway across the globe and human trials are already underway here in the US. Naturally, we hope at least one of these vaccines will effectively prevent COVID-19. But we should be cautiously optimistic, and we should not bank on this happening in 2020 even if everything goes perfectly. We need to manage expectations and think about other options. We cannot just hope we develop an effective vaccine. Optimism is not a strategy. We should be pursuing drug therapies too. There are plenty of cases where tons of research and money have been pumped into the search for a vaccine without success. HIV is a high-profile case in point example. In 1984, once the human immunodeficiency virus was identified and the U.S.
Health and Human Services Secretary said, “we would have a vaccine within two years.” On top of this, we must consider the logistics of manufacturing and widely distributing a vaccine once it is deemed safe and effective.
As it stands there are issues with distributing test kits, the proper swabs to perform those tests and facemasks and even potentially, useful antiviral drugs are tough to stockpile and distribute in a timely manner. And we really need to overcome a number of logistics barriers to scale-up vaccine manufacturing, distribution and administration. For some perspective on this, consider that it takes about six months just to manufacture and distribute large quantities of the seasonal flu vaccine. And we are not trying to discover or tests a new vaccine in that case. So, if we are really going to make this happen by the end of 2020, we need to have already discovered the vaccine, tested its efficacy and safety in humans, and we would need to start manufacturing it now, as in today so, we could distribute it and we are not. So history and real data tell us that a publicly available mass-produced vaccine is highly unlikely in 2020. We might be closer, but you should not bank on it. “Oh, I am not. I hope I am wrong, but time will tell.”
Another challenge is, we really do not know how lasting a person's immunity to the virus is and if that convert immunity would differ between those who recover from the virus versus those who gained immunity via vaccination. Plus, we will need a better understanding of that to decide if booster shots are necessary or not for either one of those groups to prevent resurgence. Some of these answers may only arise after a significant number of people are vaccinated and we monitor infection rates. Now, although there are other challenges, the last one I will mention involves antigenic drift that this virus can undergo. Antigenic drift is the minor evolution of viruses overtime.
As Dr. Lisa Urry mentioned in the last Unwritten session most viruses that have RNA as their genetic material, which is the case for SARS COVID2, experience genetic drift over time. We are already seeing some of this occurring in SARS-CoV-2. The silver lining is the virus seems to change relatively slowly at about half the rate that we see for influenza viruses.
However, the consequences of that evolution as it relates to the virus's biology and our immunological response remains poorly understood. That said, the slower genetic drift is an important upside in terms of shaping a vaccine. It dodges critical challenges that we face with flu vaccine programs.
Lastly, I think the largest advantage we have is that, scientists have had practice with related viruses, specifically with SARS-CoV-1, a predecessor of the current virus. About 18 years ago SARS-CoV-1 initiated an outbreak of Severe Acute Respiratory Syndrome that spread to about 24 countries. Studies on that virus have given us a terrific head start toward understanding, which viral proteins and the currently circulating virus could be good candidates for priming immunity in humans via a vaccine. So, lots of challenges, but also some opportunities.
Saleem Abu-Tayeh: Thank you for informing us about vaccines and how their development and the process of their development. I think, a lot of us had a lot of misconceptions about that. One question that a lot of people have is that, how can we really tell where this virus came from and how it has developed? How did the genetics of viruses allow scientists to understand how a pandemic unfolds?
Dr. Lourdes Norman-McKay: I love this question. I love it because it gives me a chance to re-emphasize that science is not magic. Rather, it is an organized process of looking at patterns,
making predictions and developing conclusions based on data. We do this all the time in our lives.
Take an investigation into car damage as an example. If you a white car had a big dent in it and there was green paint present at the dent side, you would assume the car that hit you probably had some green in its paint job. And if the police decided to only search for red cars with damage, you would say they were ignoring the evidence.
Similarly, if you had several cars lined up in a parking lot and they all rammed open their doors and inflicted damage on each other, you'd be able to figure out from the pattern of damage and paint streaks, how the cars were positioned in the parking lot with respect to one another.
This is because we can study patterns and determine the likelihood of a particular event. Genetic tracing for pathogens to include this virus is no different. We look for patterns and in so doing, we can figure out a series of events and even a timeline. Criminal investigators do this all the time. Genetics experts do this, too. And it is how we explore the origins and paths of a pandemic’s progression.
