 everybody. This is Donna Foster with the patient facing the foundation. Good morning. This is Rich Carmona. Good morning, Dr. Carmona. How are you? I'm so glad that you were able to join us. I am. I've got about 15 minutes, though. I stepped out of another meeting. I'm at a board meeting in Las Vegas, so they're already in steps. I just going to step out for 15 minutes. I hope that'll help them at least. Yes, that would be great. All right. Well, we'll go ahead and get started then. And we're going to get you to jump in in just a moment. Okay. Okay. Yes, you bet. Thank you. Okay. Great. All right. Well, good morning, everybody. We're going to go ahead and get started because we have a lot of a lot of information to share today. And I want to make sure that we get have some time for question and answer at the end. My name is Donna Foster and I am the chief clinical officer here at the patient safety movement foundation. We have three members of our board joining us this morning. Steve Barker, Robin Bess and Mike Durkin. And then also Dr. Rich Carmona. So thank you so much for being able to to join us today. Dr. Carmona, you want to tell us a little bit about your background? Well, I'm a distinguished professor at the University of Arizona, where Steve Barker also on the faculty and I have other appointments at other universities. But my background's primarily been as a mostly a first responder all my life as a paramedic, registered nurse, physician assistant, and also in the military for a number of years. And culminating in being Surgeon General of the United States. My training is in general vascular surgery with subspecialty and trauma burns and critical care. And I ran emergency medical systems and trauma systems for a good part of my career. Wow, that's great. Well, thank you so much for being able to join us today. What a great, great surprise for us. Dr. Barker, are you are you there, Steve? OK, how about Robin? Robin, can you introduce yourself? I think we might have some folks muted. Hold on one second while we try to troubleshoot that. Steve, if you're unmuted, if you would tell us a little bit about your background, you're unmuted. Let me try this. Mike. Oh, there you are. Hi, Robin. Can you hear me? Yes. OK, so I'm Robin Betts. I'm the vice president of quality, clinical effectiveness and regulatory services for Kaiser Permanente here in Northern California. We cover and ensure 4.4 million members here in Northern California and have 21 hospitals. I have infection prevention as part of my oversight portfolio. I am also an adjunct professor at a university and teach in the Masters in Healthcare Administration in another state. So and on the board of the Patient Safety Movement Foundation. So thank you. I'm really happy to be here. Thank you, Robin. All right, Mike, did I hear you on the line? Yep. Hi, Donna. Thank you very much for asking. Can you hear me? We sure can. You can. Great. Thank you. So well, thank you for asking me to join this. Join the webinar. For those who don't know me, my name is Mike Durkin. I'm currently a professor at Imperial College London, working to support the Patient Safety Translational Research Center. And my previous role was as the National Director for Patient Safety for the NHS in England. And I'm currently now working also with WHO in supporting the development of a global patient safety collaborative. And as Donna has said, I sit on the board of the Patient Safety Movement Foundation as well. Thank you. I'm very much looking forward to this this session. Great. Thank you, Mike. And Steve, are you are you on the line? I'm here. Can you hear me? Great. I sure can. OK, OK. I'm Steve Barker. As you heard, I'm a friend of Rich Carmona. I'm an anesthesiologist, professor and chair emeritus at the University of Arizona. I am also the Chief Science Officer for Massimo Corporation. Great. All right. Well, then let's go ahead and get started. And I know that everybody is anxious to learn a little bit more about what's happening right now with the coronavirus. And as everybody knows, this is a new outbreak, what we call a novel outbreak. This is a new coronavirus that has been identified as SARS-CoV-2. And that is the the name of the virus that causes the disease that is known as COVID-19. You can see on the screen here, this is a screenshot from the Johns Hopkins website. This is updated on a regular basis. I pulled this offline at 6.23 a.m. Pacific Standard Time. So that was just about an hour and a half ago. And and we are going to share the link to this if you are interested in in seeing the updates of confirmed cases. As you can see, there are several hotspots around the world. We in when we talk about outbreaks, you know, we think in terms of epidemics versus pandemic. An epidemic is when there's an outbreak in a certain particular location and a pandemic as when it has spread across the globe. Not a pandemic level yet, but we anticipate that it will be. And then we're going to talk a little bit about the background. But since Dr. Carmonio was able to join us this morning, and I know you don't have a whole lot of time with us this morning. Dr. Carmonio, would you tell us a little bit about the history of how we've dealt with outbreaks in the past? Yes, I'd be happy to. Thanks very much. And my colleagues on the line, my apologies for having to run. I'm at another board meeting right now where we're discussing the same thing, but in Las Vegas. So thanks for the opportunity to comment on this. This issue of dealing with coronavirus comes under the umbrella of what we call emerging infections globally. And for those that are interested, who are not in the first responder area, you can go to dhs.gov or hhs.gov and look at the national response framework, which outlines the national plan for surge capacity and relationship building, a whole host of issues that are necessary to deal with any emerging infection, not just coronavirus, but also any and all manmade or naturally occurring disasters that the United States may face, like earthquakes, tsunamis, active