Understanding COVID-19: Epidemiology in a time of uncertainty by Dr. Jim Dobbins

PRESENTER: Do try and get it in today. It's OK if you're too late. We will meet in class on Friday. Please be ready to have your reflection due tomorrow. I'm going to turn the time over to Justine, who will introduce our speaker today. Again, if we can scooch to the middle and scooch to the outside. Thank you all so much for coming. Please do do the scooching, we have lots of people waiting in the hallway.

JUSTINE: Wonderful. And folks who are in the hallway, please do feel free to come in if you'd like. It's my pleasure to introduce Dr. Jim Dobbins. I'm talking loudly because he's got the mic. And we're recording today. Dr. Dobbins has two degrees from the U of I, both in geography. Then he did his-- a PhD at UC Berkeley in infectious disease epidemiology.

Dr. Dobbins is an infectious disease epidemiology expert. He has had a long and wonderfully storied career chasing epidemics and outbreaks really all over the world while working for the Centers for Disease Control and Prevention and for the World Health Organization. We're really excited to have him join us here today to talk about coronavirus, COVID-19, and set some context for us. So let's get started. Please join me in welcoming Dr. Dobbins.
 

[APPLAUSE]

I think you're ready to go.
 

JIM DOBBINS: And I'll turn off the front lights.
 

JUSTINE: Yeah. [INAUDIBLE] Ooh.
 

JIM DOBBINS: Ooh.
 

JUSTINE: That's dramatic.
 

[LAUGHTER]

We might go with dramatic. Dramatic it is.
 

JIM DOBBINS: No, we can go part dramatic, can't we? Let me apologize for wearing sunglasses. I'm having surgery on my eyes and I can't see with them or without them.
 

[LAUGHTER]

Kind of a problem, but I'll be fine. I can see the screen in front of me. Thank you all for having me here. I know that somebody's class is getting interrupted and I apologize for that. But I think that the topic is a very timely one. So I'm glad to be here to talk to you about it. We'll see if I can do this without glasses.

So we have to start off with the nomenclature for the disease and the virus. And if these seem a little boneheaded to you, it's because they are. WHO came up with this one. This came-- was invented by a International Committee of Microbiologists. I'll refer to SARS-1 and SARS-2 usually when I'm speaking. And SARS-1 was the earlier one. SARS-2 now. You figured that out.

The purpose of this discussion is not to go over facts. Facts are always changing. We don't know a lot of the facts yet. But more than anything to go over a perspective that you can use when you're thinking about the disease. So let's get started with a perspective.

The outbreak began silently unnoticed in the south of the country. Early deaths went unrecognized, occurring mostly in elderly patients or in persons with pre-existing conditions. Weeks later, a child died and that was unexpected. And the child, who happened to die in a research hospital, and was tested for various pathogens. And immediately they knew that a new one was on the spot.

Going back through medical records, they could find more cases that they had missed because the surveillance wasn't working right. And they found both dead cases and people who were still alive. The initial case that they were able to find was in a woman-- a middle-aged woman who had extensive exposure to live animals. So after looking at all the data that they have been able to get initially, they estimated that the mortality from this pathogen was about 80%, which is terrifying to have something like that happen. There was immediate concern that a new pathogen could wipe out a large proportion of the population.

Initial response-- the country didn't want to release reports of it either to the citizens or to the World Health Organization. So a first response from them was to block movements of citizens without a whole lot of information. Citizens throughout the country were encouraged to wear masks, which we'll talk about a little bit later. As the virus continued to spread throughout the province, the government decreed that there should be maximum social distancing. I'll go over social distancing again.

Factories were ordered closed. Businesses were closed. Schools were closed. Everything was shut down. Additional provinces were infected. They were shut down. And the virus continued to spread in spite of this. And then entire cities throughout the country were quarantined.

Fear spread rapidly for the neighboring countries. At this time, I was in one of the neighboring countries. They banned their citizens from going there. They banned the citizens who were already in the countries from coming-- country from coming back to their country. Tourists were no longer welcome. Students who had been studying in the country were not allowed to go home to their home countries. And without anything else going on, the virus continued to spread throughout neighboring countries, as well as distant countries in the world.

Commerce had come to a complete halt. But it didn't do any good. The virus continued to spread. Cruise ships became infected and were not allowed to dock. So a panic swept around the globe just as much as the virus did. Here is this virus that supposedly kills 80% of the population. And who wouldn't be terrified from that? Who would not panic?

But wait, this all sounds vaguely familiar. This is Mexico 2009. This is the swine origin influenza virus. It's exactly like what's going on now. Everything that I just told you could easily be applied to China. The same panic, the same spread of the virus, the same attempts to halt it. Although in this case, the attempts have been much more successful.

