 I'm Jay Fidel. This is Think Tech Hawaii. It's the 12 noon show on a given Tuesday election day, so exciting. And Dwayne Gubler, Dr. Dwayne Gubler joins us for a discussion of an update on COVID and how it's doing. He's an epidemiologist. He's an infectious disease guy. And he was running and still is associated with the John A. Burns School of Medicine, I think, and the Singapore Duke NUS School of Medicine, where he is an emeritus professor in infectious diseases. How much of that was correct, Dwayne? All correct. Okay. Great to see you again. No kidding, especially now, especially election day COVID. People have been thinking about that for months and increasingly so. And we have all this disinformation and misinformation, and we don't know which way is up and who to believe and so forth. And I really wanted to weigh in with you on exactly what is going on in terms of the spread of this disease and how it is presenting on an epidemiological basis. Well, as I told you in April, when we last talked, the virus had already spread, at least in my view, anyway, the virus had already spread around the world. And there was probably very little that we were going to do to really contain it. Our best option was to mitigate it, implement all of the non-pharmaceutical intervention strategies that we knew, social distancing, cough and hand hygiene, wearing masks when appropriate, especially indoors, and not being in real close contact with a lot of people, staying away from large crowds, basically to decrease the probability of transmission and not overload our primary health care system. And I unfortunately, nothing much has changed since then. We do have some potential antiviral drugs in the pipeline and some vaccines in the pipeline, but not yet really readily available for the general population. So we're going into a second wave situation where we're seeing dramatically increased transmission in European countries and in the western part of the United States. So at this point, I think basically what we talked about in April is still appropriate today. We need to protect our vulnerable populations, that is old people like you and I, and people who have comorbidities again like you and I, people who have compromised immune responses. But other than that, I think it's business as usual. The other difference is, and this relates directly to the election today, is the question is do we lock down again or do we continue to open up and let businesses open, let schools open, let universities open, let them play football, basketball, and Brian developed some sort of normalcy from the epidemic. Well, let's talk about, let's unpack some of that. You know, I was following, still am, the plague in the 14th century and how it rolled across Europe. Of course, that's a different disease entirely. It's bacteriological rather than a virus, but it certainly had a devastating effect on Europe. And at the time, they had no idea what was, what was, you know, responsible for it or how they could slow it down. And what happened over time, even without that knowledge, is it sort of subsided by itself. And I think, you know, Trump has, Trump was suggesting early on that it would go away. It would go away as epidemics do, I mean, or do they go away? And over time, it would, it would, you know, subside. And then, of course, we heard from him about herd immunity, which is a, oh, kind of a related theory, I suppose. And the case of the plague, it did subside after 10 or 15 years in Europe. And then only to surface a couple of decades later in various different places in Europe. And since then, you know, and before, before we learned about antibiotics, until the end, actually, of the 19th century, we had it popping up here, there and everywhere, including Hawaii. So, you know, the question, and only after we found antibiotics, were we able to, you know, you know, dismiss the plague, or at least that plague. So question is, will this virus ultimately go away by itself? And the related question is, what about that, together with herd immunity, as the president has suggested? Yeah, well, you covered a lot of topics there too. And so, as you use your verbiage, we need to unpack some of it. Number one, plague hasn't gone away. Plague is still with us. And although there's no evidence that it's still in Hawaii, I visited the last plague laboratory in Hawaii when I was there in 1963 over in a place called, on the Big Island, right in the middle of the Cain Fields anyway. And it was there because it was being maintained in the rat population there. The plague was spread around the world by two methods. Number one, by an intermediate host, the rat that traveled in the ships. And when the ships docked at port, the rats went ashore like humans did. But the plague is also a unique bacterium in the sense that it has a mnemonic part that gets into the lungs and can be transmitted by the respiratory droplets the same way COVID the virus can. And so one of the, in the large epidemics of Europe when in the 1300s, when it killed a quarter of the population, it was transmitted both mnemonically as well as by rats. It's a different between what they call bubonic plague and mnemonic plague. And in fact, my wake up call in this whole process was in 1994, during what was perceived to be and reported to be a mnemonic plague epidemic in Sarat, in the western part of Monraspa. And it turned out to be a more of an epidemic driven by panic and fear than it was by the disease itself because it turns out there were only something like 50 cases confirmed in Sarat, a city of two million people. But once it was reported as mnemonic plague, it created panic and fear and something like a quarter of the