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SNS: COVID-19: Lessons on the Virus from a Top NYC Epidemiologist - May-12-2020
SNS Subscriber Edition • Volume 25, Issue 16 • Week of May 11, 2020


Lessons on the Virus from a Top NYC Epidemiologist


FIRESIDE conversation

Lessons on the Virus
from a Top NYC Epidemiologist

A virtual discussion and Q&A
with Dr. Megan Coffee

With host Evan Anderson




Pundits like to refer to coronavirus as a "black swan" event. Essentially a more elegant, nightly news way of saying, "We didn't see this coming, and we have no idea what to expect."

But when the future of your business, your health, your family's health, and your financial health depends on knowing what to expect, black swans, bless their souls, are not a helpful metaphor.

Just like all of you, we here at SNS have recently been obsessively focused on how to navigate this time of extreme global uncertainty. As a team, we're used to operating remotely. But our family is certainly bound up in our business. Just ask any of the other four Andersons who help bring SNS and FiRe into existence each year.

The good news for SNS members is that we take this all extremely seriously. The continued success of our - and your - business and families depends on knowing as well as possible what to expect. And while we may not be able to gather in person just yet, the SNS and FiRe communities are an enormous asset for knowledge, helping all of us anticipate the future of technology and the global economy, regardless of our quarantine locations around the world.

A few weeks ago, we hosted the first in a new monthly virtual event series we're calling FiReSide. Last month's focus was "China + COVID-19: Navigating the Two Biggest Business Issues of Your Time" - a set of conversations with the Honorable John Demers, the DOJ's Assistant Attorney General for National Security, on intellectual property theft and nation-sponsored spycraft; and Dr. Megan Coffee, an epidemiologist who has made her name using AI to model and track infectious-disease outbreak and who is currently working on the front lines of this issue, treating coronavirus cases as a clinical doctor in New York City.

This week's report brings you our full conversation with Dr. Coffee. We hope this will help you better understand the pandemic - and what to expect from secondary waves of infection - as we all participate in a global experiment in relaunching the economy.

New York City, in its density and complexity, offers a high-speed look at what the rest of the world can expect. And an extremely valuable set of lessons for navigating outbreaks - and secondary outbreaks - globally.

We're also sharing this in the hope that it will show you the value of participating in FiReSide events. Bleeding-edge insights into what to expect and how to plan for the future in a time of worldwide unprecedented uncertainty. A chance to speak personally with global experts, posing individual questions that will help you, your family, and your business endeavors navigate this time. Virtual conversations and real-time networking with the global SNS community.

This week's issue provides a unique glimpse into the FiReSide event series. Most of our future conversations will be shared only with those who attend - just as the conversation you're about to read is only one segment of our last event.

We are also delighted to announce today that our next FiReSide conversation, "COVID-19: The Way Out," will take place Thursday, May 21, from 2:30-4:30 PT / 5:30-7:30 ET, featuring a conversation with longtime SNS member and epidemiologist Dr. Larry Brilliant.

Some of you have seen Larry at past FiRe events, where he's described his successful work with WHO to eliminate smallpox and warned us of the possibility and risks of a then-future global pandemic.

We hope that you find the insights in this conversation with Dr. Coffee fruitful - and that you'll join us (virtually) for our next FiReSide event.

- Berit Anderson


COVID-19: A FiReSide Virtual Discussion
    Lessons on the Virus from a Top NYC Epidemiologist


Evan Anderson:Dr. Megan Coffee, it's great to have you with us. Actually, I was getting a text from Megan earlier - she had just gotten home and was just scrubbing out of general hospital attire and PPE, etc. It looks like you successfully did that, and now you're safe at home with your houseplants.

Megan Coffee: Yes, I am.

EA: Well, it's good to have you. Thank you so much for your time.