shooters, everything falls under that umbrella. And the reason is is that we term this all hazards because any and all hazards have the same first responders, the same EMS infrastructure, the same hospitals, the same trauma centers and so on. And so for those of us who work in this field, it's just an other threat that falls under that umbrella that utilizes the same infrastructure and expertise of all of the people that we have. The concept that's important to understand is surge capacity, and that is when something bad happens and often will overwhelm a local community that we have a mutual understanding and mutual agreements with other communities. And we surge, that means we start to combine assets and at some cases, like in Katrina, it becomes a national emergency and we have every and all assets responding. And in this case, each community has to be prepared for this emerging infection. Where we are today, as was already pointed out, you know, we're approaching pandemic. You can argue if we're there already with all the countries that are involved. But the most important thing here is that, I would say, social distancing at this point. And that doesn't mean the shutdown operations or anything. It really just means to be smart in how we interact with others, try and stay away from big groups, things like that, because each and every one of us could be a vector. So the idea is to cut down on the amount of vectors and transmissions. The risk really is to the very senior persons who have debilitating diseases. If you have cancer, if you have lots of chronic diseases, if you're immunocompromised or at the other end of the spectrum, infants who don't have a completely functioning, if you will, immunologic system with a newborn. But for most of us, this will be a bad cold. But yet it can still be debilitating and it will take a week or two for you to recover. But the importance about social distancing is we don't want to continue to perpetuate this. Most of my colleagues at CDC, who I've talked to often on daily calls, hoping that this is going to burn out, much like the common flu does, that it peaks in the winter and then going towards spring and summer, it just burns out. We can assist it in accelerating and burning out if we practice good hand washing, social distancing and all of the usual public health things that we talk about in something like this. So I'll stop with that and happy to answer any questions. There's something germane to me. So thank you so much. If anybody has a question for Dr. Carmona, then then write in your chat in the chat box what the question is, because we're going to have to let him go in just a second here. There's a lot of information, again, to our colleagues around around the world. I know I was just on the phone with some NHA spokes and the National Health System in Britain. You know, we're all looking at this the same way, especially in developed nations, big challenge with underdeveloped countries who are struggling that don't have the infrastructure. But I would encourage all of our colleagues to follow CDC.gov, which will give you the daily updates through the CDC eyes. NIH.gov is helpful. Tony Fauci's up there, probably the premier virologist in the world who's not only looking at this through the lens of how we stop it, but also a vaccine. And then, of course, the WHO, which is tracking global implications for this. Excellent. Thank you. We do have one question for you, Rich. Yes. What defines a large group? Well, that is, I say, in the eyes of the beholder. In other words, if you're in New York City and you find five people that have this, it's a relatively small group, what we call a cluster. And then you want to know immediately what, how they're related, where did they come from, because it helps to be able to predict what the extension is. Let's say you're in small town America, where you have a population of a couple of hundred and you have five or 10 people in that community coming up. That's a different problem because of the cluster as it relates to the total population. So these are relative terms that are used, sometimes can be confusing. But I think the most important thing, epidemiologically, we're looking where these clusters pop up of any griffin group of patients. And then it's important that in the federal level, our epidemiologic intelligence service will then start tracking and find out where you were, who you spoke to, where did you travel to, somebody in your family just came from another country. And that starts to build a picture of how this is spreading, which is very helpful to our epidemiologists to translate into common language to help people understand how to stop the spread of this problem. That's great. Thank you so much. Well, I know that you have to have to jump off the phone. I know we only had you until 8 15. We do have a couple of other questions, but I believe we're going to be able to answer those questions as we move through the rest of the presentation. All right. Well, thank you. Thank you for joining us. Thank you. Thank you. Bye bye. OK. OK. Bye bye. OK, so let's move on and talk a little bit about the background. As I said, we're seeing some questions coming in, and I think we're going to be able to answer a lot of those as we move through the presentation. If not, there's time at the end for a question and answer session. Steve, do you want to tell us a little bit about the background of what's been happening with the coronavirus and how we got where we are? Sure, I hope you can hear me fine. This is a new strain of coronavirus that started in Wuhan, China in late December. Coronavirus itself is has been around as long as we know. It's responsible for the common cold. Previous serious outbreaks include something called Mears Middle East Respiratory Syndrome, which was transmitted apparently by camels. And of course, SARS, the severe acute respiratory syndrome, which had a fairly high mortality. The last outbreak of SARS was in 2003. Both of those diseases involve animal transmission, which is a common characteristic. By the