population of that city, over 500,000 people up and left the city in a period of a couple of weeks. And that created an international global emergency. And it was the first time the global airline industry was actually shut down, not completely, but in certain parts of the world. And so that was my wake up call as to how these epidemics in today's modern world with globalization, it can actually threaten global economic security. And interestingly, my laboratory in Fort Collins at that time at CDC was the only World Health Organization laboratory left in the world at that time. The Soviet Union had folded and and the other WHO plague labs were located in the Soviet Union. So those labs had shut down and our laboratory in Fort Collins, Colorado was the only plague lab left WHO plague lab left in the world. And so we coordinated the global response to that Indian plague epidemic out of our office in Fort Collins, working with the World Health Organization, of course. But anyway, we're not talking about plague today. But that's an interesting bug that has the potential to cause major a major pandemic was not dealt with properly. So I'm wondering, I'm wondering, you know, so everybody assumes even Dr. Fauci assumes and I suppose you assume that in a year's time, the likelihood is we'll have a vaccine, but that's not a certainty. And whether it's effective, maybe not, maybe yes, maybe not, like your opinion on that. But even for this discussion, assuming there is no vaccine, no vaccine, and this thing just keeps on going. Do we have waves of it? Is there a sort of built in, you know, sine curve with these diseases, whether by way of, you know, immune response or just the failure of the virus over time loses its vitality? Or will it just get worse and worse and worse and infect millions of people around the earth and be a scourge on humanity? Which way does that go? Well, I hate to say it, but honestly, I don't know. And I don't think anyone else knows either. I say that because we don't know enough about this virus yet. We don't know whether it's going to become endemic and established in a human to human transmission cycle that maintains it forever, like influenza. But influenza has a lot of input from animal species into the human cycle too. So it may well mimic an influenza type of epidemiology where it is maintained year after year after year in a combination of animal and human to human transmission. We don't know that yet. We don't know whether whether it will disappear like SARS-1 did. It just disappeared. It was helped along by our public health measures, but essentially it disappeared. We know that these viruses mutate and we know that viruses that mutate can basically that mutation is by random drift, by genetic drift. And most of the mutations that occur are galaterias and the virus dies out. But some of those mutations actually change the virus fitness, which allows it to have greater transmission. It can cause more severe disease and infect other animals. It changes its infectivity. And we know that some viruses, for example, the virus that I've worked on for many years, dengue, that some of those mutations can actually attenuate the virus and allows it to go underground with silent transmission so that we don't detect it anymore. It becomes in a group of viruses that cause a viral syndrome. And so it's misdiagnosed and not detected. So all of these options are possible with both two viruses. We just don't know at this stage. You know, some people have suggested, Dwayne, that the virus interacts, has an interdependency with climate. For example, a small example, seems like that when the weather gets colder, the virus seems to infect more people more quickly. But is the temperature itself a factor? Is climate a factor? We know, for example, that the virus affects climate change in the sense that it slows down economic activity around the world. And there's less fossil fuel and there's less, you know, business industrial things happening. Therefore, you know, we have less greenhouse gas. And that is a way in which the virus actually affects climate change. But does climate change affect the virus? Have you thought about that? Have you read anything about that? Well, again, I have to say we don't know. But in this context, we need to define our terms. What you're talking about is weather, not climate change. And climate change is long-term trends that can affect temperature and greenhouse gases and so forth. A lot of the climate change may be anthropogenic, but a lot of it, the most of it, is basically natural cycles, ocean currents and so forth that influence climate change. Weather is a different thing. Weather is seasonal, as you're well aware. And it's influenced by a lot of other natural and environmental conditions as well. So in terms of weather and climate, as you call it, temperature obviously does affect these viruses. If you do a hotter temperature, it will kill these viruses. You leave it in sunlight, in hot sunlight, it will be killed. Cold weather, it seems to survive better from some of the environmental studies that have been done in the past six or eight months. But whether it infects, infectivity or not, we don't know. What it probably does is increases transmission during cooler weather, much like flu does, because people are indoors and they are close to each other and not outside where the open air will blow the viruses away. So these are environmental conditions that can influence transmission and people rightly or wrongly attribute it to climate change or to weather. So I think, yes, it's not unlikely that we will see increased transmission during the colder weather in a temperate climate, but there are more