Megan is a clinical assistant professor at NYU and an attending infectious-disease professional at Bellevue Hospital in New York City, where she's been involved in the coronavirus clinical response. She was also the communicable-disease advisor for the International Rescue Committee and teaches a course in communicable diseases and humanitarian disasters at Columbia University as an adjunct assistant professor, among many other things, I think one of which specifically may be interesting to our audience. Megan has worked extensively on AI-enabled studies of Zika, Ebola, and now SARS-CoV-2, right?

MC: I'm working on COVID now, yes, and worked on computer models of drug patterns.

EA: I saw the most recent study on COVID, and I think that your specific results were showing that potential leading indicators were certain liver enzymes - and that's being proven out more, right?

MC: Yes. Definitely one of the interesting things about this disease is that it starts out so mild. We really just don't know until Day 5, Day 8, Day 10, whether this is going to be a mild case or become a very severe case.

Just looking to see if our hypothesis was right, that the body was reacting to the virus in a certain way differently in some people, we did see that a very mild elevation in liver enzymes seems to be indicative - which is interesting, because they weren't actually even abnormal. They were just slight elevations.

EA: So it would be a little bit hard to detect, potentially?

MC: Yes. I saw the data before we worked on it, and it didn't ring any bells with me. It did not look surprising at all.

EA: I think that's a fantastic example of how healthcare can improve as we go along. In a more basic way, too, that's certainly one of those things that we would love to be able to know going in; as we learn, it'll be good to have a lot more new studies going on and new information coming in.

One of the things that I wanted to talk to you about tonight is, I think people are still trying to figure out what this really looks like on the ground. There are so many different stories that you hear right now or read online, where you get the full spectrum, from a mild case to a very intense case; some people have this symptom and some people have a whole other subset. Can you tell us a little bit about what you're seeing, and what you think the biggest problems are?

"There are many asymptomatic cases, and those are really driving the spread. People who are pre-symptomatic, asymptomatic, or have very mild disease who go out and about and don't realize they're spreading it."

MC:I think the first thing is that there are many asymptomatic cases, and those are really driving the spread. It's people who are pre-symptomatic, asymptomatic, or have very mild disease who go out and about and don't realize they're spreading it.

But then, of those who have symptoms, it's been pretty standard in many countries that we're seeing about 85% of people, 80% of people, be okay. But this "okay" disease can really just knock someone out for three weeks. I know many doctors who've been ill who said, "I was just absolutely shocked that I couldn't get out of bed for two to three weeks."

Then there's that 15% who need oxygen, who need some hospital care, but don't need to be intubated. Then you have 3% to 5% who are critically ill. These are the patients who need to be intubated, who need dialysis - which I'll talk more about a little bit later, but dialysis is really one of the limiting factors. There's a lot of renal disease in this.

We see a lot of atypical presentations, where people didn't realize for the first few days that they had COVID. Some will just feel tired. When we check their oxygen, it's incredibly low - they had no cough, no chest pain. We have other people who have a lot of thrombosis, meaning they have blood clots - they have blood clots in their lungs, any part of your body. It can damage any part of your body, unfortunately. Some with liver disease, some with confusion; they can even have meningitis or encephalitis. So it's kind of a whole spectrum.... Some people just come down with a rash, some people just can't smell, some people just have eye pain.

It's been kind of interesting to watch this huge spectrum of disease. Usually you have decades to study a disease. Instead, it's kind of been a firehose, with everyone having to learn all at once about it.

"It's not over in New York City. Still, hospitals have so many coronavirus patients, and so few other patients.... We didn't cure heart attacks. It means there are people having heart attacks at home who aren't coming in."

EA:Right. I think that's definitely been one of the toughest parts for the average person, is looking at all those different things, because it seems as though it can attack pretty much any given part of your body. I was asking you just the other day: "Well, I have joint pain, and I heard that that's significant for a portion of cases." So yeah, it's tough to track that, so it's good to get those numbers broken down so you get a little bit more of a sense of how often that specific symptom is occurring.

