 Okay, we're back. We're live. I'm Jay Fidel. This is Community Matters and we have Dr. Elaine Bello on the phone on VMIX call and we're talking to her about coronavirus. Hi, Dr. Bello. Thank you for joining us this morning. Hi, Jay. Thanks for having me. Absolutely. So tell me about your specialties. Tell me about your training and tell me about your involvement in coronavirus right now. Okay, infectious disease and internal medicine doctor at the Queens Medical Center. So I see patients with a variety of infectious diseases. I also am associate professor in the Department of Medicine at JABSOM and I work in the infection control program at the Queens Medical Center also. So we are actively in preparation at Queens to try to reduce the likelihood of people with novel coronavirus transmitting their virus within our institution. We're fortunate so far we have not had any either in the state or at Queens. Well, yeah, I think we have to step in your shoes for a minute and see it from your point of view. You're at Queens Medical Center and if somebody comes in on a plane, somebody has a temperature, presents as a possible case, there's a fair chance they're going to wind up in Queens Medical Center, am I right? And what happens then? Yeah. So we've actually had some patients who fit that profile come into our ER and we've been proactive at instituting what we call a travel screen. So patients who enter through the emergency room or one of our affiliated clinics are routinely now being asked about travel to China and specifically travel to Wuhan. If they have fever or other respiratory complaints, they are immediately masked and put into a room with a closed door until the first provider can evaluate them. And then our providers have been trained that they enter those rooms with appropriate equipment, which includes the N95 mask as well as a gown. They do their assessment and if they feel that the patient could be somebody who has the novel 2019 coronavirus, there's an immediate call to the Department of Health. Of course, in the meantime, they're also evaluated for the other respiratory viruses that are circulating right now, especially influenza. And maybe just pneumonia or routine pneumonia or routine viral pneumonia are also going around. You said there was a special kind of mask. Can you took more about the kind of mask that's effective as opposed to kind of mask that's not effective? Yes. So I think there's a lot of confusion around the mask because there are different recommendations from the CDC about what kind of mask who wears. So if a patient comes in, the first mask that's put on them is a surgical mask or one that covers the mouth and nose. And these are the same surgical masks that people wear in surgical procedures. But for providers who enter the room, we're trying to actually protect them from getting this novel 2019 virus. So they actually have more enhanced isolation, personal protective equipment. So this includes what we call an N95 mask or the equivalent and a isolation gown. So the patient's mask is intended to prevent spread of the virus in their respiratory droplets should they cough or sneeze. But the providers have an extra layer of basically the same kind of mask that we use for persons with TB, where we see people with TB. I remember reading that, you know, the Chinese early on, early means a week ago, had isolated, mapped the genome for coronavirus and that they had then shared it with the world. Is this true? And are there kits out there? And do you have kits by which you can make a confirmed diagnosis of the coronavirus? Yes. So definitely the genome, the full genome for this coronavirus is available. And there are US researchers actively trying to develop a vaccine. So the diagnostic test of choice is what we call a PCR, which is again, based on genome testing or components of the genome. So the Department of Health right now is the keeper of that test. So our regular community microbiology labs do not have access to that test. So if we have a patient that we suspect, again, we have to call the Department of Health directly. And they get involved in the collection of specimens and the testing. And the confirmatory testing at this point would probably go to the CDC. I imagine that both the masks, N95 you mentioned, and the testing kit are going to be in short supply, whether that's, you know, a real short supply or just sort of a public concern short supply going forward. And do we have sufficient kits? Do we have sufficient masks to deal with increase in the numbers of cases? Okay. So that actually was part of our preparation for this taking inventory of our availability of N95 masks for the providers, as well as the surgical masks for, you know, patients and our staff. And fortunately, again, we actually did this in advance of active planning for the novel coronavirus, because we did the surgical mask inventory in response to our efforts to contain influenza. You know, when this, sorry, go ahead. So I, you know, there's been a lot of concern, I think, on the part of the public because