And then months later, we figured out that the mortality was not 80%. It was below 1%. And so I'll go through some reasons about why this panic happened then and why it's happening now. And one of the things is the level of mortality. Then we'll talk about the spread of the panic.

Why was there panic then and why was it now? The first reason was the 80%. Everybody thought it was going to be like Spanish influenza that killed 60 million to 100 million people worldwide, including many of my relatives right here in Champaign. It came through Champaign three times. It came through most places three times.

Second reason-- we had just had SARS outbreak in 2002, 2003. And that was on everybody's mind. That was a very serious outbreak, which was managed to be contained by hard work of people like Justine. But-- so this was the same type of organism, causing the same atypical pneumonia. So there was panic because of that.

Third reason was that people are always talking about sooner or later the big one is coming. And so why not this be the big one? The fourth reason was that surveillance in Mexico was abysmal. They have excellent epidemiologists in Mexico. I don't know where they were when this was going on, but they weren't on the job when this was happening. And that's what led to the erroneous estimate of 80%. And again, we see that same thing going on today.

Well, why does poor surveillance cause a panic? Why does it cause the 80%? Well, you usually find the first cases in the morgue or in the emergency room. They're easy to find. They're sitting right in front of you. Especially when there's an atypical pneumonia, you don't need any sort of a test to know that something's going on with those patients that's not going on with the other patients. But all the people who didn't develop pneumonia who were infected, you're not going to find those without seriously looking for them.

Well, every outbreak begins like this. Every outbreak starts with people thinking that the mortality is really high. I can demonstrate that with the disease pyramid. This one happens to be from seasonal influenza. Every disease has a pyramid. They're not shaped the same, but most of them have the same general appearance. If we look at the very top when you first find a disease going on, that's what you find. Almost all people who have died and the more-- case fatality rate is almost 100%.

As time goes on, you find some more hospitalized patients, it's down to 80%. Time goes on further, it's down to 40%. Finally, 0.1. But in the meantime, the panic had already set in. And so people have to de-panic. And I hope that my talk with you today will help you de-panic. I think it will.

So I'm going to talk about three previous outbreaks, one of which was the one in Mexico, and just see what we can learn from those that applies to the current one. So we learned that highly infectious respiratory diseases are almost impossible to contain. They can be contained but it's almost impossible to do it. You have to identify it early and then start working on whatever you want to do for intervention. I'll talk about interventions in a minute.

So the-- in Mexico, they didn't find it early. They missed it by over a month. In China, they missed it by a month and then diddled around for another month denying it. So that's been the work there. So I've already gone over that.

And the efforts that they made for containment, which were Herculean efforts-- basically shutting down the entire country and the entire economy-- it was too late. The virus had already spread everywhere in the country and was continuing to spread in the country. They're closing off an area, it's spreading in that area. And people are constantly going in and out of the country surreptitiously.

So in the end, it reached almost every country in the world. I would say every country, but I don't know maybe there are one or two that it didn't get to. The other countries knew it was coming. They knew to watch for it. And they could at least mitigate the problems with it. Social distancing, isolation of infected individuals, increased personal hygiene are probably the most important preventive measures.

Finally, after six minutes-- six months-- the virus had finished finding new people it could infect. The epidemic was over. The virus in this case didn't disappear. The virus became the dominant influenza A/H1N1 virus in the world and it's still in the country now. These are laboratory results from CDC-- from state labs and CDC labs. And this is from I think two or three weeks ago-- the end of February, two weeks ago. And you see here H1N1 pandemic '09. That's the virus that began in southern Mexico.

Seasonal influenza-- there's just one really important take home message from this. And this is the slide. There was going to be over 20,000 deaths this year from influenza in the US. Not worldwide-- there'll be hundreds of thousands more. But in the US, there's 20,000 deaths.

And is anybody here worried about it? No. Anybody panicking, closing the university? No, you're not. And partly it is you know what to do. You know to get vaccinated. You know how to keep yourself from getting influenza personally. So we don't really care about it.

So if you think about what's going on now with SARS-2, it's the same as ordinary influenza. Try and stop that with no vaccine. You're not going to stop it. You can control it. But you can't stop it. First, our SARS outbreak in China, 2002, 2003. I wasn't there. I was in Haiti working on four other outbreaks that were going on simultaneously there. Justine worked on this one.

It could easily have caused a major pandemic. I don't to this day know why it didn't. I mean, it was really hard work of field epidemiologists and public health professionals in the field that tracked down people and got it stopped. The first one we dealt with in the jet age-- I'll show you a slide on that. It's just amazing.