We were prepping for this before, and talking about various aspects of how it's affecting everybody, as a nation, or as a global society. There's so much talk right now about, you know, "Oh, well, some states are going to open up immediately, some states don't care at all and never really did shut down, or some countries don't have the ability to." What do you think we need to see in order to stabilize things?

MC: I would say one thing: it's not over in New York City. Still hospitals have so many coronavirus patients, and so few other patients. Which means that they're - we've had a decrease in the number of people having heart attacks. We didn't cure heart attacks. It means that there are people who are having heart attacks at home who aren't coming in. So we still have a huge impact on our healthcare system.

"We're far away from herd immunity.... We don't have tests that have 100% sensitivity and specificity. So it will mean there are people who are told that they're immune who actually aren't."

But evenmore so, even with this huge impact, and all the healthcare workers who have been affected, and all the people who have died ... It's actually been 1 in 1,000 New Yorkers who have died already from this disease, and more will. We only probably have around 20% of people in New York City possibly who were infected - there's been a serology study - but that would be the upper limit of how many people have been affected so far. And that would also be shown as mortality figures. We know that the mortality of symptomatic patients is between 1% and 5%, and then there's also asymptomatic infections, which maybe doubles the number - something like that. But you just realize that we're so far away from herd immunity, which is around 80%.

And until we have a vaccine, or a drug that lowers your viral load and makes you less infectious, or prevents you from getting infected, we won't have any surefire way that we won't have these infections return.

We've seen Singapore, which had a terrific program, then have - if there's any population that's not focused on - in their case, migrant populations - it's just going to feed it back. So even if the US does a perfect job, it can always be from another country, another part of the US, a population just not thought about - meat packing workers, homeless, mental health institutions - anything like that can just act as an incubator and reinfect.

There's always a hope in the short term that we can use serologies as sort of an immunity passport, but at the same point, we don't have tests that have 100% sensitivity and specificity. So it will mean that there's people who are told that they're immune who actually aren't. And that would be quite concerning, that they would be at risk.

And moreover, immunity's not going to last forever. It's going to wax and wane over time at the population, because usually coronavirus immunity lasts for about three years. So we expect to see that there's going to be cycles, if we don't do anything in terms of more treatments, more social distancing - we would expect continued cycles, just like we see with other coronaviruses. So it's just something that we should be aware of: this isn't going to be "done" right now.

"Moreover, immunity's going to wax and wane.... If we don't do anything in terms of more treatments, more social distancing, we would expect continued cycles.... [T]his isn't going to be 'done' right now."

EA:Right. And I know that, kind of right as we speak, there have been a number of results starting to come out from studies that were serology tests trying to test for antibodies.

What level of confidence - I think that's the big debate right now - what level of confidence do you have in those specific tests? Are they different tests? Are there five different kinds being run, and where are we on that, and how hopeful is it?

MC: There are a number of different tests. What I would say is that I think that they're going to work best on populations, to give you an idea of, "Is this city largely immune, where are we in terms of infections already, what have we missed? Are we missing infections that are happening without the healthcare system recognizing them?"

I think that's what its use is going to be, rather than for individuals, right now.

It's possible - there's also the issue that there were studies showing that younger people had a lot lower levels of antibodies. Does that mean that their immune system actually is going to respond less strongly? It's not clear. WHO has brought some questions up about this. I think we suspect that people are going to have immunity that lasts durably for another year or two years, but we can't say that for sure. Nobody's had this two years ago.

EA: With that, I'm going to move to Q&A, because I can see that people are very eager to get some questions answered. Berit, if you want to start going with the Q&A, that'd be great.

Berit Anderson: Our first question is from Jason Preston, who asked: People keep talking about a vaccine as if it is a given. What are the realistic chances that there will never be a vaccine for this virus?

MC: I keep pointing out that HIV has been around for 40 years, and we don't have a vaccine. Malaria: we finally have some breakthroughs. That's been something we've dealt with even longer.

I would say the immunity of coronaviruses gives a lot of researchers who really focus on this area - and I'm not a vaccine researcher - gives them a lot more hope that this is something that they could develop a vaccine to.