way, the name coronavirus comes coronamines crown. The cells actually have spicules sticking out that makes it look somewhat like the prominences on a crown. Again, comparing the COVID-19, which is today's strain with SARS, SARS had a much higher mortality. But COVID-19 appears to be more contagious and the transmission is extremely rapid. You saw in that map from the John Hopkins website how fast it's spreading. I don't know why, frankly, they're not calling it a pandemic because it is in every continent of the world, except perhaps Antarctica. There is no human immunity. As I said, the mortality, and Donna said also, the mortality is relatively low, but there's over 3,000 deaths now. And this is being updated almost by the minute. I strongly recommend that John Hopkins website that she showed the map. That's up at least every hour. World Health Organization has implemented an incident management system, and you can check their website frequently for everything we know and have learned about it. Cases have spread, as I said, and as the map shows around the world, not mentioned on the slide, is that the number two country in deaths now is Italy already, and that's a very rapid spread they've had there. Furthermore, although the theory is that it starts with animals, and that's one possibility of how it initially got started in Wuhan, but the other thing to keep in mind is that there is a large active virology laboratory that happens to be in Wuhan. But anyway, now we have what's called Community Acquired Illness, which means person-to-person transmission documented not just several, but many countries, including the US now, there has been documented cases of human transmission, and you'll hear more about that as we go along. Again, the WHO World Health Organization website has a detailed history of that. Follow that, and also the map page on Johns Hopkins, I find to be excellent and is kept up to date. We're going to talk a little about what works and what doesn't work from previous outbreaks, but remember, these are, to some degree, extrapolations. COVID-19 is new, it's got new properties, new characteristics, and we're still learning about it. So I'll stop there with the background and pass it back to Donna. Great, great, excellent. And we've got several questions coming in asking for links and such. This PowerPoint presentation is going to be shared with everybody that is on the line, and you'll see that we have several links embedded in here, including the link for the Johns Hopkins site. This is a detailed history that is on the World Health Organization website. Sorry about that. And so when you get the presentation, you'll be able to access all of these links that we're talking about. Okay, let's move on. We'll talk a little bit about the virology of coronavirus. Robin, you want to talk about this? Yeah, I'd love to. So then I've seen some questions coming up. So this might help with some of those prior questions, but so I'll just kind of run through these different topics that kind of address many of the areas of the broader category of virology. But the incubation period, now this is the period of time that elapses between an initial exposure to a virus or other infectious organism, and then when the symptoms first appear. So it's estimated to be two to 14 days. So you could have been exposed, but not get sick for 14 days. And then you have to ask the question, well, how do you get it? And this little image here of this individual coughing is really demonstrates the difference between airborne and droplets. So airborne spread happens when germs float through the air after a person talks, coughs, or sneezes, and germs may land in the eyes and the mouth and the nose of another person, and they're very lightweight germs, and so they kind of hang out in the air and you don't really need direct contact with an infected person to actually get sick. So some common airborne diseases include chickenpox, really hard to contain in a family. Measles is probably the most contagious airborne virus that people get exposed to, and those would be demonstrated by the little gray dots. Now coronavirus is a droplet, is heavier. So droplet spread happens when germs traveling inside droplets that are coughed or sneezed from a sick person. They enter the eyes and the nose of the mouth of another person. The droplets travel short distance because they drop, they're heavier, as indicated by the red circles in this picture. They generally drop less than three feet from one person to another. So a person might also get infected by touching a surface or objects that have germs on them and then touch your mouth and nose. So droplets can spread, they say anywhere from three to six feet within a person coughing. Reports out of China indicate that most infections have occurred in close contacts with family, colleagues, or healthcare workers with it that have been in contact with a contagious individual. Asymptomatic individuals, so those people who don't have any symptoms, have been documented to transmit the virus. So even though they don't appear sick and didn't feel sick themselves, they were still able to transmit the virus. And some evidence of spread has really occurred through contact with surfaces contaminated with droplets, but this doesn't appear to be the primary mode of spread. I want to talk a little bit about transmissibility. So it's estimated to be somewhere between two to four, depending on the scientific paper. Now there's like this R factor and I'm not going to talk about this, but what it means is that one infected person will on average spread the virus to two to four individuals. So based on scientific analysis, COVID-19 is more transmissible than the standard influenza and potentially similar to SARS. So and Dr. Barker just mentioned SARS, which was kind of our last big, one of the last big outbreaks that we've had in this country. And then I want to talk a little bit about the severity. How sick do people get? And really 80% of individuals with documented COVID disease, so those are the ones that actually