And it led to new international health regulations that required countries to report things right away. Mexico did not report this right away. One doctor in Mexico reported it. He was thrown in jail for spreading false rumors.

So it began in Guangdong province-- a province that has been generous in giving the world many pestilences. It's right across the harbor from Hong Kong, in case you want to know where it is. Guangzhou is the capital of that. And the index patient was a farmer who had been at a local so-called wet market buying meat. And he was treated at a local hospital and died.

The outbreak spread rapidly in southern China. a large number of deaths. And there was no known cause for it, and, of course, no treatment. Public health authorities were not alerted within China and around the world. Finally, it spread to Beijing. And there was some admission by the part of the government that something was going on but not any international reporting that would provoke a response from WHO.

And then the one doctor I mentioned, Dr. Zhang, who, oddly enough, was a surgeon in the People's Liberation Army. He was the one that wanted to stop this, and went to the press and paid a price for it. And we have the same sort of thing that happened recently.

So the spread of the outbreak happened just lightning fast. One guy, a different doctor from Guangzhou, came across to Hong Kong for a wedding. He stayed on the ninth floor of the Metropole Hotel. He died on March 4 in a Hong Kong hospital. His infection led to a large outbreak in Hong Kong and 16 other guests at the hotel Metropole became infected. I'll show you how-- they all had rooms on the ninth floor where he had a room.

His room is that green one. And while he was there, he did not meet a single one of the other patients. They were all infected by environmental contamination right here in the hallway. We did testing in all of these areas by where the buttons are for the elevator and here right outside his room. Anybody that walked by any one of those things-- it's the 9th floor, who's going to walk down on the stairs? You're going to take the elevator. And so that's how they got infected.

And so what happened after that was that one guy, patient A in this diagram up here, comes to Hong Kong, infects-- he goes to a hospital, infects people in the hospital-- 99 health care workers. And then the other people-- the other 15 people who were infected-- spread out all over the world and cause whole chains of infection going on already. This was one of the early chains that took place in Vietnam, in Hanoi. And a number of people I know were in that-- one of them was killed in that outbreak.

This is just a diagram of the spread-- immediate spread out of Hong Kong, because those people left within a day or two from the Metropole Hotel, got on an airplane, and went halfway around the world. Canada is probably the biggest place that was hit. And Toronto was the biggest one.

So it was identified-- controlled by identifying patients and isolating them. You had to do this almost immediately, because this was more infectious than what we're dealing with now. It took nine months to get it under control. And obviously we learned that we were not ready. Certainly the Chinese government was not ready. Chinese public health is really good. Chinese government doesn't want to hear bad news. And so that was why the health regulations were updated.

So it ended up with over 8,000 cases, almost 800 deaths. The case fatality ratio of about 9 and 1/2%, which is extremely high for an infectious disease. And I mentioned that that outbreak led to international health regulations of 2005 which requires every country to report to WHO. Did it work? No, it didn't. What would you expect?

So how are these viruses spread? This is what the biggest thing here-- we saw this in the ninth floor of the hotel Metropole where people didn't have any air contact with the patient A. It was surfaces. If you-- it's possible to infect somebody by walking up to him, standing about 2 feet from him-- less than 2 feet-- sneezing in their face. Very few people are willing to do that or stand there and be sneezed on.

Also, we found out in this outbreak are fecal/oral contamination. I don't understand exactly how it took place. Whether it was airborne, whether it was hand to mouth contamination. But it definitely took place. And it still is taking place in the current outbreak. So here's a bunch of hands-- I don't know if they're a volleyball team or what-- they're going to infect all of the-- all the team if there's something--

[LAUGHTER]

--something going on. This is an important slide. This is a guy obviously sneezing. And here is where the SARS virus would be down in these large droplets down here. They're going to go down and hit his shoes. They're not going to go in this mist out here. Measles virus could float out like that. But this isn't measles virus and it's in a different sized droplets. They're going straight down. He's not going to infect anybody unless they're right in front of him. And this gets his shoes dirty anyway. Also, fecal/oral transmission as I mentioned.

So how do you control this stuff? Here's all the options that I could think of for public health options. There's also personal hygiene options which are far more important to me, far more important to you. But you have-- these you can do early on in an outbreak. You can try and identify the beginning of the outbreak.

There's a surveillance system called SARI and ARI-- Severe Acute Respiratory Infections and Acute Respiratory Infections. Some are acute-- people visiting the hospital. Severe-- people who are admitted to the hospital. And it's supposed to go on every country, reporting every week to WHO. It didn't happen in China. And it didn't happen in Mexico. It was supposed to have been going on in Mexico.

