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Dr. Robert Redfield, director of the Centers for Disease Control and Prevention, speaks at a House Committee on Oversight and Reform hearing about the coronavirus on March 11. Michael Brochstein/Echoes Wire/Barcroft Media via Getty Images hide caption
Dr. Robert Redfield, director of the Centers for Disease Control and Prevention, speaks at a House Committee on Oversight and Reform hearing about the coronavirus on March 11.
Michael Brochstein/Echoes Wire/Barcroft Media via Getty Images
When infectious pathogens have threatened the United States, the Centers for Disease Control and Prevention has been front and center. During the H1N1 flu of 2009, the Ebola crisis in 2014 and the mosquito-borne outbreak of Zika in 2015, the CDC has led the federal response.
Yet the nation's public health agency, with its distinguished history of successfully fighting scourges such as polio and smallpox, has been conspicuously absent in recent weeks as infections and deaths from the new coronavirus soared in the U.S.
President Trump has been holding almost daily press conferences at the White House, but the primary health advisers at his side are not from the CDC. Dr. Anthony Fauci directs the National Institute of Allergy and Infectious Diseases, which focuses on biomedical research, and Dr. Deborah Birx is the global AIDS coordinator for the State Department.
The public has heard much less from the CDC director, Dr. Robert Redfield, and the agency, based in Atlanta, has not held a media briefing since March 9.
On Monday, Redfield agreed to a phone interview with Sam Whitehead, the health reporter at WABE in Atlanta, where he also hosts a coronavirus podcast.
This interview has been edited and condensed for length and clarity.
Has the CDC learned anything new about the virus, such as how contagious it is or how it is transmitted, in recent weeks?
Let's take transmission. . This virus does have the ability to transmit far easier than flu. It's probably now about three times as infectious as flu.
One of the [pieces of] information that we have pretty much confirmed now is that a significant number of individuals that are infected actually remain asymptomatic. That may be as many as 25%. That's important, because now you have individuals that may not have any symptoms that can contribute to transmission, and we have learned that in fact they do contribute to transmission.
And finally, of those of us that get symptomatic, it appears that we're shedding significant virus in our oropharyngeal compartment, probably up to 48 hours before we show symptoms. This helps explain how rapidly this virus continues to spread across the country, because we have asymptomatic transmitters and we have individuals who are transmitting 48 hours before they become symptomatic.
We know there is asymptomatic spread. . Are you taking another look at the CDC's mask recommendations?
We're always critically looking at new data and . there is data from obviously Singapore, Hong Kong and China that looks at the issue and you can look at masks in two ways. . Is the mask something that protects me or . if I wear a mask, is it something that protects others, from me?
Particularly with the new data, that there's significant asymptomatic transmission, this is being critically re-reviewed to see if there's potential additional value for individuals that are infected or individuals that may be asymptomatically infected. . Obviously you can see the complexity of that, if you assume that 25% are asymptomatic, the only way you would do it — if you then sort of went into areas that were high transmission zones and had a significant [proportion of] individuals then wearing masks, assuming that they were infected. I can tell you that the data and this issue of whether it's going to contribute [to prevention] is being aggressively reviewed as we speak.
Coronavirus models the Trump administration has been looking at suggest an initial surge in hospitalizations and deaths in April or May. But [after those surges] 95% of Americans will still have not been exposed to this virus at all. To protect those 95% of Americans, won't we need massive testing all over the country to control any renewed spread?
Most respiratory viruses have a seasonality to them, and it's reasonable to hypothesize — we'll have to wait and see — but I think many of us believe as we're moving into the late spring, early summer season, you're going to see the transmission decrease, similar to what we see with flu as the virus then moves into the Southern Hemisphere. We will then have a period of time to continue to work on countermeasures.
As you know, there's a number of states right now that have limited transmission, and so getting back into those states with the public health community for early case definition, isolation, contact tracing, I think this is what we're going to be doing very aggressively May, June, July — to try to use those standard public health techniques to limit the ability to have wide-scale community transmission as we get prepared, most likely, for another wave that we would anticipate in the late fall, early winter where there will still be a substantial portion of Americans that are susceptible.
Hopefully, we'll aggressively reembrace some of the mitigation strategies that we have determined had impact, particularly social distancing.