got tested were asymptomatic or had very mild illnesses. So really just had those light cold symptoms. Now there's different reports about mortality and it's estimated to be around two to three percent. However, we really don't know the denominator, which would significantly lower this number because most people who are asymptomatic never go to the doctor and have not been tested. So we really don't know how many people have had it and we probably will never know. But it is very, I think it was Dr. Carmona mentioned. It's really the elderly and frail. We've had one death and it was a very elderly frail individual. And when I say one death, I mean one death in my organization. So the convalescent period, this is the period in which an individual is clinically recovered and no longer capable of transmitting the virus. And that's determined to be about 15 to 30 days after the onset of the infection. So we're still learning about the virus. These are kind of broad ranges, but like we said, we're still learning about this emerging, this emerging germ in our world. So that's kind of, I think I can turn it back over to you, Donna. Okay, excellent. Thank you so much. All right. Well, currently, where we're at right now is, as we mentioned before, there is global spread. We do anticipate a pandemic classification shortly. As Robin said, it is a roughly two or three percent mortality rate. But about 16% of those infected are going to get seriously ill. And so that means that hospitals really need to start preparing for their capacity surge. And Robin's going to talk a little bit about that in a moment. Of course, this has caused significant anxiety and concern across the globe. And one of the things that we hope to be able to reinforce today is that there is no need to panic at this point because most people are not going to get seriously ill from this. And so we're going to talk a little bit later about the things that people can do to keep themselves safe and their loved ones safe and hopefully to bring them to mitigate some of that anxiety. At the present, there is no vaccine. So in terms of treatment, we're just following standard flu symptom management. Tamaslu, the medication that we use for influenza won't work for this particular virus because it's specific to the influenza virus. But there are some other antivirals out there that are being tried. We don't have any definitive information on that yet, but we're working on it. And testing kits are slowly becoming more available. Everybody's probably heard on the news that there were some difficulties getting testing kits out but that's starting to abate now. So the more the testing kits become available, the more we'll be able to know. Oh, my mom still responds. Oh, I spoke to her and they said they're up to date. If somebody is... We went through that already. She hasn't read the direct. That's obviously... You're on the WebEx? Yeah, if we have to reschedule. Oh, I haven't read my email. So I think where I propose is having someone full care to see Hold on, guys. We're going to try to... We're going to try to call the mom and see where the last place they were at. If they're on LCR... Give us a moment. I apologize. I had a time to try to get records. That would be helpful as well. Hello? Yeah. If you can hear me and you can... Thank you so much. Excellent. Okay. All right. So as I mentioned, the testing kits are slowly becoming more available and so that is going to help us to identify who is infected and who is not. And as Robin mentioned, the more that we are able to test and find out how many people are infected with the virus, the more we're going to be able to determine exactly what that mortality rate is. And hopefully that will be lower once we identify how many people have the virus and just don't have any symptoms. In the meantime, our communities are responding with containment strategies that they have been, as you guys have probably heard, several events are being canceled as we have had to cancel our summit here. So have many other conferences across the world been canceled. There's a lot of schools and workplaces that are trying to determine how they're going to mitigate this. And as I said, we start with containment, but we really, as you can see on the map on the page, we're kind of past the point of containment right now. The virus is out and so now we need to move into a mitigation strategy and Robin's going to talk a little bit about that moving forward. The Johns Hopkins map that we talked about on the first slide is linked right here. And as I mentioned, we'll send you this PowerPoint presentation and you'll be able to access all of these links. All right, Robin, you want to talk a little bit about the recommendation. Yes, I can do that. Thank you. So here are some just general recommendations for the public. So keep in mind it is still cold and flu season and you really use the same precautions for COVID-19 that you would use to avoid catching a cold or flu. So I won't read them all. However, good hygiene is hand hygiene is really critical. Keep your hands away from your face. Avoid crowds and keep your distance from those who are sick. Stay home if you're sick and prevent to prevent spreading contagions yourself and then disinfect high touch surfaces at home. So we just kind of laid these out for you knowing this can come out. These are kind of general practice standards to avoid virus spread, viral spread. And you can use these to share on your websites. I know many of the people that are part of the Patient Safety Movement Foundation have venues in which they can share information. In fact, the next slide, if you want to go to that, we have some links to some helpful videos around hand hygiene. Oh, I guess the... I apologize, Robin. I think it's the link, yeah. That one there, yeah. Thank you. That's okay. Yeah. So we've provided these links to some of the public education videos that promote hand hygiene. And you can share them with your community or add links to your web pages, share them at staff meetings. It's just as much as we