 Hello, thank you for joining today's event. This is a challenging time and that's why it's so important that people come together as you are today to pool knowledge and work together to combat COVID-19. First, let me say thank you to all the frontline public health and humanitarian workers joining us today. You are truly heroes in this crisis. I appreciate my colleagues from the CDC being here to fully share information in the transparent and timely manner so that together we can defeat this pandemic. Southeast Asian countries were among the first countries to be affected by COVID-19 and the United States is working closely with ASEAN to help the region respond to this new challenge. Today the Charger d'affaires for the US mission to ASEAN is meeting virtually with colleagues from the ASEAN member states and dialogue partners to discuss COVID-19 and other health related matters. And tomorrow morning Secretary of State Pompeo will meet virtually with ASEAN nation foreign ministers to share information, discuss solutions and show unity in support of our joint efforts. From Singapore developing and sharing testing capabilities to Vietnam sharing essential medical equipment with Cambodia and Laos, Southeast Asian countries are showing the world how good neighbors help each other. In addition to helping your own peoples many of you have assisted and treated Americans in your countries and for that we thank you. Americans have benefited from the goodwill of your nations and we have consistently endeavored to provide humanitarian support during this crisis. We are delivering a comprehensive package of services to support our Southeast Asian partners in combating COVID-19. This package builds on substantial and long standing US government global health and humanitarian assistance that goes back more than 20 years. To date the State Department and USAID have made available $35.3 million in emergency health and humanitarian funding to support ASEAN countries in their response to COVID-19 and $1.1 million for Timor-Leste. And last week we launched the US ASEAN Health Futures Alumni Network. This network connects 2,400 ASEAN medical and health professionals to facilitate sharing of best practices across Southeast Asia and to engage with US experts. I welcome the exchange network alumni who are joining us today. Thank you all and I hope you find today's event helpful. Thank you Mr. Bryan for the wonderful introduction. So my name is Ithap Rheera and I'm so happy to be your host today. So I remember years ago in 2009 I was working with the Indonesian MOH together with the WHO and the CDC. We were developing a national guideline to respond to pandemic influenza and we even did two big simulations in Bali and Makassar preparing how to respond to the pandemic should it occur. We did the healthcare response, trying out the referral system, lab testing, sort of failing, the lockdown and all the things that we really experienced now. But it's totally different story because now it is real. And currently I'm working with the IFRC together with the Indonesian Red Cross. And I think what I experienced right now is just a small example of what happened in other places too. The pressure for those on the front line like in the PMI hospital in Bogor as one of the referral hospitals is real. The health services are struggling for a limited health worker, limited of the PPE laboratory access and so on. So I'm very excited and this is a very good opportunity for me too to be here with all of you hosting this conversation with a colleague expert from across Southeast Asia. Now I'm accompanied by three distinguished guests, Dr. John McArthur, Dr. Joe Woodring and Dr. Bebs Keck, all from the US Centers for Disease Control and Prevention, but each with unique skillsets. So we will discuss on how to detect, treat and combat COVID-19. This is a very interesting topic and very relevant to the current situation, not just in Southeast Asia but also around the world. So we will exploring how health professionals are fighting this pandemic and safeguarding our communities from this disease. It's a huge topic but with consultation with our gas and partner we will be focusing on some sub themes. First is epidemiology, second is healthcare for patient and infection control and the last one is laboratory efforts. We will zoom in on different efforts being undertaken to address this issue and we will be hearing from our guests from the CDC and of course all of you our online viewers. We will also invite it to jump into the conversation so please ask your question in the Facebook live chat window. So you might be wondering how to date even with loop so this is a short overview, very simple. During the first part we will be hearing from our guest speaker as we share some opening thoughts about today's topic and then this will be followed by open conversation where you will be able to interact and engage with our speakers. There is some rules for this event. Given the breadth of topic let us focus on health related efforts to combat the disease. We want to understand the problem as it presents here in Southeast Asia and the efforts of the health professional are undertaking and if you want to ask a question online can you type your question in the comment box directly in the question format. Other team member of the event will be passing the question to me and I will ask your online question to the panelists and then please use the hashtag USAC Health Futures throughout today's discussion and we most likely won't be able to accommodate all the question in the next hour but don't worry it's not the end of the conversation. We will invite you to continue the discussion online. So again we are streaming live via Facebook live hosted through the at America Facebook page. So let's cross the finger hope the internet connection will be great today. We will start with the first session. We have Dr. John MacArthur Dr. John works for the Center for Disease Control and Prevention also known as the CDC. He is the CDC's regional director for Southeast Asia and has a depth of experience in epidemiology with a medical degree from Georgetown University and a master in public health focusing on international health from the very prestigious Johns Hopkins University. Where to working for the CDC Dr. John work with the World Health Organization. So Dr. John we'll kick off our conversation today with thoughts on the origins of the disease and its spread throughout Southeast Asia and the world. Some of our audience already asked questions even we haven't start our show. One of the burning question is like this question. How did the coronavirus first start to spread and what factors cause the first person to become infected. So Dr. John what can you tell us about the pattern of COVID-19 based on epidemiology perspective. Dr. John. Thank you Dr. Ida and it's it's wonderful to to see you again. Before I answer that question I just want to thank all of the health providers in Southeast Asia for everything you're doing. These are clearly unprecedented times for all of us. The U.S. CDC has a long and strong history of working with ministries of health and health providers throughout Southeast Asia and we are really honored to be able today to share some of our experiences with you and to hear from you and some of the struggles that you're having it's truly truly an honor for us. With regards to the etiology I'll have to say that first and foremost this point in time CDC is working hand in glove with our our partner ministries of health throughout the region to really act quickly and to save lives. I think at this point in time we're focusing on on what we call test and trace is to test persons to try to identify where cases of COVID-19 are to isolate those patients to do the the heavy lifting of epidemiology with contact tracing to identify their context to quarantine them so that they may not pass that virus on to other persons and then to work with with with the governments around the region with community mitigation interventions to try to as we say flatten the curve and to lessen the impact that this virus will have on the communities in Asia with regards to etiology I think that's an important question and certainly CDC and other scientists throughout the region and in fact the world will be working very hard to identify the the source how this virus enter the human population and how it spreads so quickly we're going to need to know that epidemiology in order to be able to prevent such a pandemic teacher next so colleagues what I'd like to do first is just walk you through the last 20 years of emerging infectious diseases in Asia I know many of you know this story but I think it's important to know where we've been where we are and where we're heading in the future I sort of think back to the late 90s when Nipah virus hit the region in pig farmers the numbers of