"This is a very powerful weapon"
First, I'd like to thank all the Americans and all the people in our nation that have taken this to heart and really practice aggressive social distancing. Secondly, for those that are still on the sidelines, I'd like to tell them now's the time to really embrace this. This is not just a little recommendation on a piece of paper. This is a very powerful weapon.
This virus cannot go from person to person that easily. It needs us to be close. It needs us to be within 6 feet. If we just distance ourselves, this virus can't sustain itself and it will go out. I'm reminded about the NBC [motion graphic] and it's now on my Twitter, lining up matches and then lighting the match, and they all light and then you just take out one match and the fire goes down.
So this social distancing that we're pushing . is a powerful weapon, and that will shut this outbreak down sooner than it otherwise would have been shut down. And as next season comes up, it's going to be important that we reembrace that social distancing.
When will the CDC have some kind of public tracking system of every single test result in the country, whether that's done in a hospital or by a public or commercial lab? Knowing where these cases are prepares you to respond.
I think we're really close. I mean, we get daily reports from all of the testings coming in. Obviously, FEMA is the data coordinating center, but I think really strong, integrated data is currently occurring down at the county level, where we're getting positive tests, and where we're seeing new clusters, and where we are responding.
One of the critical areas is, of course, long-term-care facilities. We now have over 400 long-term-care facilities in this nation that have now outbreaks. We're constantly going into those care facilities trying to limit these outbreaks or obviously trying to prepare other assisted living centers.
At the end of the day, most of us who get this infection will recover. The majority of people do — probably 98%, almost 98.5%, 99% recover. The challenge is the older, the vulnerable, the elderly, those with significant medical conditions where this virus has shown a propensity to have a significant mortality.
Once we know what the outbreak truly looks like, local public health agencies will need to respond. What is the CDC's plan to help with those efforts long-term?
One thing that I think this coronavirus outbreak has really illustrated, something I've said since I came into this position, is we should be overinvesting in public health, overpreparing not underpreparing.
Can you commit to actual money or personnel to do that work? What, practically, does that help from the CDC look like?
The CDC provides between 50% and 70% of the public health funding for all state, local, territorial and tribal health departments. Clearly with the first supplemental [coronavirus funding from Congress] that came, CDC got additional funding . [we sent] close to $565 million out to the state and local health departments to begin to let them expand their local capacity. With the third supplemental, CDC is getting an additional, I think, close to $4.4 billion, most of which is going to go out to help.
But it doesn't help if we can't create these jobs in a way that individuals want to come and enter the public health workforce. So we're going to continue to try to increase, encourage and facilitate the local, state and territorial health departments to have the resources to hire these individuals as we try to motivate many in the American public to say that this is a great vocation to be part of it. [March 30] is actually National Doctors Day, but rather than just thank doctors today, I want to thank all the health care workers and all the public health workers, all the first responders.
We have areas in Georgia where we still don't have confirmed cases, but we can't assume that there aren't cases there. Some of those same counties don't have robust health care systems. So how does the CDC convince people in counties like that, or officials in counties like that, to take this outbreak seriously?
We are continuing to try to provide additional resources and guidance. We will be expanding surveillance throughout the United States so that we'll have a better eye on where this virus is. We'll be working with the state and local health departments to do that.
As we get to a time where we're able to begin to start to reopen some of the economy, based on data showing that this outbreak is now at a point where that balance can be met . we have to make sure we don't then have new, huge community clusters [in] these areas that have had very limited transmission. So we do have the resources to go in there and make that early diagnosis of those original cases through the isolation, contact tracing.
"This virus is going to be with us"
I don't think anybody would disagree that for decades, collectively, our nation's underinvested in public health. Now, I think people understand that that can really have significant consequences, and now is the time for us to overinvest overprepare in public health.
This virus is going to be with us. I'm hopeful that we'll get through this first wave and, and have some time to prepare for the second wave. I'm hopeful that the private sector in its ingenuity and working with the government, NIH, will develop a vaccine that ultimately will change the impact of this virus.
But for the next 24 months, you know, we're all in this together, and the most important thing that we can do is twofold: the American public fully embracing the social distancing that we requested to protect the vulnerable; and secondly, to operationalize the bread and butter of public health — you know, early case identification, isolation, contact tracing — so that this outbreak does not get the upper hand, as it has, unfortunately, in New York City, in northern New Jersey, and now New Orleans.