can get the general population cooperating and understanding what they need to do, as well as mitigating fear. And I think, Donna, you brought up a really good point about, you know, there's a lot of sensationalism around this. So there's a lot of constant media. And so it kind of raises the fear in general society. Any pandemic kind of has this curve where, you know, you kind of... It's a steep bell curve where you get this exposure and then pretty soon, like a flu season, it kind of dies off and we have general exposure. And coronavirus will remain in our communities over time, but we'll have built-up immunity. And so we won't see the spike. But also preceding that curve is often a societal fear curve or panic curve. And we really need to do all that we can to prevent the anxiety of those that we work with, that those that we associate with and help them understand that they can control their exposure and their potential risk. So I'll turn it back to you. Thank you. Great, thank you. And Mike, do you want to talk a little bit about this great little video clip that you shared with us? Yeah, thank you, Donna. And thank you, Robin, for such a clear exposition there of what we need to do. Some of the key elements, as Rick Kamon has said, was actually this behavior modification that we need to carry through with. And this is a societal issue as well as a personal one. So alongside social distancing, which he talked about, it's absolutely vital that we do recognize the importance of hand washing, and also then particularly touching our nose, our mouth, our face, where most of our own droplets will be resident. And so it's very difficult to do that. I just want to share with you a video that was posted, which was, it'll be interesting to see what you think of it, but it sends a couple of messages out for me. Thanks, Donna. Okay, great. Apologize. So for those of you who are looking but can't hear anything, we'll run it a couple of times, but in fact, these are colleagues who are talking about coronavirus and giving an update on the current situation in their area. And this lady is being very good in really giving good advice to the public. But then as you can see, just as she talks about the importance of hand washing and of keeping your fingers and hands away from your nose, your mouth and your face, she automatically licks her tongue to move the paper forward from her crib sheet. So in some situations, this may be seen as quite funny. In others, it may be seen as quite sad. And we don't actually know whether she did it on purpose. But the key element, I think, is to demonstrate how difficult it is for us to go through not only five minutes of not touching our hands or our face, but going through 24 hours, 36 hours, as long periods as possible. The other key issue, I think, is to remember that after we touch our face, that's when we should be washing our hands and also before food and after food and also incredibly important when we're in public spaces and using any sort of area that we're trying to protect ourselves and protect our fellow populations. That's all I wanted to say on that one. Thank you, Mike. Thank you, Mike. That's a really great point. You know, it is human nature for us to touch our faces. And as Robin mentioned, these links are here in this presentation that you'll receive. If people need some instruction on how to wash their hands, a lot of folks don't wash their hands long enough, so these links will help to show people exactly how they need to do this. All right, Robin, do you want to talk a little bit about how healthcare facilities need to prepare for this? Yes, I can do that. And I just want to start, you know, we've been using two terms, containment and mitigation. And both of those have different approaches to how we have to manage the population as they come in and out of our system. In containment mode, the strategies are really designed to halt the spread of an infection. So ultimately, the goal is to isolate individuals with the infection as well as those potentially exposed to the infection and with the goal of preventing spread to the general population. So we do things like isolate people or quarantine people in quarantine or staff. In fact, in Oregon, where they had an exposure in their ICU because of the containment model in which they were operating in and because it was a community where nurses often worked at multiple hospitals. They literally had so many nurses furloughed it was hard to deliver care because they were all quarantined under the containment model. Once we realize it's in our population, we have spread within our community, which is what we're seeing here in California. The hope is that the government will move to a mitigation strategy. And California has moved. They've established a state of emergency which allows us to move to mitigation. So the mitigation approach is really designed to divide the patients based on the severity of symptoms. So individuals receive the right level of care in the right setting. They're designed to minimize the effects of an infection on a population when the infection can no longer be contained. Mitigation strategies also allow for the appropriate use and deployment of resources to really respond to large-scale outbreak that is already embedded in the community. So it really your staff aren't any safer being quarantined in the community than they would be wearing protective equipment at work. So it just changes the accessibility to resources. So no matter whether you are in containment mode or mitigation mode, there are some core things that you and your teams need to be thinking about and that is what's your infection control plan. And that really is based on what we understand about the epidemiology and virology of this bug. So for instance, right now we're treating it and using really airborne precautions but once you move to mitigation and we're not quarantining anymore you can treat it for what it is and that's droplet. So really understanding the virology and the recommendations that are guiding the regulations that