cases were relatively low with 300 but unfortunately one third of those creations died just a few years later the country the region again was faced with a new emerging infectious disease SARS which was first reported in Asia in 2003 this was a infectious disease that essentially got on airplanes and traveled around the world so it affected people beyond the Asia region there were over 8,000 cases with 774 deaths and a case fatality rate approximately 10 percent just a year or so after that we began to battle bird flu or avian influenza with the H5N1 influenza strain this led to over 800 cases with 449 deaths with a case fatality rate of about 53 percent and then most recently we saw another avian flu strain originate in China H7N9 with a case fatality rate just under under 40 percent next so in fact I think the Asia region has had a long history in dealing with emerging infectious diseases that's why when the world health assembly in 2005 launched the international health regulations the countries throughout Asia were prepared and committed to the international health regulations or IHRs unfortunately by 2012 when they did a review of the 194 signatories to that those regulations they found that only 16 percent were actually prepared to detect and respond to pandemics this really led for a global movement in the global health security agenda to be able to do deep dives and build the capacity for countries to be able to detect respond to public health emergencies and I would have to say that all the countries in ASEAN have been actively engaged and I think it's partly because of the 20-year history of these various emerging infectious diseases that I just presented to you the region has provided not only regional leadership but global leadership and health security examples of that would be Indonesia whose government hosted the last ministerial in 2018 and Thailand who COVID willing will host the next ministerial in 2020 currently Thailand serves as a permanent member of the global health security agenda steering group and many countries throughout the ASEAN region are providing leadership in certain action packages or supporting other countries in these action packages next let's drill down a little bit to what we're dealing with today and that's COVID-19 as most of you are probably aware this first presented itself as a viral pneumonia of unknown etiology in Wuhan China in December of 2019 the Chinese scientists then sequenced that virus and identified a novel or a new coronavirus that had never been seen in humans before the early epidemiologic work linked those initial cases to a large seafood and live animal market in Wuhan but subsequently as time went on we identified more and more cases that had not been linked to that market and this really led the global community to understand that in fact the virus is now being passed from person to person the first case outside of China of this virus was actually here in Thailand which was picked up in a traveler from Wuhan in the airport with a fever on January 8th 2020 it was then confirmed laboratory on the 12th and announced on the 13th next so just to give a few numbers right now as of this morning the World Health Organization is reporting 2.4 million cases globally with 173,000 plus deaths closer to home in our region the Western Pacific regional is experiencing 134,000 cases in the Southeast Asia region over 32,000 cases next this is just a representation from the WHO website which really shows how our regions are comparing with the rest of the world Europe has the most cases with over 1.1 million cases followed by the Americas Eastern Mediterranean and then Western Pacific and the Southeast Asia region next I want to spend a little bit time since I'm based in Thailand to talk a little bit about what Thailand did with regards to COVID-19 early on they recognized that they were potentially at risk for the introduction of this virus and they developed a three phase approach to controlling it the first phase which they deemed with containment of imported cases this is when they saw mostly their cases coming in were just travelers and they had either no or very few cases of locally acquired COVID in phase two you started to see more and more local transmission of the cases but vast majority were still linked with travelers coming up and then in phase three which is where we are now we saw a the community transmission of the virus now I just want to highlight this curve to all of you because it's important we hear this term flattening the curve the dotted line in phase three is what we would see if there were no effective interventions if there was no community mitigation physical distancing in place we would see high peaks of cases and the goal I think of the Thai Ministry of Public Health and ministries of health around the world are to flatten that curve by introducing effective interventions now the bottom part of this slide really highlights the impacts on health on on society in the economy as you go from phase one through phase three you can see I think all of us are experienced this now that the impact on health on on society where we're living and on the economy not only in our country our region but globally is traumatic next slide so what the Thais did during phase one which is in containment is they wanted to identify cases rapidly and to isolate those patients so that they would not transmit that case to another person they kept them in isolation until they had two PCR tests negative separated by 24 hours they identified these cases by setting up thermal screening at airports and looking at places where the the risk persons might be staying because at that point in time most of them were tourists they did very aggressive contact tracing so what I mean by that is that they identified all persons that had contact with that case and they actually tested them and then they had they would adapt their case definition as needed so they didn't have a rigid strong case definition as the epidemiology changed they changed their case definition as they moved moved into the second phase where they started to see a limited local transmission they really essentially doubled down on the first phase so they continued with the containment activities and really did more enhanced targeted active case definitions so they sent teams out to to investigate hotels where certain populations would stay and look for active cases as more and more cases developed in Thailand they began to put non-pharmaceutical interventions in place such as closing schools entertainment venues shopping malls bars restaurants etc and then in the third phase of the outbreak the initiative of soft lockdown and the prime minister then launched with an emergency decree which essentially gave the government some more power to enforce that soft lockdown they had some movement restrictions among the different provinces and put in a curfew next so this is a epidemic curve of Thailand I've shortened it a little bit because the left hand side of this curve goes all the way to that first case in in January 8th but on the x-axis you see the dates on the y-axis you see the number of cases and so as they began to have clusters and peak that's when they initiated these non-pharmaceutical interventions and I just have highlighted a few on this slide for you to take a look at and then just note that approximately two weeks after some of these work were put in place you started to see a dropping or a flattening of that curve unfortunately over the last two weeks in Thailand the cases have been really under 50 cases per day next so by last slide I just want to share a little bit about what the US CDC is doing in Asia as I said in my opening remarks we have a long standing history of working very very closely with your ministries of health throughout the region we're in six of 10 of the ASEAN countries we're also in Bangladesh China and India and right now we're focusing with our partners in the ministries on key areas such as surveillance laboratory infection prevention and control border health and points of entry community mitigation and helping countries prepare for the introduction of a COVID-19 vaccine when that becomes available next thank you very much Dr. Jan for your presentation it's really interesting for me from your earliest slide so regarding the response to the IHR 2005 there's only 16 percent from 194 countries in 2012 were prepared to detect response and pandemic to pandemic so I mean like right now everybody finally see like how how the reality of the pandemic and every every country even those who are already prepared still struggling to respond to the pandemic also following with your slide regarding the curve there is one question from people around the south east Asia or maybe globally really want to know it's about how long this pandemic will last we've got a lot of questions