We've seen here in Georgia municipalities and counties taking a piecemeal approach to issuing stay-at-home orders or other kinds of prevention measures. It seems naive to think that people don't cross city or county lines or even state lines. What can the CDC do to encourage a more unified response?
I think the big thing is that in order to operationalize this, you really do need not only the buy-in of the American public, but you do need the buy-in and guidance of the civil leaders. We can put out strong, sound public health advice to try to motivate people to embrace these.
I think early on, maybe the younger generation may not have embraced them as greatly as the older generation. My sense now is there's a greater embracement by really all segments of society. . Yes, if you're young and healthy, you're likely going to do fine if you get this virus, but we're trying to protect the vulnerable.
So I asked people to see the face of their parent or grandparent or their neighbor, or co-worker with diabetes or HIV, or kid trying to enjoy life [while] confronting cancer at a young age. We're doing it for them. . It's a powerful weapon, and from what I'm seeing is the American public is responding. People want to be part of the fight.
Is it possible to isolate vulnerable populations while allowing other people to let up [on the social distancing]? Is that something that we can actually do, let people have normal lives while still protecting the most vulnerable among us?
I think there could be an evolution, and we're going to say that it's premature right now. We want the whole nation to stay all in, as the president announced the other day, to the end of April. We're going to be looking at data.
It is important that one size doesn't fit all, and there are parts of our country that will — when they have the data to know exactly how much virus is in their community — they may be able to make local decisions that begin to allow parts of the economy to open up.
And there'll be other jurisdictions that the data will say there's just too much extensive, widespread community transmission for us to do that. Now, I think you're going to see that analysis and that data be used to find that balance over the next four, six, eight weeks as our nation does come back to work.
The last thing I wanted to say, just to be very clear, I have total confidence that we will get through this. I have total confidence that we'll bring this virus down, but the tool that we're going to do that is this request — for all Americans to really embrace the social distancing that we've requested.
Last updated: March 5, 3:00 GMT
- 3.4% Mortality Rate estimate by the WHO as of March 3
- Mortality Rate in China as of Feb. 20 (3.8% nationwide, 5.8% in Wuhan, 0.7% other areas)
- Mortality Rate in China as of Feb. 4 (2.1% nationwide, 4.9% Wuhan, 3.1% Hubei, and 0.16% other provinces) reported by the NHC of China
- Study providing a tentative mortality rate of 3%
- Death rate among patients admitted to hospital (HFR): 15%
- Days from first symptom to death: 14 days
- Comparison with other viruses
- How to calculate the mortality rate during an outbreak
In his opening remarks at the March 3 media briefing on Covid-19, WHO Director-General Dr Tedros Adhanom Ghebreyesus stated:
“Globally, about 3.4% of reported COVID-19 cases have died. By comparison, seasonal flu generally kills far fewer than 1% of those infected.” [13]
Initially, the World Health Organization (WHO) had mentioned 2% as a mortality rate estimate in a press conference on Wednesday, January 29 [1] [2] and again on February 10. However, on January 29 WHO specified that this was a very early and provisional estimate that might have changed. Surveillance was increasing, within China but also globally, but at the time it was said that:
- We don't know how many were infected ("When you look at how many people have died, you need to look at how many people where infected, and right now we don't know that number. So it is early to put a percentage on that." [1] [2] ).
- The only number currently known is how many people have died out of those who have been reported to the WHO.
- It is therefore very early to make any conclusive statements about what the overall mortality rate will be for the novel coronavirus, according to the World Health Organization [1] [2] .
The Report of the WHO-China Joint Mission published on Feb. 28 by WHO [12] is based on 55,924 laboratory confirmed cases. The report notes that "The Joint Mission acknowledges the known challenges and biases of reporting crude CFR early in an epidemic" (see also our discussion on: How to calculate the mortality rate during an outbreak). Here are its findings on Case Fatality Ratio, or CFR (the mortality rate):
"As of 20 February, 2,114 of the 55,924 laboratory confirmed cases have died (crude fatality ratio [ CFR: 3.8% ) (note: at least some of whom were identified using a case definition that included pulmonary disease).
The overall CFR varies by location and intensity of transmission (i.e. 5.8% in Wuhan vs. 0.7% in other areas in China ).