are guiding what mode you're in will drive your infection prevention plan. Human resources are our greatest commodity and they need to be equipped. They need to be trained on how to put on we call it dawning and doffing. Put on and take off their protective equipment without cross-contamination or self-inoculation. We need clearly defined workflows so we know exactly what we're going to do when someone presents themselves in our emergency departments or they've called for an appointment with flu symptoms so we can anticipate them coming in and are we going to have them meet at a back door with an escort. All these workflows are clearly defined so that our staff feel confident and protected as they face uncertainty. When we don't have clear workflows and everybody's just operating under the unknown there goes that fear barrel curve and they don't feel valued they don't feel protected by their organization. Supply chain strategy is really important as you know much of our medical supply chain does come from China and that has been halted so making sure that you're monitoring your supplies and have a daily inventory of where you're at and how many days of equipment that you do have and what is your relationships and how are you going to order and partner with other organizations. In fact one thing that we did recently is we loaned some protective gear to an organization and when they returned it they returned it tenfold so that was just really a kind you know it was nice it was nice of us to share but we hadn't you know it was had no idea that it would be so kind of the return so those are just some things to think about and of course the screening workflows so based on your entry points in your organization how are you going to screen individuals you know what are the questions you're going to ask have you traveled and do you have those scripts for your staff and then the communication plan both internal and external as people will be who need to come in for healthcare might be afraid to come so make sure you're communicating not only to your teams to mitigate their fears and concerns but also the community that you serve and then our hospitals and so you can go the next slide I think with help our hospital facilities you can work within your service lines to define your workflows things will be very different for surgical services and places where they're inserting airway tubes and things like that are going to be a little bit different on how they what are the workflows for that versus a medical surgical unit so and as well as the level of care of which you're providing and how invasive that care is will determine your workflows so really work closely with your clinicians and your service lines to define those and and then in the outpatient area there's often you know we can often anticipate our visits and people call in for their appointments there's the walk inside but then there's the anticipated side so really making sure that as your schedulers or advice nurse lines are taking calls that they're screening people so you can anticipate the population coming and again can greet them at the entry point to have them safely navigate into your environment if you want to just go to the I think the next slide yeah so there are actually you're not alone so the World Health Organization and the Centers for Disease Control have wonderful guidelines that can help healthcare facilities have a framework to work off of Kaiser Permanente we have our mitigation playbook template it's a word document that you can that we've given to the patient safety movement foundation that you can actually download and scale and scope based on your environment we have a very complex environment so we didn't include everything because we have a fully integrated model of care but I think it'll give you a nice framework to launch off of and because it's a word document you can adapt it to your your organization the scope and scale of your care delivery so I'll turn it back over yeah to you Donna thank you thank you and I just wanted to mention that link is here embedded in the PowerPoint presentation but we have also linked it on our website where the webinar will be posted so everybody can download it and and modify it as needed thank you so much Robin for sharing that wonderful resource okay Mike you want to tell us a little bit about the international perspective yes thank you and I think I just want to also try and frame this within the some of the cultural elements of safety and some of the aspects and ethical values of safety that we think are really so important and in this particular context I think transparency is vital in his key but I think also is it is honesty and trust honesty and trust with with the systems that we are supporting in the systems of delivery of care so I think for me this is very important and then candor candor when we when we work at how we could have done better and where we will do better so what we do know in the UK and I'll give you some data we have a system in the UK of updating on a daily basis and you'll see this coming through in terms of the Johns Hopkins data but also a number of other elements that I'll talk about in a little bit later but so we have as of 2 p.m. today which is the when we post the data on the Department of Health website we have 20,338 people who have been tested for the COVID-19 but of those 20,000 plus just 163 have been confirmed for us this this demonstrates that we're actually we're actually testing large numbers and we have the ability to test large numbers which is really important I think not only for for the health system to understand that testing is available that is and is relatively rapid but it also gives confidence I think to the public that if they require testing then they can have it testing by is done through access through a an open system we have a telephone system of access to local local advice and you give your symptoms to a call handler over the advice and then you will be given advice about whether or not you need to go to a testing centre we've asked