So you can-- if you identify it early, you can find individual cases and trace who they had contact with, and quarantine them or ask them to quarantine themselves. But that all has to take place very early in an outbreak. Later you can do what Mexico tried and what China's doing, what Italy's going, you can quarantine entire geographic areas and let the virus burn through that area and not the rest of the country.

Social distancing-- you can do it anytime. This is extremely important. If the virus were in Champaign and the university were still in session, you would probably sit every other seat. You wouldn't sit next to-- it's hard to infect somebody right next to you. But if you turn around and sneeze or something, you could do it. So social distancing is like that personal social distancing, or not having volleyball games, football games, or having the games, but no fans.

And I think we're going to see that coming up very rapidly. The Big Ten basketball tournament for men is coming up. It starts today I think. And I don't know how they're going to handle the crowds there. Women's tournament was last week. Everything was fine. They did not do any blockage. And then comes March Madness. Will they be able to play basketball on the national level without-- with or without a crowd? I don't know.

Disinfection of public surfaces-- you see this happening a lot. And it's a good thing to do. It's not really going to stop stuff. Let me give you a hint. Nobody is going to infect you. You are going to infect yourself. So you have complete control. We're going to come to that on the next slide. I just couldn't wait to give you that take-home message.

[LAUGHTER]

And so encouraging personal hygiene is one other thing a country can do. Screening of travelers at the border is interesting and I want to mention it. It takes place-- almost every country does it. It doesn't do any good. But it does do one thing. It makes people think that the public health authorities care about them and are trying to do things to protect them. And that's part of what public health is. It's part of people having trust that you're doing things.

They can't see contact tracing. They can't see quarantine if they're not being quarantined. But they can see that the border people are getting their temperatures taken. Or they have that image where they walk by. You should see the ones they have in Hong Kong. Oh my god. It's really neat. Color screens and-- I didn't set it off. I was just in Hong Kong, Thailand, and Singapore three weeks ago.

This is the one-- if you want to just wake up and pay attention to one slide, this is an excellent one to do. Personal social distancing-- don't get within 2 meters of somebody face to face, especially if there are any symptoms of illness. This really doesn't have to be that far. It's really less than a meter. But CDC says 2 meters. I'll go along with that.

Hand-washing is absolutely your best friend. I just came over here to this class on a bus. Every time I'm touching something on the bus, I'm like, ooh, and I get off the bus and go right into the restroom and wash my hands. And that-- do that as often as you can. And then they say when you finish doing that, do it again.

And disinfect surfaces-- you all have these little tables as part of your chair. Those things might be contaminated. The armrest in the airplane when you're flying around-- wipe them off. The tray in front of you. Carry the little baby wipes-- a little portable package of baby wipes and disinfect the thing. Why-- I mean, you want to get them cleaned anyway. They're never cleaned with all sorts of other things.

And then the last thing on here-- well, if you get down here-- self-quarantine. If they ask you to do that or you have symptoms that match closely, do stay home. Don't go to class. Don't be a hero. Don't go to work. Covering coughs or sneezes-- sneeze into your elbow.

[INAUDIBLE]

[LAUGHTER]

Let's talk about some of this stuff. Here's two unknown people bumping elbows.

[LAUGHTER]

Don't shake hands anymore. Actually, the head of WHO came out yesterday and said, don't bump elbows. But please, really-- he said, just don't touch at all, just wave to somebody. Well, bump elbows. Wash your hands. This is a guy showing you exactly what you need to do to wash your hands. Wash back, forward, thumbs. WHO tells you wash all the way to your elbow. Why? When was the last time you put your elbow in your mouth?

[LAUGHTER]

So but they want to make it difficult. You're supposed to do it for 20 seconds, which is supposed to be like singing "Happy Birthday" twice. I can never remember the words to "Happy Birthday," so I don't do it.

Hand sanitizer-- yes, it works fine. Lots of luck finding some. It's sold out. I was really happy the other day when I figured out on the internet that you can make your own. But you can't-- if you can't buy the ingredients-- the ingredients are all sold out. But the bathrooms here have sanitizers, right? I think.

AUDIENCE: Not all.

JIM DOBBINS: They don't? OK. I was over in the armory, they have it there. But then on the wall-- maybe it's just in the men's room. Anyway, hand sanitizers, if they're over 60% alcohol, they work fine.

What about masks? They were really popular in Mexico. They're very popular now. Did they slow things down? Can they work with the current one? This was Mexico City years ago. They used so many masks, they ran out.

[LAUGHTER]

This is China right now. This is at an ice skating exhibition. I've looked at this picture a lot and I can't find a single person in there without a mask. Notice that they're all wearing surgical masks, not N-95 masks. Surgical masks, which we'll talk about for a minute.