When specialists report that there is no evidence to link this virus to the Virology Institute in Wuhan. They are saying that, we have green paint on our car and that the virus studied at the institute is a solidly red car unless new evidence arises, it would be illogical to continue to point at the red car parked at the Wuhan Institute of Virology as the culprit.
Of course, the trouble is, people who are not experts are having a hard time figuring out who is and who is not an expert. They are struggling with trust, and that is really a terrible place to be. It is actually something our country really needs to work on, and depoliticizing science is a crucial step toward that.
Saleem Abu-Tayeh: Thanks, Dr. Norman-McKay. I think, those were some very insightful information. We do want to take some questions from the viewers who have joined us. I am going to send it over to Laura, for some questions that have been coming in from our audience.
Laura Howe: Good. Thank you. We have got some good questions coming in. There has been a number of questions about the effect of COVID-19 on children. So, we are seeing the emergence of new and sort of different symptoms in children. Can you talk a little bit about that and why scientists believe this is happening?
Dr. Lourdes Norman-McKay: Right. So, in pediatric patients, the complications in the vascular system are especially concerning. And while seemingly rare at this time, more information is being collected on the prevalence. And the reason why this is thought to be related to COVID-19 has to do with how the virus binds to the ACE-2 receptor. We have ACE-2 receptors on very cells in our body. The normal point of entry within our body, though is ACE-2 receptors on specific cells in our lungs.
And the ACE-2 receptors affect like I said events in the in the blood vessels. So, you can get this massive inflammatory event occurring in the vasculature that can lead to complications and that is the pediatric syndrome that is being noticed. And the syndrome, another thrombotic related event syndrome is being seen in adults who normally would not be at risk for stroke for the same reasons.
And as we learn more about this virus, we will probably see some other side effects that it can induce, which is, again, another reason to approach this cautiously. You know, you may say, “Oh, the child doesn't develop severe respiratory symptoms, but what percentage then of children who were asymptomatic can progressed to a complication like that?” It is worth asking the question and investigating.
Laura Howe: Great. So, another question that came in and I thought, it was sort of an interesting one. We had someone up, first of all, we love the story about the San Francisco pandemic. So, a really good sort of go back in history there. But they wanted to know, can you talk a little bit more about how the 1918 pandemic ended without a vaccine?
Dr. Lourdes Norman-McKay: Yeah, sure. It snuffed out. It was so virulent that over time that it snuffed out like what we see with Ebola actually. The virus evolved, became less dangerous and sort of became the seasonal flu that we have now. As I said, viruses do this.
Now, influenza virus mutates at a much faster rate than the virus that causes COVID-19 does. So, it would take a bit longer for the virus we are dealing with now to become less dangerous although, it is a possibility that it could over time. Viruses have a tendency to do that because less damage you can inflict on your host, the more likely your host is to go about their daily business rather than being under lockdown and spread the virus. So, that is a natural way that viruses tend to evolve and it was not because of vaccine, it was not because of massive herd immunity.
Laura Howe: So, one question that I had is, over the last couple of days, you might have seen a story from NBC News about one of their medical correspondents that actually has coronavirus. And he said, he believes he got it on an airplane and he said, he was on the plane, masked up, he had the gloves on, he was, sanitizing everything on the plane, but he thinks, he actually got it through his eyes. And I think that was kind of interesting and that is something you are not hearing people talk about a lot. Can you talk about the eyes as a potential entry point into the body for the virus?
Dr. Lourdes Norman-McKay: Yeah. So, a lot of attention has been placed on viral entry through the mouth and nose and people have been warned not to touch their faces as a way to reduce transmission risk. And it is really important for people to remember that our eyes are also a part of our face. Do not touch your eyes.
A report in the Journal of the American Medical Association Ophthalmology just last, actually it was in March, suggests that,SARS-CoV-2 could enter the body through the eyes and viral transmission through ocular surfaces definitely should not be ignored.
If you wear glasses, then in addition to a face mask, it can make sense to trade out your contacts for your glasses before heading into a store or some other area where you may be exposed to airborne droplets containing the virus.
Laura Howe: All right. Great. Well, that is all the time we have the questions. So, I am going to throw it back to Saleem to wrap this up.
Saleem Abu-Tayeh: Thanks Laura and thank you for your time, Dr. Norman McKay. I would like to thank everyone who joined us today. And to everyone who has joined previous episodes of Unwritten. I hope this conversation was just as insightful for you all as it was for me. My heart goes out to everyone during this difficult time. Please stay safe and be well. Thank you.
Dr. Lourdes Norman-McKay: Thanks.