"This disease is so strange ... with that just kind of deranged, overly effusive immune response, which causes so much of this damage. You have to be careful that you're not creating any kind of immune reaction.... It has to be truly tested in population."

Clearly there has been interest in developing a vaccine for MERS, which is a very similar virus. SARS disappeared, effectively, before it would have had enough time to create a vaccine. But there is hope that this will be more amenable to vaccination.

But because this disease is so strange, in that you have this high viral load at the very start, but then the viral load goes down very quickly, and you're usually healthy while you still have the viral load. And then you have this immune response, with that just kind of deranged, overly effusive immune response, which causes so much of this damage. So you have to be careful, in any vaccine study, that you're not creating any kind of immune reaction in some of these individuals. So they'll have to be carefully tested. It's not something that we're able to just say, theoretically, "This vaccine should work." It has to be truly tested in population.

BA: And then, a question from Shalev Lifshitz: What are the criteria for us to loosen quarantine guidelines or restrictions? Do we have to wait for herd immunity or a vaccine, and should individuals wait, if possible, even if the government loosens up beforehand?

MC: I would say to think about the world as having been changed. And that we can't have the same amount of social contact that we used to. I think it's even strange sometimes when I see in a movie people in large crowds, now. I think it's something that we have to realize that we can't have for a while.

That doesn't mean people can't "go in," that they can't travel to different places, as necessary, but we have to really minimize the amount of contact. Hopefully the serology tests are improved to the level that we're able to give a good idea of whether they're at risk or not, and will develop a better idea of how long this immunity lasts, and give people a better picture of this, so I think we can tell individuals, eventually, just not today.

But it's going to be baby steps. It's not something that we're able to just immediately respond and say, "This is the perfect solution; we're back to normal."

BA: From Brad Holz: What is your opinion of the concept of an "immunity passport"?

"My biggest fear about immunity passports is that people will try to self-inoculate.... [T]his will lead to people risking their lives. And then, moreover, they will infect other people."

MC: My biggest fear about immunity passports is that we'll lead people to try to self-inoculate. That was something that was done throughout history. It was something that yellow fever - it was a rite of passage, that you had to live through yellow fever in order to be able to be employed, because no one wanted to employ someone who was not immune to yellow fever.

My fear is just that this will lead to people risking their lives. And then, moreover, that they will then infect other people. So I think we should be very careful on how it's prevented. But I hope that we'll have serologies that have good sensitivity, specificity, and then we're able to tell people quite effectively, "You are probably at risk, and you are probably not."

I think we'll have to figure out a lot of ethical issues here, in terms of how it's rolled out in the workforce. I know that many employers are looking to this. I would wait until we have a better test, and know confidently that this works.

There's also the question, you could have cross-reactivity. They've tested against sera - all these tests are tested against sera that came before there ever was this virus, like 2019 September. They're not seeing cross-reactivities, but it's always possible that there was one coronavirus that spread in a population and led to people having a false positive reaction. So it's just something we have to be particularly careful about before we give people false information.

BA: Thank you. So, John Petote just wanted to clarify: Does your estimate of New York City exposure factor-in data which he thought was from Iceland, showing a huge number of asymptomatic carriers?

MC: Mine is more based on some studies about serology, and some studies about our death rate. There have been some studies on serology to date that have not shown that we have an 80% immunity level, even though New York City has been through a lot.

I think it's really heartening that Iceland saw all these asymptomatic infections, but I don't know that we're seeing that serologies are reflecting that we've had that level of infections - meaning close to herd immunity - in New York City.

BA: That's about all the questions that we have, but I have one personal question, which is: I'm curious how this global pandemic has affected your experience of being a doctor? What kinds of medical barriers that might have existed before, between different institutions, or as far as data sharing, have changed in this case?

MC: One: I mean, there's been this whole question of our experts being not taken seriously, in this modern era. It's been quite painful to be an infectious-disease doctor. We all saw the train coming towards us, and kept yelling "Leap!" I feel like that was one of the worst things, was just knowing that we had the expertise, we knew this was coming, and yet there was just a level of denial that was just painful to see.