I guess some of the local stores are out of surgical masks. And, you know, I don't know if it's still, they're still available on Amazon. But, you know, there are other things besides just masking that that one can do to protect oneself from the virus. I mean, there are some obvious things like not traveling to China, you know, not traveling on a plane if you don't need to. Yeah. When the virus was first made public, what I saw was the incubation of three or four days. But more recently, the word is the incubation is up to two weeks. And more recently also, it seems that we've had transmission among people in the US, two people in the US who have not been to China from people who have come from China. And then finally, the other revelation here is that you can, you can catch it from somebody who shows no symptoms, who doesn't present at all in that, I guess, that 14-day incubation period. So my question to you, Dr. Bella, is this, you know, the whole defensive model is based on people coming from China, vectors from those people to other people here, and you track back from, you know, whether disease presents to see whether there was a connection with somebody who came from China. But, you know, sometimes you don't know. Sometimes in that 14-day period, it can jump from somebody who came from China to somebody who doesn't know, to somebody else who doesn't know. And I don't know how many levels it can go, but it can go to someone who has no idea about the vectors. How do you deal with that? Yeah, that is the major public health challenge that I think everyone is dealing with right now. So you're correct. Initially, it was thought that the incubation period. So the incubation period is a time between actual infection and the development of symptoms, where people with respiratory viruses may still be able to transmit the virus and the infection. So it is difficult. And, you know, there are, so I just read something today that Russia has actually closed its Chinese, you know, its border with China. So I guess that's the extreme of, you know, what one can do in a country such as Russia is to actually close the borders and not allow anyone from China to come here. So I think most countries, you know, have not taken that approach. But that would be one way to guarantee, you know, if you don't let people enter your country, then the likelihood of anybody transmitting the infection is low. But you know, we don't live in that kind of society. Well, it just strikes me on a mathematical basis. And I think this is a good backdrop to understand about how this spreads or doesn't and how it ultimately burns itself out. Is that if you have people coming from China and infecting other people, you're going to know pretty much within 14 days, or maybe a small multiple of that, the extent of the damage, the extent of the spread. But if you close the border and you say no more people from China, nobody can come in, then you can do a mathematical calculation, can't you? And say that all this will be spent. You know, the disease will burn itself out in X days because we will know, we will isolate and quarantine everybody who might be infected. And at the end of a certain period of time, there'll be no more infection possible. Am I right? Is this part of it? Yeah, so technically, but you know, there's a lot of detail that we don't know about this virus yet. So again, the incubation period went from initially two to three days and, you know, a few weeks later to 14 days. Again, I think we don't know yet the real details about transmission. And even for SARS, MERS, some of the information about vectors, about transmission, we really didn't confirm until years later. But that's one of the challenges of having acute outbreaks. You have to do the best thing based on the information you know at that time. And like I say, for again, this constantly evolving disease, there's just so much we don't know. You say evolving, and that's an interesting term because I saw something for the proposition that when coronavirus first hit the streets, so to speak, it was a certain kind of virus. But then somebody said, wait, it has mutated even in a short period of time. And that's coronavirus number two, and made worse by the mutation. And then I suppose, like you thought on this, I suppose you could have mutation number three or four. And it can, you know, keep us chasing because it keeps changing. Am I right? Yes. So again, all of this is speculation. But definitely viruses can mutate in varying time periods. You know, one of the challenges with say HIV virus, I mean, that's been one of the challenges of HIV virus, you know, the capacity to mutate over time. And again, we just don't know. Yeah. Yeah. Well, I'm sure what I say is not inspiring confidence that we have this under control. But you know that it is what it is. Yeah. I think we all have to be realistic about it. Now, you had a bunch of slides and I guess the overarching question is what do we know about this virus and the way it spreads? Why don't you pick some of your slides and help make