we ask individuals not to go to their local health facility but to go to a designated health testing centre where there'll be samples will be taken tests will be done and results will be handed out the interesting element about the testing system is that we're now also as it is also happening in the US we're now starting to sequence the viral genome which is really important in terms of determining the mutation scale and the mutation numbers that are likely to happen with this current strain so of those numbers that that we have we have now we're certainly now looking to see well what impact is that going to be and the modeling that we've done which we've now shared and is available through Public Health England and also the UK coronavirus action plan which is a a guide from the from the the Department of Health and it has within it a guide of what to expect for the public within that those two plans the Public Health England plan and the the Kroner Action Plan we've described that there is a the modeling would suggest that we're into a three to eight week period of increase vast increasing in numbers a bit likes happened in it has happened in in China in all our countries and that as the more we can delay that those numbers the more we can level out that plateau the peak effect so that we can then move into into the the summer season which gives two benefits one is that if this coronavirus does react the same as others which is an unknown quantity at the moment it may it may start to to with a slightly in the summer months but the other element to us for it particularly in countries of our system which is a population about 60 million we start to think about whether or not we can use the spare capacity in the summer that we wouldn't necessarily have in the winter so that three to eight week period the plateau period and then the fall down is is vital also shared with you the BBC link which is another link which has a series of mapping exercise on it maps on it and it's very interesting to look at the China effect which is also Johns Hopkins as well but if you look at that you actually do see that this three to eight period is probably modeled well and hopefully that will be an example that we can build on I think that's that's enough from me because I know that people are anxious for questions Donna, thank you excellent thank you so much all right one other thing sorry sorry one one other apart from so the yes I'll come the one other thing was travel advice often travel advice is coming forward we've taken the view that if if you have traveled from the initial high impact areas then you will definitely need to be tested on arrival and then or you self quarantine and then test if you have symptoms that is starting to be extended a little bit initially there was concerns about northern Italy in particular in Europe but now I think we've just now I think that the that spread further afield within Italy and so I think that the advice is changing almost on a a definitely if not certainly weekly basis on that so travel advice I think is something that needs to be tailored in and each of our our systems around the world is giving tailored travel advice with regard to our own systems don't forget the World Health Organization online training resources which are fantastic resource for for all of us to follow and certainly will be a great benefit to a number of resource restricted countries around the world thank you sorry Donna thank you no no problem thank you so much I really appreciate it we have a few more minutes left for questions from the audience and we have several questions and Mike you actually hit on one a little bit one question was why is the spread limited in certain areas of the globe like for example Africa yeah I did see that question pop up I think it's a question that we've we've asked here I don't think anyone knows the answer to that one I think one also has to recognize that the the ability to capture um symptoms the ability for patients to go into local health communities to describe their symptoms to health care workers whether that's worker nurses doctors or whatever or whether or not there is a local surveillance system I think is a key issue in some of some of our lower middle of countries of which many are in Africa so so I'm not entirely sure we know the answer to that and it may be one of of not entirely understanding the spread but also it may be one that we don't really understand the surveillance methodologies that are in place and certainly the testing abilities in some countries may not be may not be in place yet although I know that WHO is ensuring that those will be taking place so I think that's I think that's a watching brief I think certainly for me Africa is a watching brief and and in that same vein Mike if there are people that are traveling from a area that does have a significant number of cases what what precautions should they take should everybody be quarantining themselves if they're traveling from a place like for example Italy so so I think you should you should certainly first of all take the advice that you're that that is in place for your own country residents that's the the first and most important thing and that's the socially responsible issue to take I think the for the vast majority it's it's one of self quarantine if you've come from an area that has the situation pretty much endemic in it I think you also have to recognize that you may may or may not have symptoms and so therefore don't use necessarily symptoms as the as the way forward for you but if you do have symptoms and you've come from an area that has has a high incidence then you you should you should get tested and and then self-quarantine until you've both until you've had the test result back but certainly at least self-quarantine in the early stage definitely excellent thank you Robin we have a few questions about the environment and about PPE can you talk about why why math why people may be saying that math don't work and also talk a little bit about how long that virus lives on a