So masks probably are not going to control anything. Well, that's not quite right. We'll go through some of these points. Overwhelming majority are surgical masks, which I'll show you in a moment why they're not so good. They will not protect you from droplet spread. You shouldn't be close enough to anybody anyway to worry about droplets spread.

They will stop you from spreading your virus to other people. That's why when you go into a clinic, and they say if you have these symptoms, put on a mask. And a mask is a surgical mask. So you put it on and it'll stop you doing droplet transmission to someone else. There is a downside to surgical masks. And that is you create this warm moist environment right in front of your mouth where you're breathing out so all sorts of other things can grow in there.

The only thing that really helps about surgical masks is it's harder to put your hand in your mouth. But when you get home, you take the thing off anyway and then put your hand in your mouth.

[LAUGHTER]

N-95 masks-- I'll show you what they are in case you don't know-- they can help a little bit with both you not getting infected and you not infecting other people. But again, this is not really spread by droplets. It's not airborne. It's airborne to the floor, to the surface, to your hand, to your mouth, your nose, your eyes.

You will see on the internet, campus news, local papers, Julie Pryde, the head of the Public Health District here in Champaign-Urbana. Pay attention to what she has to say about recommendations for doing things. She is extremely sensible and she's excellent. You'll see a lot of advice coming from the national level.

Some of it's coming from scientists at CDC and at NIH. They know what they're talking about. Administrators at CDC and NIH don't know what they're talking about. They also-- they're getting information coming down from above and coming up from the bottom. And they have to decide, well, which am I going to talk about? So pay attention to the scientists and to Julie-- Julie Pryde.

This is an example of a surgical mask. And you can see why it's no good. It's puckered out by her cheeks. So if she wants to take a breath, the air just comes in on the sides. This is an N-95 mask. They're extremely uncomfortable to wear. And if you look at the top, you see there's a little piece of aluminum and you can smoosh that down on the bridge of your nose so the air doesn't come in there.

And these fit-- things fit pretty tightly on the face. Here's a guy with one right up against his cheek, right up against the bridge of his nose. And right over here is what you don't want, which is a surgical mask all puckered out, the guy breathing and breathing in on the side.

A problem with surgical masks is that your glasses and your goggles fog up. She doesn't-- she hasn't pinched this down, so she's getting-- exhaling into her goggles. She's supposed to be cleaning a subway car in Beijing. How she can see what she's doing, I don't know. But she should be wiping these things down [INAUDIBLE].

In Milan, they had an even better idea for those things-- those handles you grab like on the bus or the subway-- they took them all out. I don't know how people are going to be pin-balling all around the buses and the trains there. Masks are made in China. Dang. There aren't any anyway, so I don't know why I'm even talking about them.

So how infectious are these viruses? You've all-- not all-- but most of you have studied R0, R naught-- how many people can one person infect? And with this virus 2 to 3.11. Well, China is estimated 4. The thing to remember about R naught is that is the intrinsic value of a virus when an outbreak starts. Once you start doing control-- implementing controls-- it will go down. It will continue to go down.

And the outbreak-- if it goes down below 1, the outbreak will start to stop. And I'll show you a curve that demonstrates that. Ebola-- yeah, Ebola to measles is huge. Zika virus, not quite so big. Seasonal flu is right about that 2.5. SARS-2, we don't know. SARS-1 was finally figured out to be about 2.8.

And the R naught-- this is from a equation-- population growth equation. And so R naught is British for zero. Nothing big deal about it. But they say naught instead of zero. And so you just-- you want to know how the population grows over a period of time. Then you would start with that and you could easily determine if it follows that equation-- what you're putting into the equation, it will-- you can figure out every time period.

The outbreak in China that's going on right now, it's a coronavirus similar to the previous one. It's similar to MERS-- I don't know how much you know about Middle Easters Respiratory Syndrome. It's a bat virus that got into camels. Very slow moving, very lethal. There's also coronaviruses-- many of you have coronaviruses. There's about four of them that circulate here every year and cause the common cold.

They're not related to those coronaviruses, except that they have this kind of a surface which looks like a corona-- a crown. And where you see these projections on here-- one of these is to help the virus get into, infect a cell. And then once it replicates in the cell, the other one is to get it back out-- the new copies back out of the cell.

So this was a virus that came from animals to humans. Bats are thought to be the natural host. Just by sequencing the viruses, you could tell that it's a bat virus. And also the other two that we're talking about, they were also bat viruses. This one that's now circulating is thought to have passed through an intermediate host, which is a pangolin. And I'll show you what a pangolin looks like. This is called intermediate horseshoe bat. Extremely ugly.