similar like this like when do you think the curve of the coronavirus will start to flatten Dr. John Dr. that's a that's a that's a great question and it's a it's a challenging question there's no easy answer for that as I said in my my comments that CDC is working closely with the ministries to try to strengthen the public health infrastructure they're necessary to flatten that curve and as I mentioned that's identifying the patients testing them and then isolating them so they're not able to infect other persons that's doing real strong contact tracing identifying every person who potentially came in contact with that infected patient and to put them in quarantine for 14 days so that they won't infect other persons and then I think the governments throughout the region are putting in these non-pharmaceutical interventions so the community mitigation strategies that can help to flatten that curve we can look at a variety of examples throughout the world where countries have been able to do this effectively they've actually been able to push down those cases and and flatten that curve thus diminishing the impact the virus is having on their population okay thank you Dr. John so we will come back to you with other questions but for now we will move forward to our second panelist we have Dr. Joe Woodring here he is the critical and infection prevention and control lead for the CDC regional response team Dr. Joe is a direct patient the direct patient care is such a critical part of responding to an epidemic situation like this so I will invite our online audience to share their experience and questions regarding hands-on patient care right now on facebook and we have one question maybe later on you can follow with your presentation what can you share about the clinical experience of doctors and nurses as they treat patients and what kind of steps are necessary for preventing infection between patients and care providers so Dr. Joe the floor is yours thank you Dr. Ida very much pleasure to talk with you all and regarding the question of what healthcare providers can do to prevent transmission of COVID-19 to them we'll actually be I'll be talking about that in the slides but just as a quick preview ensuring that people have properly fitted N95s and they know how to don and doff personal protective equipment is very important to help prevent transmission to healthcare providers to ensure that they remain safe when they're doing different interventions for patients so I'll be going into that a little bit more now but if I can get to the next slide please as as I'm talking I'll be discussing some case characteristics in China at-risk populations in fashion prevention and control measures and briefly discuss contact tracing so this is the largest case series describing the clinical characteristics involving over 44,000 confirmed cases in China which represents about 62 percent of the total cases for the study 81 percent of these cases were mild with 19 percent of cases being either severe or critical and so while the vast majority of the cases were between 30 and 79 years old there was sufficient sample size in other age categories to determine that the overall case fatality was 2.3 percent so less than the different diseases that Dr. John MacArthur had described but 15 percent of people aged 80 years or older were among these case fatalities and 8 percent of people aged 70 to 79 years old died as a result of COVID-19 so to get to your point earlier Dr. Ita healthcare workers made up about 4 percent of all the confirmed cases with 15 percent of these being severe or critical including five deaths among about 1,700 healthcare worker cases. Next slide please. So the question then becomes which populations are at increased risk of severe illness? You all have heard that people 65 years and older are at increased risk for severe illness including death after contracting COVID-19 also those in nursing homes or long-term care facilities are also at risk. For the list of various underlying medical conditions listed here that puts you at an increased risk please let me highlight that immunosuppressed includes many conditions such as cancer treatment smoking bone marrow or organ transplantation immune deficiencies poorly controlled HIV or AIDS and prolonged use of immune weakening medications. Now I know that some people while reading this may be looking at this list of medical conditions and be thinking well what can I do to prevent my long-standing asthma as a 70-year young male from getting me hospitalized from COVID-19 and the answer to this is in the highlighted text on the page namely if not well controlled so if you're as if you are asthmatic CDC has issued guidance to please follow your asthma action plan to continue taking your asthma medications and avoid your asthma triggers similarly if you're a diabetic continue to take your diabetes pills and insulin as usual but you may need to test your blood sugars every four hours and monitor the results plus ensure that you have at least two weeks of diabetes pills and insulin on hand. Next for those who recover from this virus countries then must discern determine whether and when patients can be discharged from a hospital. Thailand had originally required that anybody with confirmed COVID-19 will be hospitalized regardless of severity and they would be discharged after having two negative nasopharyngeal and oral pharyngeal samples taken at least 24 hours apart. This includes asymptomatics which some studies have shown make up up to 25 to 50 of all cases but based on the published findings shown here the Thailand Ministry of Public Health moved away from a test-based approach of requiring these two negative samples and went towards a time-based approach after realizing that once a patient became a fibril around six days after the onset of symptoms they would have a median of eight days where daily samples will remain RNA positive. So Thailand now requires that anybody with COVID-19 must complete a 14-day isolation window since the onset of symptoms before returning to the public. So COVID-19 patients may stay perhaps two to seven days in the hospital but then they could be discharged to complete their 14-day window in home quarantine or some isolation ward to free up that isolation bed after the patient had clinically improved. So additional research is really needed to determine if the tail end of those 14 continuous days of detectable RNA represents true virus viable capable of being transmitted versus RNA remnants that cannot be transmitted to others. So we're currently looking to develop some viral shedding studies. Next slide please. So community-based interventions such as temporary school dismissals postponing or canceling large events and social distancing have been shown in many countries to slow the trajectory of cases and spread over time. So as was discussed and alluded to by Dr. MacArthur this flattening of the curve graphic shows that the faster the infection curve rises the quicker the local health care system can get overloaded beyond its capacity to treat people. A flatter curve on the other hand assumes that an equal number of people could get ultimately infected but over a longer period of time where health care systems can absorb the strain and not overwhelm the system from say under-resourced PPE or personal protective equipment lab tests or available hospital beds. Next. So regarding COVID-19 prevention there are non-pharmologic intervention mainstays that include personal community and environmental components that you all have probably heard many time but deserve a quick few highlights including the importance of washing your hand often with soap and with soap and water for a full 20 seconds especially after you blow your nose cough or sneeze going to the bathroom or before eating or preparing foods. Also cleaning high touch areas is a good idea in in highly trafficked areas of the hospital clinic or embassies and sometimes it may be culturally challenged to say at home while you're sick but it's better to call your health care provider about your symptoms to see if you should get testing rather than exposing your colleagues and loved ones. So several drug treatments are being tested and but no specific antiviral drug treatment or vaccine has been licensed to date for this novel virus. So while there are many vaccines in the pipeline and NIH our sister agency is supporting the development of some of these candidate vaccines, candidate vaccines, drug regimens like animilarials such as hydrochloroquine, antiretroviles like ritanivir or antivirals like redemizivir is as we know it we owe it to patients to ensure these different pharmacologic regimens are not only safe with well documented side effects but we also know that these determine that these regimens are efficacious in either preventing or treating clinical components of this