surface or even on the on your elbow if we're telling everybody to cough into their elbow Yeah we actually don't know right now how long it lives as far as surfaces one of the one of our workflows is that after we have a what we call a person under investigation in a room or a positive COVID individual once they leave the room we close the door and we kind of let the environment settle for one hour before we go in and clean all the surfaces so that's that's just one thing we we don't know how long it does live on surfaces so that's the other and that's the whole concept around don't touch your face don't touch your eyes and wash your hands so right now I can't really give you that information this is Steve if I could add something I've seen some reports that it if it's in droplets it can live on surfaces for at least six hours so I would I would just assume the worst on that that surfaces need to be cleaned and clean dry that's right it's it's the dwell time right make sure that you know how long something should a cleaner should kind of dwell on the surface to actually kill the germ again that goes to your workflows or you know even in your own home environment you know if you use some sort of a cleaner that has a germicide in it make sure that you let it sit on that surface for a little bit of something or make moist and just let it dry that's really the best way to do it great thank you so much there's another question about immunity does anybody want to talk about whether or not where are we with the you know the knowledge that we have about immunity to this virus one one another point can you get it again after you have it there's one documented case for sure of somebody who got it twice in china so lack of that it's still coming out yeah yeah so the you know the the belief is that this is a a novel virus so a first time so more people will get sick but with illnesses we do especially these especially viruses and other corona type viruses we do develop an immunity to them and don't get them again in general but like Dr. Barker said there's always you know there's always the immunosuppressed and we can get things again if we become compromised over time however a consecutive inoculations in a community are generally at a much lower level than the first great thank you so much there are some some questions about the the handling of PPE and I think that for the just in the interest of time because we only have two minutes left I'll direct everybody with questions about how to manage the environment PPE and such to the resources that we have linked in the PowerPoint presentation and and then I think there was one more question about about staffing somebody from a critical access hospital I think this is a great question not just for critical access hospitals and but for all health care organizations Robin you touched on it a little bit but how what do you have any ideas of what strategies we can we can put in place for health care organizations that are terribly short staffed yeah well you need to have you need to anticipate it so as part of our strategy we are we anticipate that more people will be out so if we have a registry that we use for contingent staff workers which most people do have a relationship we make arrangements in advance and we just say hey we we think we're going to need about five or six resources and could we in advance kind of have an arrangement where you would make those individuals available for you sometimes you do prepay you know a percentage of the fee but that's one thing that you can do to anticipate but really the best thing to do is to keep yourself your staff healthy by giving them the equipment and that they need and then to have workflows and environmental cleaning protocols that will keep people healthy excellent excellent well we're right at nine o'clock but there is one question that I think might be worth talking about real real facts the question was about pregnant women is there any specific concerns that pregnant women need to be worried about or a nursing mom anybody have the the answer to that I don't I don't know that I have a specific answer but I wouldn't I would encourage to continue nursing your baby because even if you have a cold or or something you're developing immunity immunity and we know that through breastfeeding that those things are passed to the baby I don't know Dr. Barker any other thoughts you're just to clarify you're saying the immunity is passed to the baby not not above itself that's correct and I I think that's usually true yeah but I I think we don't know about the virus so right yeah there's so much about this that we don't know that's the yeah yeah that's the scary thing to keep in mind we're making assumptions based on our previous experience with coronavirus but this one is new that's right and and you know so that's a great way for us to end this I think everybody needs to you know recognize that because this is a new outbreak there is information that is coming out from the World Health Organization and the CDC on a continuous basis and so so we'd like to direct you to those sites for updates moving forward based on how fast things are changing this particular presentation may be outdated pretty shortly here so we will have this we will post this presentation on our website we will send the PowerPoint as a PDF to everybody so that you can have the link to click on but moving forward if you're looking for additional information please make sure that the World Health Organization or your country centers for disease control are your source of truth okay well thank you so much we are two minutes past the hour and so thank you everybody for joining us and we will have all of this on our website very sure oh it's actually already on the website so this is exciting and we will send this to you as a as I said in a PDF form but if you don't get it for some reason please head to our website and and you'll find it there thank you everybody have a wonderful day very good okay bye bye thank you guys bye bye bye bye thank you Donna for hosting it