"There's been this whole question of our experts being not taken seriously, in this modern era. We all saw the train coming.... [O]ne of the worst things was just knowing that we had the expertise, and yet there was just a level of denial that was just painful to see."

Two: In terms of data sharing, I think we need to improve that. I'm very interested in data privacy and ethics, but I think we really need to be able to move fast in order to recognize the patterns we have in our data, to be able to share any information, to be able to work on recognizing whether drugs are working or not, as quickly as possible.

And I think you really need to be able to leverage the data that we're collecting at great personal cost - namely, all the healthcare workers and all of the patients. So I really hope we're able to learn from the experience we've been having in New York City and the country.

BA: And are you seeing that happen at all now? Somewhat, but not enough?

MC: I would say there are definitely a lot of studies going on. But it would be really great if we worked on polling data. I think science is still fractured in a lot of ways between, and there are just a lot of concerns, even over sharing de-identified data. There just needs to be a safe way to have a clearinghouse, in order to have researchers work with de-identified data in an ethical way, on a larger scale. In order to be able to make the decisions we need. Otherwise, we just have a lot of piecemeal studies. That's what I think would be best.

BA: A new question just came in, from Mark Mahan: Early news is that COVID-19 is causing so much damage to the lungs that scuba divers will no longer be able to dive. Reports from the mountain-climbing community are similar. Where do you feel that we are in learning what the lasting effects are, and what percentage of people will be permanently seriously affected?

MC: The permanent effect we see the most is actually kidney damage. In terms of lung damage, if people make it through, and they get back, we see it being a long recovery - meaning that they need rehabilitation for weeks or months - but it seems that there's recovery without massive scarring. But I don't think we've had enough time to be sure.

I think we would need a few more months to see if lungs are actually scarred - and that's something you could tell. In a few months, we could do studies to see if there's fibrosis or permanent damage. But I think it's too early to say for sure that people will have that kind of damage, and people seem to be bouncing back fairly well, once they're better.

BA: And just to play on the same topic: I don't know if many people on the call read the report from the New York Times yesterday, but they had a big piece about blood clots in the lungs and throughout the body. I'm curious about how the blood-clot issue factors into that, what you're seeing.

"It results in this kind of pro-inflammatory response in the whole body. And that leads to blood clots. We know this with influenza. There's always increased risk of having a heart attack in the month after having a case of the flu. This is just that on steroids."

MC: I feel like blood clots have been, besides the dialysis-kidney issue, that this is not just a lung disease. It definitely results in this kind of pro-inflammatory response in the whole body. And that, then, leads to blood clots. We know this with influenza. There's always increased risk of having a heart attack in the month after having a case of the flu. And this is just that on steroids, much larger.

We do see a lot of very bad outcomes from people having blood clots, and that can happen quite suddenly. I think that's what happens with some people who at home were doing okay and then do a lot worse. Which is a scary thing, to be able to monitor people at home who are not sick enough to be in the hospital, but that they could have this risk for blood clots, which is very real.

BA: Thank you. Okay, so, last question: Is it possible for coronavirus to mutate enough while a vaccine is under development that t he released vaccine would not be effective on the coronavirus?

MC: The scientists who are working on the vaccine do study the mutations, and do try to take that into account. So they should be trying to find an area that makes sure that this is targeting something that is not as prone to mutation and is not as vulnerable to that issue.

There are a lot of smart minds working on this, and they are aware that there are mutations in viruses, and what the rates are, and where the mutations are in this virus. Anything is possible, but I really think that there will be a lot of attention to avoiding that kind of issue.

BA:Alright, we have a couple more questions, and I know that your time is limited, and I want to be sure that we get in as many questions in as possible. I'm going to do a few more.

One would be: With respect to the FDA approval process, after a Phase 1 test, do you see any chance that AI could replace Phases 2 and 3?