virus. So next so with the global shortage of some PPE supplies CDC has developed guidelines on making distinctions over what our preferred PPE for healthcare workers versus acceptable alternative PPE for healthcare workers Wednesday and then 95s maybe in short supply and should be reserved for aerosol inducing procedures like a bronchoscopy intubation or nebulized treatment. So on the right side of the slide is a useful PPE burn rate calculator that CDC developed which helps to optimize your facility's PPE supply but it's important to note that controlling exposures to sources ranks first engineering controls then administrative controls and then PPE so ensure that you get fit tested for an N95 and practice the donning and doffing of this PPE to ensure proper protection of yourself from exposure. Next so containment is another strategy that has proven effective to help break disease transmission cycles by identifying close contacts shown here in red and testing suspect cases who came in contact with the confirmed case and removing those from removing those exposed from the public. So it involves testing to identify cases doing line listing of close contacts and characterizing disease transmission. Next so this slide shows the 43 close contacts of the first confirmed U.S. Embassy Thailand index case. Depending upon the level of exposure to this confirmed case different measures were established to break the cycle of transmission by having high risk contact contacts tested and put on home quarantine for 14 days since last exposure to this case. On the low row of this display you can see that one close contact I'm sorry under the top row you can see that one close contact depicted here in red was actually tested positive and he actually was asymptomatic. The low risk contacts in the left lower portion all tested negative and self-monitor for 14 days. In the bottom right after about five days into the contact investigation we learned of a meeting of people where the index case for this index case one person tested negative after having some upper respiratory infection type symptoms while the other eight completed their last four 14 days of quarantine without having any symptoms and were not tested. Next so social distancing and extreme minimal staffing have been put in place by the time this third case from the embassy was reported only within 10 days after the first confirmed case. So unlike the first contact investigation which involved 43 close contacts here we have only four high-risk close contacts who are family members and two medium-risk contacts who shared a meal with the index case. So social distancing can help diminish this second and third generation of virus transmission and contact tracing can identify these close contacts and ensure those identified as positive cases are isolated and treated to prevent further transmission. Next so in summary while we eagerly await safe and effective vaccine and drug treatments to become available various personal community and environmental infection prevention and control measures are our best strategies prevent transmission and populations at risk for severe illness should understand their underlying medical condition know and communicate their treatment plans and perform preventive actions to prevent disease transmission and finally contact tracing will remain an important surveillance and control activity to break the cycle of disease transmission by preventing multiple generations of cases. Thank you. Thank you very much Dr. Joe it's very interesting presentation you had and that's really underscore the situation in the almost everywhere health services regarding our health providers on the front line to serve the patient and regarding your explanation about the clinical symptom as well there is one interesting question from the audience the question is people in developing countries who have been exposed to all kinds of virus in their entire life have antibodies that may not be specific to COVID-19 but could it be partially helped them to protect from the COVID-19? Thank you Dr. Ida so you know the interesting part with this pandemic is that this is truly a novel virus so while it's it's really too early at this point to say whether exposure to say a prior disease or a prior vaccine leaves you more or less susceptible to developing COVID-19 so what's really important is as we learn more each week each day about this virus that we ensure that we're doing the infection prevention and control methods that are well established and are well documented in preventing disease transmission. Thank you very much Dr. Joe for your explanation and again we will come back to you and Dr. John after the next presentation from our third panelist. I have Dr. Beth Scott here currently serve as a laboratory branch chief physician of global health protection and CDC Thailand. She's been served with the CDC for quite many years in many countries so Dr. Beth I give the time to you to present this. Great thank you Dr. Ida hello everyone it's certainly a pleasure for me to participate with you all in this important program. So today I'll be speaking on the laboratory aspects of the COVID-19 response. So I'd like to take this opportunity to give a shout out to all of our laboratory ins and laboratory experts that are participating in this program today. The work that you're doing to contribute to the testing capacity within your country is certainly critical to the COVID-19 response and we all value and appreciate your hard work. Keep going. So accurate and timely testing is is most certainly the cornerstone for a successful response to this COVID-19 pandemic and the pandemic has put an important spotlight on public health laboratory systems in all of our countries where this disease is spreading. The ability of the public health laboratory network to rapidly deploy and scale testing is essential to informed disease control measures. So over the next few minutes I would just like to share some information with you about the types of tests that are currently available for COVID-19. Some of the biosafety aspects related to working with clinical specimens from confirmed or suspect cases of COVID-19 and then lastly talk a bit about various strategies that countries have used and how CDC is advising countries to scale testing to the levels that are needed such that we can begin to see flattening of the curves. So this slide here really is to demonstrate that the range of real-time RT-PCR assays for COVID-19 target a number of different genes within the SARS-CoV-2 viral genome. This is important because if you've been watching the emergence of new diagnostic tests into the pipeline over the past few weeks you will you will see there's been an explosion of new tests coming onto the market. In fact there are more than 500 SARS-CoV-2 specific diagnostic tests in the pipeline but the quality of each of those tests is not going to be the same and so the process of the the Food and Drug Administration in the US which can provide an emergency use authorization or an FDA approval for a given diagnostic assay that meets certain performance standards is certainly a best practice and countries within the ASEAN region have their own systems by which in vitro diagnostics are approved for use in clinical settings. The RT-PCR assays that are currently available will will target genes which are either specific for the SARS virus family or and or specific for the SARS-CoV-2 virus itself and in in that scenario it gives us the opportunity to use RT-PCR for screening which means these would be tests which would identify a person that would contain virus within their respiratory specimens belonging to the SARS family but those positive tests must be confirmed with a SARS-CoV-2 specific real-time RT-PCR assay. So it's important as you look at the different diagnostic tests that you might be considering for your for your laboratory or for your country that you understand if the target of that RT-PCR assay is a conserved gene or a unconserved gene with regards to SARS-CoV-2 viral genome. Next slide please. So the WHO guidance and CDC guidance says that only the the real-time RT-PCR assays are appropriate for diagnosing an individual with COVID-19. That means that these test methods need to be available and accessible to meet the testing demand such that the the disease control efforts can appropriately target those individuals which are truly infected and then can inform the follow-up contact tracing as we've heard about. So the scale of testing is is important and it must be appropriate for the level of laboratory within a tiered laboratory system. I'll speak a bit more about tiered laboratory systems but in general we're talking about usually a three-tiered system with a national laboratory at the top of the tier, provincial or state level laboratories at the mid-level, and district and community