human behavioral factors that are driving this as opposed to actual influences of temperature. Although the cooler temperature, the virus does survive better at cooler temperatures. Dwayne, can you talk for a minute about viruses as a part of the ecology of the planet? You know, I don't think people have been aware of thinking about this, but it seems to me that viruses are part of our world. They've been here a long time. They're going to be here a long time and we're always going to have to be thinking about it and dealing with them. Can you talk about that? Well, viruses are ubiquitous. They're everywhere. There are hundreds of thousands of them in the ocean surrounding Hawaii. There are thousands of them in just about every ecological niche that we have. We're learning now that one group of viruses that has a tremendous impact on human health or the flavor viruses, and it's becoming more and more clear, at least this is speculation on my part right now. But the evidence is more and more suggestive that these viruses actually evolved in insects and then jumped to humans when the mosquitoes took up the blood-sucking habit to lay the eggs. Other viruses obviously involved in plants, and they circulate in the flume in the plant juices. When mosquitoes or other insects, homoptera suck the juices from those plants, they're infected by the viruses. You can see how these viruses all evolved. Every species, including humans, have viruses that evolved with them, but there are mechanisms that in nature, ecology, allow them to jump species to infect other animals. We know that, for example, and this is just the tip of the iceberg, we've identified probably over 500, probably 550,000, 500,000 viruses that infect animals that are potentially infect humans, and out of those 500,000 viruses, 100 of them actually infect humans. I'm sorry, I just misspoke there. They're not 500,000, they're 500 plus viruses, and 100 of those viruses of animals we know can jump to humans and infect them. Because they don't maintain, it's not an easy transmissibility. The transmission is a complex interaction between the host, the immune system of the host, and the virus itself, and then the genetics of the virus. Most of these species that jump to other animals don't take, they just die out, but some of them take. Like the coronavirus, actually found a host that is permissive and it's taken off. So one really interesting possibility is that one day in the world, through modern medical science, somebody will find a parallel to antibiotics, call it, maybe they already have in some ways, antiviral, that'll stamp out viruses everywhere, every kind of virus will go away. One, is that possible? To what extent have we achieved that already? And two, this is a more interesting question, is there an interdependency between viruses and other life? If I destroy all the viruses in the world, every single last virus in the world, is that a good thing or will I find that we are interdependent on viruses and it would have an adverse effect on life as we know it? That's a very interesting question. There is an interdependency but take up your first question first. Because there's so much diversity in these viruses, I doubt that you're going to find one drug that kills all. I suspect that through genetic engineering and modern technology, it's not inconceivable that we will develop methods that will allow us to prevent viral diseases. And I have no doubt that that will come sometime down the road as technology develops. But there is an interdependency as you put it. Primarily the interdependencies on the viruses and the host. The viruses need the host to actually replicate themselves and propagate. Without the host, they actually take control of the host cells and use the proteins and chemicals in that host cell to replicate or actually propagate. So there's interdependencies there. There are cases where humans benefit from the presence of viruses as well. And your question about whether if we got rid of all the viruses, could we survive or would we regret it? My guess is we'd probably regret it because there are probably a lot of beneficial viruses that are circulating that we don't even know about yet. And I think the best approach here is to identify those bugs, those viruses and bacteria cause problems for humans and control them and let the others go about their business. Don't mess with the ecology. Unless you have to. Something about mother nature. Yes, exactly right. So one last thing we touched on this earlier and that is where are we in terms of a vaccine? And I know of course there are serious problems in deployment, in delivery systems and getting it out to the world in order to avoid recurrence and further spread of the infection. But what do you see as the likely limits of a vaccine here? What do you see as the timing? How far can a vaccine go in terms of dealing with this virus? We know it's not perfect. I think that's been made clear. Some people have sworn never to take it because it has a risk that they perceive as something that's too threatening to them. But what are the boundaries of a vaccine as we might be able to develop it? Israel, I read yesterday Israel was in phase three trials on a promising vaccine. I think they're very practical about it. They expect to be able to deliver it in a year, which is certainly not optimistic, but it may be practical, realistic. But anyway, what do you see as the likely parameters, the likely boundaries of a vaccine as may be developed now? Well, there are a lot of companies and individual scientists around the world that are working on a vaccine and on viral, antiviral drugs as well and therapeutic antibodies as well. I think