people aware of our current state of knowledge about this virus? Maybe the first slide with that picture. So this is just some basic virology. So the name coronavirus actually comes from the crown like experience, appearance of those spikes, those protein spikes coming out from the virus. And this is a RNA virus. It can cause a range of disease in animals. And this is again important because it's thought that the current novel virus originally comes from animals. And if I can have the next slide here. And this is just another picture, the structure. Again, you can see those crown like appendages. Next slide. And this is also an interesting slide. So this actually came from my talk on the MERS virus, the Middle Eastern Respiratory Syndrome virus. And you can see it's down there in the purple petal of this sort of branching flower here. And then right next to it in the green is the SARS virus. I actually don't have enough knowledge about the phylogeny of the novel 2019 to know whether it's going to fall either in the purple or the green or it's going to have an arm of its own. Next slide. And the coronaviruses overall are found pretty much everywhere in the world. They tend to circulate in the winter in temperate climates. And they can cause up to 10% of acute respiratory infections in adults. It also is an important cause of acute ear infections in children. And it's an infrequent cause of diarrhea in infants and children. Next slide. In adults, you can actually isolate the virus in about 4% of people who present with an acute exacerbation of chronic obstructive pulmonary disease. And typically it's a flu-like illness. It can cause an acute exacerbation of people with chronic bronchitis, pneumonia, and again, two of the previous important coronaviruses are the SARS virus and the MERS virus. Okay. Well, let me ask, you know, I remember that the SARS virus struck something like 8,000 people and 800 died. Of the 800 who died? Actually it was more like five, I think 5,000 total. Because there's just been some observations that the SARS count so far has exceeded the total number, I mean the novel 19 coronavirus numbers have so far exceeded the total SARS cases reported. And similar with the Middle Eastern MERS virus, I don't know the exact number, but it was a pretty substantial percentage of fatality in there by the time it spent itself. And in both cases, both SARS and MERS, health workers were a substantial percentage of the fatalities, yeah? Yes. So a lot of those health care worker cases, I think, you know, they definitely health care workers got it. But I think a lot of people were infected in those epidemics before people knew what they were dealing with. So they probably were not taking appropriate precautions. The current recommendations for any coronavirus infection, including the current one, is that, again, health care workers use both airborne and contact precautions. So that's the N95 respirator and also wearing an isolation gown and gloves and keeping people, if possible, in negative air pressure rooms. So as for what the individuals should do here or anywhere in the country, because I think it's always a possibility these days, it's a health emergency these days. One is you would use hand lotion sanitizer often and you'd wash your hands for more than 20 seconds and you keep doing that all day and you wouldn't shake hands with anybody. You'd give them the elbow maybe, but you wouldn't shake hands with them. And you'd stay your distance away from them, from everybody, to avoid the droplets getting on you, am I right? Yeah, so if I can have my last slide, I think it addresses a lot of those issues. So, you know, what can people do to protect themselves? And we've already talked about not traveling to Wuhan, not traveling to China, avoiding unnecessary plane travel or even crowds where, again, you don't know much about what the other person has. You can't control coughs or exposures. And then Jay alluded already to cough etiquette, you know, covering your mouth and nose area with your when you cough or sneeze, practicing frequent hand hygiene and either an alcohol sanitizer hand sanitizer rub or actual hand washing. And one of the things that we've tried to emphasize at Queens is, you know, if you if you don't need to go to the hospital or a clinic, don't come. And we discourage people who have fevers or symptoms of their own from coming into the hospital, not just for novel 2019 Coronavirus, but for influenza and other respiratory illnesses. Of course, if you have a patient who's dependent on you or a child, for instance, you have to accompany them to the healthcare setting, again, take those other appropriate precautions. So suppose, suppose, you know, a person, a given person is diagnosed. I know that if you're elderly and you have respiratory issues in your life, you're at greater risk. Or if you're very young, you have greater risk. But in the fatality in SARS and the rate of fatality in SARS and MERS was both what over 10%. I don't know exactly what it was, but and we can expect something like that