laboratories at the lower level. So what I wanted to show you here in the slide is that reference laboratory national level laboratories will be and have been implementing high throughput real-time RT-PCR based assays. And the example is here on the left side where we have a fully integrated, fully automated system that can both perform extraction of viral RNA from a clinical sample as well as PCR amplification and detection. All without any hands-on interaction with the laboratory technician. These these instruments can test upwards of three to four hundred specimens per eight-hour work shift. So they're they're appropriate for a reference laboratory that's receiving specimens from a Y geographical set of locations within a country. In contrast, on the right hand side we look at again a very important test methodology but it's considered point of care or near point of care. So these systems are as you can see small, simple, and will enable the the clinician or healthcare worker to collect a sample from these from the individual and immediately introduce that specimen into this closed diagnostic system and get a test result usually between 15 and 30 minutes. So these kinds of test formats are are appropriate for the lower tiers of your laboratory system and even at clinical settings so in clinics or doctor's offices for example. What you'll also notice is these are not high throughput instruments but instead one specimen is tested at a time. So it's it's mostly appropriate for settings where you would be testing only between eight and ten specimens per day. Next slide please. So now we'll shift to a different type of assay for the detection of an immune response to the SARS-CoV-2 exposure. So these tests are different than the real-time RT-PCR tests. These tests are not looking for the virus within a patient specimen but instead they're looking for the immune response of the individual person that they would have developed or they will develop due to exposure to SARS-CoV-2. So these tests are not diagnostic tests and that's critically important to differentiate the use and the utility of antibody-based tests compared to PCR-based tests. So the antibody tests are also coming into the market at a rapid pace. However the the data the evidence for their performance and for the role that these tests will play in our COVID-19 response globally remains to be determined. So at the moment WHO and CDC guidance recommend the use of these tests once validated for surveillance and for research use only. Next slide please. I now wanted to say a bit about biosafety and I had the great opportunity to visit the National Reference Lab in Jakarta some weeks ago and one of the the areas that we discussed is how to ensure that the laboratory workers can be safe while handling and testing specimens from patients who are either already confirmed to be COVID-positive or are suspected patients. So the again we we really would like to encourage everyone to to follow guidance posted by WHO and CDC. These are evidence-based guidelines for how to work safely with clinical specimens suspected of having SARS-CoV-2. The first thing I want to note is that specimen handling is one of the steps within the laboratory process that produces the most risk to the laboratory worker. And it's critical that the laboratory conduct a risk assessment which is very specific to their laboratory and for their procedures and protocols for handling clinical specimens. Based on that risk assessment the the laboratory can put into place the proper PPE as well as biosafety cabinet or workstations which provide a barrier between the specimens which the laboratory is handling and the laboratory in themselves. So the point is risk assessment is essential to identify specific risks that may be present in your particular work setting given the the infrastructure that you're working in and the methodology that you have in place. So WHO and CDC guidance is that clinical diagnostics of suspect specimens can be done at biosafety level two with a biosafety cabinet. Biosafety cabinet class two biosafety cabinet should be certified and be well maintained. Certification should have been done within the past 12 months. Now we've gotten questions about whether laboratories or laboratorians can do testing using some of the newer enclosed diagnostic systems such as gene expert in the absence of a laboratory setting without a biosafety cabinet and the recommendation is that yes testing for gene expert can be done in the absence of a biosafety cabinet however laboratory staff should use additional PPE which again creates a barrier to minimize any kind of exposure to aerosols or droplets that can be generated during sample handling. So on the left hand side of the slide you'll see a laboratory and working safely in a class two biosafety cabinet wearing typical PPE of gloves and lab coat as well as safety glasses. You'll notice that she's not wearing an N95 respirator or a surgical mask. The biosafety cabinet creates a a sufficient barrier for any kind of aerosolization. So N95 respirator is not recommended in the setting in the surgical mask or other kind of face covering would be optional based on the current policy of the laboratory. In the panel where we see the laboratory worker working with a plastic face shield and face mask this is a great example of how to work with clinical specimens again for routine SARS-CoV diagnostic testing in the absence of a biosafety cabinet. Now four procedures that involve working with live virus that would be virus culture, virus isolation, any kind of propagation. This is strictly a biosafety level three type of activity and the work must be done in a biosafety level three laboratory with functional biosafety cabinet and appropriate PPE. This kind of this kind of work handling live virus growing live virus propagating virus should should never be done at biosafety level two and should be limited to those reference laboratories with expertise in these types of practices. Next slide please. And then the last point I would like to to share with you is some guidance from from CDC regarding strategies to expand testing capacity within your country and this is where again I show you a pictorial of a tiered laboratory system. Over the past 15 years CDC through our global health program has worked with ministries of health in this region to strengthen public health lab systems and we have really emphasized the importance of creating a tiered laboratory network. This tiered laboratory network is essential such that you reduce redundancies and duplication across laboratories at different tiers. You don't need to have duplicative equipment which increases costs for sustaining those equipments maintaining those equipments but you need to have good flow of specimens through specimen referral networks that are well established to move specimens from lower tiers to the higher tiers as needed for more complex testing and as well you need information to flow from one tier to the other. The approach recommended here for scaling SARS-CoV-2 diagnostic testing is as outlined in this slide where at the lowest tiers of your laboratory system the focus would be on specimen collection and referral of those specimens to a laboratory at a higher tier that perhaps has real-time PCR capacity or the use of point of care tests particularly in settings where there's the demand for testing or the need for testing is not beyond the testing capacity of that point of care system which I indicate here is usually 10 to 15 tests per shift. What we're seeing mostly countries expanding testing capacity from reference labs down to provincial or state level labs these labs probably already have real-time rtpcr capacity in place for another disease and this is where there's opportunities to utilize existing equipment for the diagnosis of COVID-19. These types of instruments are capable testing upwards of 200 specimens per shift and in many cases this is sufficient testing capacity at provincial level and then the final and highest level is more at reference lab level this could be either within the country itself a national reference lab or it could be a supranational reference lab in a neighboring country and this is where the high throughput fully automated systems are in place testing upwards of 600 specimens per per shift. When considering referral of specimens outside of your own country this is where it's important that relationships are already established with a reference lab within your region. First of all agreements in place for that laboratory to receive specimens from from your country for testing. There's systems in place to be able to share those results back with you and also issues with shipping infectious specimens across borders has already been addressed. These are the kinds of public health lab system strengthening activities that we focus on in in