I'm optimistic. I think we'll be seeing some products, some intervention products that we'll be able to use either in the clinic or as a prevention intervention, like a vaccine in the next year or so. A lot of progress has been made. There are some promising vaccines in phase three trials right now. And what they're trying to do with this warp speed program, though, is short circuit the time it takes to get a safe, efficacious vaccine into the population. And that's what worries a lot of the people who are following this. They assure us that they are not cutting corners and it's possible that they're not. With all of the money that's been poured into the vaccine development, it's allowed them to really short circuit the whole process. But what they're trying to do is develop a vaccine in less than a year that normally takes 10 years. And that's what worries a lot of people. Now, assuming that they do get a vaccine that is immunogenic and safe and efficacious, and the last one is difficult because I'm not sure how we're going to show that it's efficacious without following it in the population to see if it actually prevents disease. The other thing that we've got to do is I haven't seen a lot of work, a lot of publication on what is the main input that we're trying to achieve? Are we trying to prevent infection, subsequent infection with this coronavirus? Are we trying to just reduce transmission? Are we trying to prevent severe disease? And those are three different endpoints that need to be defined when these vaccines are brought out and put into a population. Do you know you can pretty much define safety over shark term in phase one and phase two and phase three trials, but the long-term safety is going to take several years to determine. So that's the problem. Now, the way we get around this is we don't get around it, but the way we can help these vaccines succeed and get into the population is transparency, be open. And what the governments have to do is open up the whole process so that it can be independently evaluated by scientists who are not in government, not part of the program. Our FDA and CDC, both in the United States, have programs that are transparent and evidence-based. They're the ones that determine whether a vaccine is ready to go into a human population. FDA does that, and they have an independent committee that actually is an independent expert from outside scientists, doctors, epidemiologists, immunologists, who actually look at the data and actually advise FDA whether or not make recommendation to FDA on whether or not move ahead with the particular product, whether it's a vaccine or a drug. Then if they decide to do that, then it goes to CDC and CDC has another committee, what we call the ACIP, which is also made up of outside scientists, epidemiologists, physicians who look at the data and they then make recommendations on how to use this vaccine, what age group, how to administer it, etc. And so these are usually very transparent processes. That needs to be maintained. It's evidence-based determination. If they go through that process and both the committees say, yes, let's go ahead, then I think we can be pretty sure that the vaccine or the drug is going to be safe and hopefully efficacious. Again, it gets the efficacy depends on what the end point we're trying to reach, but it's a complicated process, Jay, that it's very difficult to to short circuit that end part of it. Once you get a vaccine that looks good in the trials, then bringing it into the population is what's going to take time. Unless there is full transparency, I suspect there's a lot of people who are not going to buy it. We haven't had full transparency over the past few years and I'm sure as a person who came up through NIH and CDC that has concerned you, science must rule in this area and not politics. And maybe hopefully this election will clear that up and we'll have a better connection with CDC and NIH and FDA and they'll be able to restore some of the credibility they had not only nationally but globally in years past. Do you have any thoughts about that? Are we looking forward to the de-politicization of these agencies and is that what you're talking about when you're talking about transparency? That is and I'm not optimistic that we're going to see these agencies de-politicized. The trend has been from the time I joined CDC in 1980 through the present time it's become more and more politicized and I suspect public health is political by nature. Public health agencies, as I wrote in my op-ed, public health agencies develop very good plans to deal with these kinds of situations, pandemics, epidemic, but the decision to implement those plans is not a public health decision, it's a political decision. Made by a minister of health somewhere or someone in the health hierarchy who doesn't like to make mistakes because if he makes a mistake he's damned if he does and damned if he doesn't because if he implements a plan and nothing happens or if he prevents the epidemic then he gets crucified and be unaccused of wasting money. If he waits until it's too late and they have a big epidemic then he gets crucified because he waited too long and didn't implement the plan and that's what happened with the COVID and, you know, CDC is going to have to work very hard to earn that credibility back. I mean they were the best public health agency in the world, I think they still are, but they just dropped the ball on this pandemic because they had good plans in place and I don't know whether it was a political decision not to implement that plan in a timely fashion. It should have been implemented the 1st of January when we first heard about this virus, but