here now. It's already happening something like that now. What do you do? What are the chances of beating this if you get it? Well, the majority of people have survived. Okay, but there are a percentage who have developed severe respiratory illness. And the specific term is ARDS or ARDS. Where you have severe inflammation in the lung. And there are patients who have died from the novel 2019 Coronavirus who have gone on to develop multi-organt failure. But the majority of people have survived. But in terms of the demographic risk, certainly people who have underlying lung disease, diabetes, heart disease are at greater risk of dying because they have, if they do develop a severe complication, they already have some degree, they may have some degree of organ compromise. But what is interesting so far, and I think I have a slide on the demographic of a series of 41 patients who were admitted to a hospital in Wuhan. And if you look at the demographic, you'll see that actually people in their 20s and middle age were affected just as much as the elderly. And actually the number of people, the proportion of people ending up in intensive care units was actually quite similar in all of the age groups. So remember, this is a novel virus. So nobody in, nobody has inherent immunity. Yeah. Well, just on the, on the governmental side of this, this morning I read that the World Health Organization had declared this a global medical emergency. I don't know what that means or what they can, what they are funded to do, what they, what steps they will take. At the same time, the CDC, the Centers for Disease Control, I guess that's in Atlanta, is it? They have not declared it a national emergency. And for that reason, they have not released the emergency money that they have, which they can release any time, which is $85 million. I wonder, you know, what it is, what it means to declare it an emergency, either by the World Health Organization or by the CDC? And why they're not on the same page? Okay, so I emphasize that I'm not an expert on the politics. So again, I'm just speculating here. But early on, the CDC, once there were cases outside of China, were lobbying to have this declared a, you know, worldwide pandemic. And WHO actually only today declared this an international public health emergency. But what this does for WHO, as well as the CDC, now that it's declared an international public health emergency, actually allows them more latitude in intervening and going into China to assess the situation from their points of view. So up until this point, you know, largely what we've been getting is what the Chinese government really allows to be publicized outside of China. But this also, you know, gives I think China the chance to accept some assistance in just public health assessment. So I think it's a good thing. With regard to the CDC money, I think, you know, CDC in terms of US cases, and I do have a slide also of the US cases, I think right now in the United States, I would not consider it a public health emergency either, just based on the relatively small numbers of cases. But again, as things evolve, this may change. So this is the latest data from January 29. So you can see really it's four states that have been reporting cases. So Illinois, Washington, California, and Arizona. So these are confirmed cases. There are what they call PYs or persons under investigation in larger numbers in all of those states. And I think notably, for Hawaii, you could see that we have not had any cases. But I think we are a little nervous because we are the state that's closest to China. I've heard that, you know, some say based on the experience with SARS and MERS that this will is likely to burn itself out by May of this year. And that could be completely speculative. And I've also heard it said by Novartis, a drug manufacturer and drug research company in Europe, I guess, that will take a year to develop a vaccine. But finally, I've heard, I think that Johnson and Johnson is working on a vaccine right now, and maybe more optimistic than that. So, you know, where are we in terms of a burnout? Where are we in terms of the development of a vaccine? Yeah, so I don't think we're anywhere near burnout. I don't think we've seen the curve for cases peak yet. And the vaccine, the vaccine is difficult. So once you know the genome, you can start work on the vaccine. But in the United States, vaccine development proceeds by very organized specific steps. So you have to go through phase one, phase two, phase three trials. The Food and Drug Administration has the capacity to fast track drugs, including vaccines. So I think, again, a lot of this is a moving target. And to say that, you know, by May, we're going to have burnout, I think is very difficult to predict at this point in time. Yeah. Well, thank you, Dr. Bellow, Dr. Elaine Bellow at Queens Hospital. Thank you so much for sharing all this and helping us educate ourselves on what is happening and likely to happen. Thank you so much. Aloha. All right. Thank you, Jay. Thank you for having me.