times where we're building systems and not in times like this where we're utilizing and needing to utilize those strong public health systems. So in many I've seen many examples within this region where those relationships between reference labs in neighboring countries has been incredibly valuable for countries to to be able to test clinical samples very rapidly. Next slide please and this is my final slide and I really just wanted to summarize those points as countries look to expand testing capacity. Think about capacity that you already have in country. Number of vertical disease programs HCV, HBV, HIV, TB, donor support, technical assistance, influx of funding have put a number of laboratory instruments in place that can be used for diagnosing COVID-19 so consider those. And again point of care instruments are are going to be the essential tool in the response to this pandemic and they have their place at the lower tier levels of the lab system and in clinicians offices. Another important strategy is pooling samples pooling samples for real-time RTPCR testing and this is going to depend on the prevalence of disease within your population but data so far suggests that pooling samples from a five-member pool upwards to a 32-member pool are successful and can be used for COVID-19. And then the very final point as a laboratory and whose focuses a lot on helping countries develop quality management systems to ensure the accuracy of laboratory diagnostics. I want to emphasize that all testing modalities within a given country must be validated within your country and each lab should have access to an external quality assurance program to ensure that the test results they produce are accurate. Thank you. Thank you very much Dr. Beth for your explanation so that's quite a help to explain to us what's happening inside the lab during the pandemic because like even for me as a medical doctor a laboratory is also like a different kind of work for me. It shows how important is the lab role for the disease surveillance of reputation and response. Following your presentation there is one question related to the like the characteristics of the virus. How different or how similar this COVID-19 virus compared to the influenza virus I mean like maybe you can help to explain what happened at the molecule molecular level. Sure thank you Dr. Ita. Great question. There are a number of laboratories that are focused on sequencing these viruses from individual patients so we're getting a growing database full of SARS-CoV-2 genome sequences from around the world and this is essential to understand the genetic variability strain to strain and to understand if this virus is mutating rapidly or slowly. So I'll first say that the SARS-CoV-2 virus is is evolving slowly compared to influenza. What does that mean? That means that if we look at viral genomes from the very earliest cases of COVID-19 in China and we compare that to recent cases of infection in the United States or in another country around the world we'll see a very small number of nucleotide mutations genetic mutations. There is there has been sufficient diversity amongst the viral genomes to be able to divide three groups so three groups of viruses A, B, and C. But I think it's really critical to to come back to the point that this virus is very different than influenza and it is evolving at a much slower pace than influenza viruses tend to evolve and with with regards to vaccine development that's actually a very good sign. What that means is even though we we see enough variation amongst virus genomes to divide them into three groups any vaccine that would be developed would be equally effective against viruses belonging to all three groups and that virus would be I'm sorry that vaccine would be effective for multiple years such that the virus the vaccine would not have to be re-engineered and each year like we we see with influenza. Thank you. Thank you for your explanation Dr. Bess. Okay so we've made our special panelists do a lot of talking from three of them so right now let's we start the Q&A session. We will take some more questions from the audience so please let us know what do you really want to know more about so we can ask to our three panelists here ask your question in the Facebook live chat box right now. Okay I'll check the box and I already have a few questions for all our panelists I can choose one right now for Dr. John. Are you ready Dr. John? So the question is is there a possibility of getting a positively stopped after recovering from COVID-19 the first time? What is the severity when someone is triggered with COVID-19 for the second time? We know that usually a second attack of Gengi is worse than the first attack so would COVID-19 symptoms be worse in reinfection? Thank you Dr. Iida and thank you colleague Gautam in Asia for that question. I think that one thing that we are learning about with regards to this virus is in fact people do produce antibodies so we know that and I think Dr. Beth and her presentation highlighted some of the research diagnostic tools that are beginning available to look at the production of antibodies. With that said and unfortunately when I talk to health health providers and public health officials throughout Asia I have to keep repeating this we are still learning an awful lot about this virus it's still only been around for four months or so and so what we don't know yet is what level of protection those antibodies will provide the patient, how long they will stay with the patient, and whether or not as you say we see with Gengi will there be some amplification of clinical deterioration with a subsequent test? We simply I don't know that those are active areas of research or at least things that we're doing with surveillance and trying to learn more about the epidemiology how this virus behaves itself. I will say that recently some of you may know this already there's been some reports of patients in Asia who initially were positive and then through the course of their hospitalization they became negative in fact were discharged from the hospital. Sometime later they developed some mild symptoms and presented back to their healthcare provider who tested and were positive and so of course that's causing some concern for us and what we're trying to do is understand is that second positive test after testing negative and meeting discharge criteria from the hospital is that positive test in fact a reinfection? Is it a new infection and did the antibodies not protect that patient or is it simply a recurrence of the original viral infection perhaps the the patient's immune system lower the viral load to the point where the PCR couldn't detect it and then it replicated after some period of time and came back those are things that we don't yet understand and we're certainly trying to to get to the bottom of it but it will take some time. Thank you Dr. Jan for your explanation I know this is a quite challenging for all of us because this is a novel virus so everybody is still learning and we try our best to find a good answer for it. Okay so we go to the next question for Dr. Joe it's related to the clinical. The question is why are we seeing different case fatality rates for different countries besides the underlying chronic medical condition and age population what other factors effected? Does the baseline healthcare ability affect the increased fatality rates? Please Dr. Joe. Thank you Dr. Ita I think part of the answer to that question is as we perform our surveillance and as we're doing testing we're finding that what I had mentioned a little bit earlier regarding asymptomatics this is a unique disease process whereby if people can present and look clinically doing just fine you test them but they're positive and you can have them admitted they still remain positive for a certain amount of time some actually go on to be you know the asymptomatic can be seen as almost pre-symptomatic that when you test them at a certain point in time that they go on to develop symptoms so you know trying to find a case fatality is very challenging it depends upon many factors but I think part of the the divergence among some countries is in part because whether or not that the country is doing a good capture rate of those that are asymptomatic which in some recent studies have been shown up to be up to 25 to 50 percent the the princess diamond cruise liner that docked in japan a few months ago 50 percent of all those cases were asymptomatic so I think we need to really make sure that we have a good capture good surveillance systems to be able to detect not only symptomatic cases but also understand the portion of disease that are asymptomatic that could go on with different underlying medical conditions that may develop are more at risk for severe outcomes thank you dr joe that's a very detailed explanation for us to know