it wasn't and I don't know what decision-making process was in play to make that decision to not implement proactive surveillance in ports of entry. What occurs to me is that we need government to deal with a virus like this. We need American government, I have to say, because we do have the resources, at least theoretically, and the medical expertise, the epidemiological expertise, you know, to deal with it and we have to get government to step in. I was disturbed earlier this year when Trump said, wow, this is the responsibility of the states and if you, and still today, you know, don't wear a mask and don't care about social distancing and so government has abdicated at least in this period of time and so what I get out of this is that, A, we're not going to have a vaccine right away and B, it's not clear, you know, exactly what government is going to do in the period between this election and the time we get a vaccine because, you know, we have people who don't want to wear masks and they believe it's their legal right. We have people who don't care about social distancing. There are a lot of people that say testing and tracing, you know, it's too late for that and in high infection communities, it's just too late and so it all seems to be, you know, a surrender and I really wonder what can be done, what can government do, what can people do, you know, and the law is troublesome because the law says, well, if he doesn't want to wear a mask, he doesn't have to in a lot of places even though the obvious community interest is in protecting not that person but all the people around him, they have rights too and so I don't see this as getting resolved easily but clearly how do you see it as getting resolved in the period between now and the time we do have a vaccine where it will spread and spread and spread unless government takes a role, unless people are actually forced to follow, you know, safety requirements. Well, yeah, again, a lot to cover there but let me just begin by first addressing your first point. I agree we need government but the US has a unique system, Jay. For example, when I was at CDC, I run an international program and I also ran a domestic program. I could not go into any state and do anything in any state without permission from that state. CDC can't come into Hawaii and tell you what to do. They have to have an invitation from your health director of health which actually has to come from the governor and so it's what we call state's rights. Now, you may argue that in terms of public health that shouldn't be the case but if you take it away from public health and take it away from commerce, I mean there's a lot of decisions that go into this whole process but what we did when we were in CDC and what CDC should do is coordinate all 50 departments of health. If I would have been in charge on January the 1st when we first received that message from China, I would have been on the phone to all 50 state health epidemiologists or state health directors that listen, these are the situations. It's already spread in Asia, it's almost surely spread to the United States and to Europe and other places. We need to implement active surveillance at ports of entries immediately. I wouldn't have recommended shutting down the entrance but that probably could have come but basically that's where CDC didn't. CDC has a lot of influence with those state public health programs and so with good communication, let's come back to the second. The way we deal with this is better communication, consistent messaging, messaging that's based on good science, messaging that is reasonable and out to all segments of the community. There was no communication at all about this. WHO drug their feet about they wouldn't declare an emergency of international concern. They didn't declare it a pandemic until late in February I guess. It became political almost immediately and I think probably one of our biggest problems in the US during this pandemic is the politicization of the pandemic. That prevented the adequate communication, prevented the types of interaction that was required between federal and state public health department. But you know, Trump was right. He could not do anything unless he declared a national emergency which was not justified at that point. But worry failed I think is by not getting on the phone to Redfield and say, you know, you better get your butt and gala and get your people working with the states to get on top of this. Well it sounds like all that considered we do need an administration that will respect the science, that will rebuild the credibility of these agencies, that will make decisions that are evidence-based and will communicate those decisions to all of the state agencies in the country in the hopes and to the people in the hopes that we can have good policy and implementation of that policy to everyone in this really dangerous interim period. Dwayne, go ahead. I agree. We need to get the politics out of public health. I don't care who's sitting in the administration, you've got to get the politics but public health should be apolitical in terms of decisions. But as we in today's world, that's very difficult. Hopefully we can get back to that. Dwayne, I hope we can touch base with you, Sirpleback, as this goes forward. I'm sure there'll be more really interesting and maybe frightening issues that come up and I would certainly like to update with you again. I'll be happy to, Jay. I get on my stump about these things. It's a very valuable discussion. Dwayne Gubler, Dr. Dwayne Gubler, epidemiologist, a national if not global epidemiologist in infectious diseases. Thank you so much for joining us today. My pleasure.