MC: No. Not yet.

One - I mean, doctors still carry beepers. We are a profession that tends to be the last adopters of technology. But there's a reason for that - it's that many things seem like it will work. There have been so many trials where something that worked in silico - and I've worked a lot on in silico models of drug design, or in vitro use of drugs, where it's in a Petri dish - it seems like it will work, and we have every reason to think it will work, but there's just some unexpected consequence in people.

So I think we really need to see, in people who are sick, whether this drug actually has an unusual outcome that we weren't expecting, particularly in a disease like this, where the immune system itself is causing a problem but we want to have the immune system help us.

It just becomes a very complicated picture. It's kind of a butterfly effect - if there was something you could just do that kind of changes the entire picture and creates a much worse outcome than we ever expected. At this point, we really do need to be able to have testing in people who have the disease.

I'm all for using AI wherever we can, but it needs to be safe.

BA: That makes sense. Okay, last question, from Ty Carlson: One of the challenges we're seeing is the ability to have clean data reported on COVID-19, while the end number of patients is high. Where is a reliable repository that is clean enough to serve as a credible or reliable data source?

MC: There was just a study from Northwell - one of the hospital systems in the New York area - a lot of it's on Long Island. They had over 5,000 patients from the New York area. That's the largest database of lifting clean data from the New York outbreak right now.

I'm sure we'll see a lot more, and I really hope that we can compile this data and have researchers share it. We've had so many cases in New York City; it would be great to have a dataset that's large enough, that's done in an effective way, a safe way, and with data privacy and ethics always forefront.

Evan Anderson:I think one of the things that we should do here, noticing all the questions - some of that's, like, "Where is that data posted?" I don't think we should get into that here, but perhaps what we can do is, I will collect the Q&A. We've got this on recording, and so then I will shoot this to you, Megan, and if you have the time to pop in ... we'll see if we can get that done and send it out to everybody on the call.

MC: Yes!

"We need more data to understand what's going on with the kidneys. We've had very few autopsies or pathological samples from patients to see exactly what's going on."

BA: Alright, last question: Can we get a bit more detail about the impact on kidneys and longer-term effect?

I think they're just looking for a little more texture about what impact ...

MC: We're still ... We just need more data to understand what's going on with the kidneys. We've had very few autopsies or pathological samples from patients to be able to see exactly what is going on. And because the disease has different effects on different people, we're not sure exactly the full spectrum of what's going on with the kidneys.

We know that patients end up very dehydrated, with high fever, and then that kind-of sets things off. They can then have blood clots as well; that can affect their kidneys. But it may also be that we discover that there's a lot more direct effect on the kidneys. But we're still waiting for better trials and better studies to be able to understand that.

In terms of the long-term effects, we'll have to see what happens. There are definitely patients who are confused immediately after recovering, or as they're recovering - but I think we're going to have to see, over the course of months, how people improve, and it's just too early to be sure about the final outcomes for people. There are just a lot of people who have to be in the ICU for weeks, or months, even. And any time you're in an ICU, you need to have rehab for days. You kind-of need to think of having a couple of rehab days for every day that they're in the ICU. So there are going to be patients that just need to have really long recovery time. It's really debilitating.

BA: Alright. Ev - back to you.

EA: Thank you so much for your time, as always.... and I think as we move forward you're going to be able to stay - is that true?

MC: Yeah, I can stay for a little bit of time.

EA: Okay. So, we'll be breaking into breakout sessions, and for those of you who still want to chat with Dr. Coffee a little bit more, we'll see what her schedule allows, but she'll be joining us in some of the breakouts. For now, I'm going to turn it back over to Berit, who will explain how these breakouts are going to work, but thank you so much, Dr. Coffee. Nice to see your face, as always, and I really appreciate what you're doing.

MC: Thank you.


I would like to thank Sally Anderson, Editor-in-Chief, for preparing the transcript for this week's issue.


Your comments are always welcome.

Mark R. Anderson


Strategic News Service LLC


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