about the clinical symptoms okay so oh my god we have a lot of questions here I think many people join us we'll try our best to answer the question so the next one is for dr beth there are so many tests described for diagnosis of COVID-19 how are they different you already explained some from your presentation and how are some better are some better than others and what is the rate of false negatives in testing and which rapid tests are sorry can antibody rapid tests help to increase the number of people who get tested for COVID-19 sorry it's a lot of questions that's the best sure thanks dr etan thanks to the community for the questions they're important questions right so as I mentioned there's a number of tests and you know the simplest answer is they are not of equal quality for sure how do you begin to differentiate high quality accurate tests from lower quality inaccurate tests amongst the 500 plus options that we have to draw from and this gets to the quality management system within your laboratory and really your national laboratory policy for how do you evaluate new diagnostics and determine which diagnostics get rolled out across the laboratory network in your country this is a critically important role for the national reference lab in every country under the global health security agenda there is a one of the priorities is strengthening national laboratory systems and one of the the aspects of strengthening a national laboratory system is having a lab policy in place about how new diagnostics are introduced into your laboratory network so that's how you differentiate the good test from the bad test it starts at the national reference lab level first of all you select a test that either has an emergency use authorization or a CE marking or is on a WHO pre-approval list because some of the homework has been done for you already these tests have undergone some degree of evaluation and validation prior to them appearing on such a list so recommendation is you select tests from these kinds of lists second of all every single test that comes into your country must be verified within your national reference laboratory using clinical specimens if you have access to them which national reference lab should so using clinical specimens from individuals within your population or which these assays will be deployed so that's that is how we can we can differentiate the good test from the less good tests perhaps I say it that way now let's move on to to false negatives so so certainly false negatives are possible it no laboratory test is 100 perfect what we're looking for though is the test that offers the greatest sensitivity meaning we we won't miss any positive cases but we will likely pick up a few false positive cases but we also want a test that's very specific which means if your if your test specificity is high then you your false negatives are going to be lower but it's not possible to have under these conditions a 100 percent sensitive and a 100 percent specific diagnostic test we we have to work with something that is less than perfect so false negatives are going to be are going to happen for sure but our greatest concern is that we do not have we we have the most sensitive test so that we do not miss any positive cases we can tolerate a few false positives but we don't want false negatives we're looking for the most sensitive tests that we can find and then your last the last component of that question was about can we use antibody tests to to scale diagnostic testing and the answer is no at this point antibody tests are not for diagnostic purposes diagnostic tests are i'm sorry antibody tests are for surveillance and for research so antibody tests cannot be used to increase diagnostic capacity real-time rtpcr are the only test formats that are approved to diagnose an individual with SARS-CoV-2 sorry thank you very much Dr. Bath that's a very important information for us so okay currently because this is a novel virus so we still really learn about the laboratory we don't have a perfect test tool right now but we are improving and the most important for the to choose which the diagnostic tool is also depend on the country's national policy following the global recommendation also from the like WHO right okay so okay for Dr. John there is a question about like what about the the virus carrier is it possible that someone can carry the virus spread the virus and never get sick and also like um what about the vaccine how long it could take to have a vaccine please Dr. John your floor yeah i apologize i i i had my microphone on mute um but no that's that's an extremely important question and it's one that's i think becoming much more much more important as we try to flatten the curve and that's that you know when we are looking to detect the cases um i think it's uh it's important that we're able to find those cases and the way we generally find those cases is because the patient gets sick and we've sent messages out i think throughout the region you know fever respiratory symptoms call your doctor fever respiratory symptoms call your doctor and what do we do if you're feeling perfectly fine i think that's that's the question and and how many of those people are out there and this is something that is really uh under active investigation i can say that some studies that have looked at this have have found anywhere from 25 to 50 percent of COVID-19 patients actually did not have symptoms sometimes they they never have symptoms sometimes when they're tested they don't have symptoms at that point time but two or three days later they develop symptoms we're starting to call that a pre-symptomatic phase but it's important because in order for us to flatten the curve we need to identify these individuals um i will say in Thailand i mentioned this in my opening remarks that the Thai Ministry of Public Health is a very aggressive a contact tracing program in place where they in fact don't just put those people into into a quarantine status and then monitor them for fever and symptoms they actually test those those persons and a number of these contacts did in fact test positive uh when they never develop symptoms and i think uh dr joe also highlighted the diamond princess cruise ship in japan where nearly 50 percent of the COVID-19 infected passengers on that cruise ship uh were in fact uh asymptomatic now this is a problem and i think it's it's why the physical distancing that many countries around the region most countries around the region are putting in place are so vitally important is because it's easy to say this patient is sick put them in isolation and they won't come in contact but what happens when people are walking around and they're they're perfectly fine yet they have the possibility to spread that virus to other people i will say that other studies have shown in fact that the viral load in the in the pre-symptomatic phase so one or two days before the patient actually starts having uh symptoms is actually quite high and often higher than even two or three days into the symptom so this is an area that's that's very very concerning for us and i think one of the reasons why the physical distancing policies that are in place are so vitally vitally important the second part of the question that you posed Dr. Ida is is vaccine which is sort of different from this this uh this question i will say that cdc as an agency we are not actively engaged in vaccine development or vaccine testing that responsible responsibility rests with our sister agency within the us department of health and human services which is the us national institutes of health and they are in fact funding vaccine trials in the united states and around the world to look at pre-clinical and clinical uh uh experiences with different vaccine candidates we certainly hope for that tool as as soon as possible when i hear dr. Fauci the director of the national institute of immunology and infectious disease excuse me allergy and infectious disease um he says the timeline is likely 12 to 18 months and if i walk through what a vaccine has to go through i can understand why he is saying saying that one thing that us cdc is doing in the region and we have funds to support this is we're beginning to work with ministries around the region to begin to contemplate should a vaccine become available how might we best implement it into the epi systems within within the ministry so that's something that we're currently looking at thank you very much dr. John your answer is really underlined the importance of physical distancing as part of our response to try to flatten the curve right now okay um i think we still we really have a lot of questions and i think we can add a little bit time and maybe we can answer one or two more questions the next one is for dr. Joe uh can surgical mask and closed masks really prevent infection by uh from