[LAUGHTER]

And somehow that bat passed it to one of these things. These are anteaters. Unfortunately, people, especially people that follow Chinese medicine, eat the scales because they're supposed to help with arthritis. And this is now an endangered species. And so this happened-- I'll show you where it happened. But one of these was for sale in a market. And even though they're not supposed to be for sale.

The official story is it began in this Huanan Seafood Wholesale Market in the first week of December. But looking at genetic sequences, you can tell that it began maybe two weeks, three weeks earlier than that and then got into the market. Once it got into the market, it was a perfect place to be a virus. You'll see a little bit about why it's a perfect place.

This is comparing SARS-1 with SARS-2. This is the big difference-- 10% mortality. And this is with total surveillance. And the current virus is now estimated to be less than 1%. I think it will end up being between 0.1 and 0.5. The people who are going to get it-- bottom line-- it's not any of you. I mean, this is people who are going to get serious disease. You'll get it, it'll be just like a cold.

But it's elderly, because they have weakened immune systems. People with pre-existing conditions, especially affecting the lungs. People who have heart disease, they can't get fluid out of their lungs if the heart's not working right. And people with-- medical personnel get so close to people.

The doctor I'll talk about in a minute-- he was an ophthalmologist. And ophthalmologists get like this close to you-- probably less than a foot-- when they're looking at your eyes. A lot of other medical specialties, too. So they're getting-- they are getting droplet contamination and it's going right down the pipe, right into their lungs.

So the outbreak began in Wuhan, China and spread to the other cities in Hubei Province, which is the province where Wuhan is the capital. And we know now that it was found earlier in Guangdong province. When the outbreak began, I have to admit, with all my degrees in geography, living in Southeast, Asia for years, I had never heard of Wuhan ever. I didn't know there was such a place. So I figured it was probably kind of a podunk place.

Well, it's the fifth largest city in China. And it's also, I think, the fifth largest city in the world. And I didn't even know about it. It was really embarrassing. I feel embarrassed to tell you. But this is the top five cities in the US. This is metropolitan areas. These are metropolitan areas. So all together our top five just come up to the same size as Wuhan. There is a picture of it-- just part of it. I mean, it could go forever. That's the Yangtze River floating by.

The virus began its real circulation in a wet market. And wet markets are where they sell and slaughter live animals, which means, as Emily Landon points out, everything is aerosolized, floating all around in the market. All the surfaces are contaminated.

You're not supposed to sell wildlife in the market. As soon as that outbreak-- they asked people where they-- where they had been. And they right away zeroed in on the Huanan Market. It was closed right away. But people that had been there earlier listed all of these live animals as being sold in that market, including pangolins right there.

This is a market-- this is a fish market. This is taken before this outbreak. You can tell that because nobody is wearing a mask. But you could see that everything is wet. After they clean the fish, they're going to hose it down. Everything will be soaking wet. And to get around in the markets, you have to navigate up this corridor right here.

You're going to have face to face contact with maybe 50 people if you're going from here all the way to the end of it back there. 50 chances to get infected. Again, a great place to be a virus. And it was a great place to be a virus. Now that's what it looks like. It's completely closed. There's police keeping people out.

So it spread from there all around into Hubei Province from Wuhan. Spread all around into other parts of China. Spread over to South Korea from Wuhan with the church members going back and forth. On the 23rd of January, authorities placed Wuhan under quarantine. 23rd of January-- long time after it started.

And it really didn't stop anything inside the city or inside Hubei Province. By the end of January, 15 other cities in the province were also-- have travel restrictions. 57 million people lived in those areas. And we may talk a little bit more about Italy, what they're doing.

Then they imposed travel restrictions all over the country-- inside cities, outside cities. This was during Chinese Lunar New Year, the busiest travel season. I'll show you a picture in a minute. By the end of January, the virus had a two-month head start. Gone all around, spread to every province. And so then they put travelers restrictions inside all those other cities.

This is last year's train station at Lunar New Year. And this is this year's station. Trains are going nowhere. They're all parked in a parking lot for trains. Guy walking across the street. This is in Wuhan. This is an ambulance bringing a patient to a hospital in Shanghai. More ambulances behind them.

But those travel restrictions in the other areas work great. It didn't work here in Hubei Province because Hubei was shut down long after the horses were out of the barn. And so here, even if these numbers are too low-- double them, triple them, quadruple them-- it's still too-- it's still a great success compared to the rest of the country.