In China, the overall CFR was higher in the early stages of the outbreak ( 17.3% for cases with symptom onset from 1-10 January) and has reduced over time to 0.7% for patients with symptom onset after 1 February. " [12]
The Joint Mission noted that the standard of care has evolved over the course of the outbreak .
Asked at a press conference on February 4 what the current mortality rate (or case fatality rate, CFR) is, an official with China NHC said that [7] :
- The formula they are using is: cumulative current total deaths / current confirmed cases. Therefore, as of 24:00 on Feb. 3, the formula used was 425/20,438.
- Based on this figure, the national mortality rate to date was 2.1% of confirmed cases.
- There might be mild cases and other cases not reported.
- 97% of the country's total deaths (414) were in the Hubei Province.
- Mortality rate in Wuhan was 4.9%.
- Mortality rate in the Hubei Province was 3.1%.
- Mortality rate nationwide was 2.1%.
- Fatality rate in other provinces was 0.16%.
- Deaths in Wuhan were 313, accounting for 74% of China's total.
- Most of the cases were still mild cases, therefore there was no need to panic.
- Asked why Wuhan was so much higher than the national level, the NHC official replied that it was for lack of resources, citing as an example that there were only 110 critical care beds in the three designated hospitals where most of the cases were sent.
- National mortality rate was basically stable, as of Feb. 4 at 2.1%, and it was 2.3% at the beginning of the epidemic, which can be seen as a slight decline.
- Front the analysis of death cases, it emerged that the demographic profile was mainly male, accounting for 2/3, females accounting for 1/3, and is mainly elderly, more than 80% are elderly over 60 years old, and more than 75% had underlying diseases present such as cardiovascular and cardiovascular diseases, diabetes and, in some cases, tumor.
- Elderly people with basic diseases, as long as they have pneumonia, were clinically a high-risk factor regardless of whether it is a coronavirus or not, and the case fatality rate was also very high, so it is not that the case fatality rate of pneumonia is high because of the infection with the new coronavirus. "This point must be explained to everyone," concluded the NHC official. [7]
A preliminary study published on The Lancet on January 24 [3] provided an early estimation of 3% for the overall case fatality rate. Below we show an extract (highlights added for the relevant data and observations):
Of the 41 patients in this cohort, 22 (55%) developed severe dyspnoea and 13 (32%) required admission to an intensive care unit, and six died.
Hence, the case-fatality proportion in this cohort is approximately 14.6%, and the overall case fatality proportion appears to be closer to 3%.
However, both of these estimates should be treated with great caution because not all patients have concluded their illness (ie, recovered or died) and the true number of infections and full disease spectrum are unknown.
Importantly, in emerging viral infection outbreaks the case-fatality ratio is often overestimated in the early stages because case detection is highly biased towards the more severe cases.
As further data on the spectrum of mild or asymptomatic infection becomes available, one case of which was documented by Chan and colleagues, the case-fatality ratio is likely to decrease.
Nevertheless, the 1918 influenza pandemic is estimated to have had a case-fatality ratio of less than 5% but had an enormous impact due to widespread transmission, so there is no room for complacency.
Fatality rate can also change as a virus can mutate, according to epidemiologists.
A study on 138 hospitalized patients with 2019-nCoV infection, published on February 7 on JAMA, found that 26% of patients required admission to the intensive care unit (ICU) and 4.3% died, but a number of patients were still hospitalized at the time. [9]
A previous study had found that, out of 41 admitted hospital patients, 13 (32%) patients were admitted to an ICU and six (15%) died. [5]
The Wang et al. February 7 study published on JAMA found that the median time from first symptom to dyspnea was 5.0 days, to hospital admission was 7.0 days, and to ARDS was 8.0 days. [9]
Previously. the China National Health Commission reported the details of the first 17 deaths up to 24 pm 22 Jan 2020. A study of these cases found that the median days from first symptom to death were 14 (range 6-41) days, and tended to be shorter among people of 70 year old or above (11.5 [range 6-19] days) than those with ages below 70 year old (20 [range 10-41] days. [6]
The JANA study found that, among those discharged alive, the median hospital stay was 10 days. [9]
For comparison, the case fatality rate with seasonal flu in the United States is less than 0.1% (1 death per every 1,000 cases).
Mortality rate for SARS was 10%, and for MERS 34%.
| Virus | Death Rate |
|---|---|