covid-19 and can tpe protect healthcare workers from being exposed to coronavirus and should say the healthcare workers be quarantined after they have contact with covid-19 positive patients even if they wear ppe please dr. Joe thank you dr. Ida so uh three sets of questions we'll try to tackle them uh each separately so regarding whether masks cloth masks and surgical masks are really effective in preventing covid transmission like any barrier method we you have to wear it appropriately and you have to be trained in how to use that to ensure that you're protecting yourself as a healthcare worker from covid-19 so like in my opening remarks ensuring that you're fit tested for an n95 as a healthcare worker so that you know that you've got a good positive and negative uh seal when you're when you're putting that on and practicing donning and doffing your personal protective equipment doing the right order getting used to it so that you become well familiarized with wearing ppe properly um regarding the cloth mask uh you know cdc has recommended that we when in in public situations because you know we're finding that asymptomatic transmission that a person can have this virus and be shedding it without having had any symptoms wearing a cloth mask is really an effective measure to prevent you as a person who could be asymptomatic from from uh transmitting it to your loved ones or colleagues um I think you know I'm trying to remember the other parts of the question oh whether quarantine is uh required if say a healthcare worker was doing an aerosolized procedure like doing a bronchoscopy and you know didn't wear the equipment appropriately then there are different levels depending upon the level of exposure that cdc has guidance on um you know if it was say in that circumstance where they're doing a nebulized treatment for an asthmatic and a healthcare provider wasn't wearing goggles or didn't have a cloth and was was coughed on that that high risk exposure knowing that the virus particles are well permeated with a nebulized treatment um that would require a healthcare worker to be away from the workplace for full 14 days so the importance of wearing the equipment appropriately and knowing depending upon what procedure is being performed what level of PPE is required is really important so uh becoming familiarized with the high medium and low risk exposures um depending upon the procedure and what the interaction and timing of working with patients is is uh is of vital importance i think there's a third part of the question that i'm missing now thank you very much sorry for the question in a row no i just i didn't copy down the second question no it's okay so uh it's really unaligned about the importance of how to use the PPE appropriately right so that's the point because different level needs different uh different set of PPE and if you don't do it appropriately then it is a increased risk and you have to to be away and quarantine yourself for 14 days so uh i think we still have time for one more question for Dr. Beth if that's okay Dr. Beth uh okay so the question is what is the gold standard for COVID-19 antibody assay any of the current POCs great question right so your question is a gold standard antibody test and at the moment we do not have a gold standard antibody test for SARS-CoV-2 the work that's underway right now in in evaluating the number of antibody tests that are on the market will be bringing evidence to answer that question but i think that i can say a little bit about the type of of evaluation so an antibody test looks for the presence of an antibody specific for the SARS-CoV-2 virus which suggests that individual has been exposed to the virus they may have developed symptoms they may have been diagnosed resolve their case and resolve their infection and now they have antibodies but they could also be um have been a person exposed to the virus like we've talked about asymptomatic cases had no idea that they were exposed or ever infected but it's still important to know that that individual has antibodies um what we don't know is how long do those antibodies remain active against the virus so the the immunity the immunity that a person has is not directly correlated to the presence of the antibody so at the moment the the type of experiments being done is trying to to um make a link between the presence of antibodies at a given concentration and the actual effectiveness of those antibodies to produce immunity of that individual against a second exposure to the virus um so we call these virus neutralization assays so these are the two types of work that are that is happening looking at the quantitation of antibody in individuals who have been exposed who've had mild disease who have had severe disease and then the the function of those antibodies and the ability of those antibodies to be able to effectively neutralize the virus meaning those antibodies are active and um capable of defending the the individual against a second exposure to COVID-19 okay thank you very much uh Dr. Bath for your answer and so because of the time limitation uh I think we should end the Q&A session and I would like to ask to uh all our three panelists if you have any final thoughts uh after this discussion you can share with us Dr. Ida maybe I'll go first on just behalf of of US Centers for Disease Control and Prevention I just again want to thank those of you who who are tuning in to this this important event um you know you're the healthcare workers you're the public health officials you're the nurses you're the frontline people in Asia who are battling this uh this disease and um I'm honored to spend this time with you uh I just I want to say that one of the strengths of the ASEAN region is long ago you established a network of field epidemiology training programs uh and through ASEAN plus three FVTN which is a field epidemiology training network but you really have trained a a huge workforce of disease detectives who are doing really the the hard work of finding these cases of doing the contact tracing of of really trying to flatten the curve and I'm just again honored to have spent this time with you when I hope you've learned something from us uh if we weren't able to answer your question I would suggest that you go to www.cdc.gov we have a tremendous amount of information on on COVID-19 and I think if if we can't answer your questions likely the website can so Dr. Ida you're fantastic I think you're a a Facebook star you've done this before clearly and it's been a pleasure to spend time with you today thank you Dr. John uh just about Dr. Joe any last words or any thoughts maybe I can chime in just a quick quick little plug for infection prevention and control so you know we've talked about how we're eagerly awaiting tested vaccines and different drug regimens to ensure that those are both safe and efficacious in both preventing and treating disease but I want to stress the importance of different measures that we can do as healthcare providers and as community members to try to break those cycles of transmission so you know whether it be on an individual level of washing your hands uh having a good cough etiquette coughing into your into your sleeve of your arm um then those are important from a community level ensuring that we practice social distancing when we know that there's community transmission or from an environmental level to stay at home when you're sick you know all these efforts are tried and true and we have to work as one to ensure that we're doing the best by doing our patient care as healthcare providers and what we're doing really has an effect and that we're preventing the spread of disease as healthcare providers ourselves as well as promulgating good guidance that we can give to our patients so thank you very much dr ita for moderating and the fellow panelists and uh have a great day and dr beth if if you have any comments please dr beth thank you thank you well just just short and sweet thank you dr ita for an excellent moderation thank you to the organizers for the opportunity to be part of this program and most of all thank you to all of the healthcare professionals that are participating today and i hope that some of the information we share is useful to you as you continue to go out there and fight this fight thank you so thank you to our wonderful three panelists for sharing the your expertise and your experience with us and thank you very much for all of you who join us online and also for the team behind this event uh we already discussed so quite broad topic from uh uh uh from the epidemiology area to healthcare and then to infection control and also laboratory uh we won't stop here we will try our best to answer the question we might put a link to help answer your question uh so thank you very much for all of you physical distancing wash your hands next event thank you