This is a curve that shows Hubei Province cases. This is a classic sigmoid curve that's going to come up here and it's starting to become asymptotic to this 90,000 line up here. This jump right there is when they redefined a confirmed case as clinical confirmation. And then they changed back the next day after they were criticized for it. They never took those 15,000 cases out of there. So that's why there's just that awkward jump in there.

This is taken from this morning-- about 6:30 this morning. This is Johns Hopkins Bloomberg School of Public Health runs this website. And you see the current things that are going on. Over 4,000 deaths, 121,000 cases. And of course, these estimates-- look at Iran-- 9,000. Gee, what a nice round number. Well, it's a guess. That's why it's a nice round number.

[LAUGHTER]

These five-- these five areas have active outbreaks. Diamond Princess is over because they finally got them off the ship. Hubei-- they got a late start. And they're not-- they never caught up. It's just burning itself out silently in a little lockdown down areas. South Korea-- the church didn't cooperate with authorities and it was allowed to spread all over the country.

Northern Italy-- they didn't suspect the guy who was the initial case-- the initial symptomatic case had never been out of the country. But he had met a guy the previous four days before who had come from China. Italy's having a terrible time with their-- I think first they locked down the north. Now I think the whole country is locked down. I don't know how severe it is. If it's just travel or inside its cities as well. The Diamond Princess-- if you're not-- if you're a virus and you don't get into a wet market, you want to get into a cruise ship.

[LAUGHTER]

Air systems, water systems, sewage systems are all connected throughout the ship. So if somebody's sick in one cabin, the air is going to move on into the next one. And that's why there's huge numbers of people in that cruise ship and the previous-- in the pandemic from Mexico was the same thing.

Iran-- we really don't know what's going on. They have excellent public health. But the public health people are not the ones making the announcements. It's the government and they're very secretive about what's going on.

Can we stop it here? I'm going to go a little fast, because I want to leave a little bit of time for questioning. I only have five minutes left. Can we stop it? Well, we can't keep it out of the country. But we can certainly mitigate what it does based on what we did in the Spanish flu pandemic, which is basically social distancing and personal hygiene, which you already now know everything you need to know about it.

Will there be a vaccine and drug? Short answer-- no and no. They take a long time-- they don't take a long time to develop. They take a long time to test. Some cocktails of existing antiviral drugs have been tried and might work, but there's been no clinical trial.

So what's going to happen? Well, it's going to continue to spread. It's over 100 countries now. Some countries will contain it. Most countries will be playing catch-up. We can contain it here because it's not here in Champaign County yet. And then we don't know will it eventually disappear? Will it come back seasonally like other coronaviruses we have here? Or it will be here constantly? I don't know the answer to that. My gut feeling-- it will disappear just like SARS-1 virus disappeared.

There is the good Dr. Lee who passed away, that wanted to alert everybody. I have one slide-- oops-- here. There's a big discussion going on campus about what to do. Should you close the campus? Well, you want to think of things like this in terms of logical epidemiologic facts not the panic that's going on. Right now the virus is not in Champaign County. There's no reason to do anything.

The problem is going to be spring break. And the provost has a plan of what to do, how to take care of individual cases. McKinley Hospital is excellent. The public health on campus is excellent. So you have these three choices. What they're going to decide to do-- I'm sure they're not going to cancel spring break. If it were my decision, I would cancel spring break. That's because I'm not a student anymore.

[LAUGHTER]

If I was a student I wouldn't cancel spring break. And canceling it after-- two weeks after spring break-- who's going to come back two weeks early when you can just stay on the beach or on the mountain? So I don't know what will be done here. You have to have some way of getting people to come back and then not go to class. So we'll see what happens with that. So that's all I want to say to you. Thank you. You've been very attentive.

[APPLAUSE]

If anybody has any questions, you can shout them out or come up here. I'll be glad to--
JUSTINE: Do you want to field in front of the audience or do you want to field them one on one?

JIM DOBBINS: I'll walk out there.

JUSTINE: Do you want to field the questions in front of everybody or do you want them to come one on one.

JIM DOBBINS: I can do either-- both.

JUSTINE: Yeah. We can field it-- I know some folks have to leave to head to their next class. We can also field some questions in the large audience if you want. Dr. Dobbins will stay afterwards to do one on ones, too. But does anyone have a question that they'd like to field from the audience? Speak up. And if you can talk loudly, just cause he's got the microphone.

AUDIENCE: Yeah. I was wondering what other diseases or co-morbidities are worse for-- because obviously someone our age might not die from coronavirus. But what other diseases might make us more susceptible to having a more severe case.

JIM DOBBINS: Well, the one that comes to mind-- the one that comes to mind-- the question is, what other diseases are actually attacking your age group that would make you more susceptible to coronavirus? And certainly HIV is the one that comes to mind because that is going to basically destroy your immune system. Mono would weaken your immune system. Mono's always big on campus. I don't know if there's any going around now. Other ones I don't know-- mumps isn't here anymore. So that's the only ones that I can think of off the top of my head. Yes.

AUDIENCE: Do you have any advice for spring break plans and what we should be doing?

JIM DOBBINS: That's a good question. And the advice is no, just continue as you planned and wash your hands. You're going to go on an airplane. You're going to go-- even if you go to Italy-- don't-- I mean, I wouldn't go to Italy.

[LAUGHTER]

I guess there's no planes going to Italy anymore, anyway. But just wash your hands. All you have to do. Just pay attention. And remember what is the one thing I want you to remember-- you are going to be the one that gives you coronavirus too. Not me, not anybody else. It's you. Yes.

AUDIENCE: How much does it matter if soap's like anti-bacterial or not?

JIM DOBBINS: Oh. Anti-bacterial soap in general is good. This is not a bacteria, so it doesn't--

AUDIENCE: But just like--

JIM DOBBINS: Yeah, I use-- well, they took the anti-bacterial out of my soap. So I still use it because I like it. I like the smell.

[LAUGHTER]

Other questions? Yes.

AUDIENCE: If morbidity and R naught are so low, along with the fact that we've seen diseases like this in the past, why is the response to this one so severe?

JIM DOBBINS: Were you paying attention for the first four [INAUDIBLE]? Yeah. No, it's just-- we didn't know R naught when it started. All we knew was the 80% mortality.

AUDIENCE: I thought that was for SARS in Mexico, not for--

JIM DOBBINS: Both. Yeah. I'm sorry. I didn't make that clear. I can't read without my glasses, so I can't see it.

[LAUGHTER]

Other questions? Yes, young lady.

AUDIENCE: Do you think that the seasonal flu rates will go down this year because everyone's freaking out so much and washing their hands so much and staying home when they should--

JIM DOBBINS: Yes, I think-- the question is, will flu be mitigated by all of us taking steps to protect ourselves from the coronavirus? And I think that is true. Excellent point. I'm glad you brought that question up. But the season's almost over. So I could make any predictions and it'll come out-- come out true. It's a little late to get immunized. If you haven't been immunized, go ahead and get a flu shot. I think it'll be over by then anyway.

I think that this will be over by summer. That-- don't go to the bank on that. But that's my gut feeling just based on my life experience. I don't have any data to support that, just my experience. Other questions? Yes.

AUDIENCE: So my parents-- I worry about my parents because they've gotten

[INAUDIBLE].

JIM DOBBINS: Wait a minute.

AUDIENCE: I worry about my parents because they're getting much older in age. What can they do besides just wash their hands? My mom works at a hotel. So what could she do to prevent [INAUDIBLE]?

JIM DOBBINS: Where is she?

AUDIENCE: She's here by Chicago. What can she do to prevent-- or what can my parents do?

JIM DOBBINS: I think that all the people that should be washing their hands-- she'll probably be working with gloves on-- nitrile gloves. And the thing she'll need to do is change those gloves after everything she's cleaning. It's tempting to keep them on because they look perfectly good. But they're not perfectly good. And they go into your mouth just as easily as your fingers. So-- or your ear, your eye, or something. So gloves and then hand-washing. Yes.

AUDIENCE: Is there any validity to the claim that warm weather might limit the spread of this virus [INAUDIBLE]?

JIM DOBBINS: Yes, there is. We don't have any idea. The-- if the coronaviruses that are here now do diminish in warm weather-- it's not ever been completely clear, but I think it's because the mucous membranes dry out in the winter and mucus is part of your immune system. And so if that's dried out, it's easier to get things. In the summer, it's not dried out and so they'll-- normally, respiratory viruses will go down. Given that the transmission of this is not so much respiratory, or not directly respiratory, it may not happen. Other questions. Yes.

AUDIENCE: Speaking of the [INAUDIBLE], in the winter during cold weather, I have to wear gloves when I go out. Like my leather gloves and so on. So when I come home and what do I do, wash my gloves or wash my hands?

JIM DOBBINS: Throw them away [INAUDIBLE]. No, don't throw them away. Don't wash them.

AUDIENCE: My god, they're expensive gloves.

JIM DOBBINS: No, don't-- this virus is easy to kill. It doesn't survive a long time. You can get it to survive a long time in the lab. But we don't live in the lab. And so-- I'm not going to throw my gloves away and I'm not going to wash them. I'll just leave them-- leave them there. They'll dry out and everything will be taken care of. Good question, though. Somebody else had a question. Yes.

AUDIENCE: So what is happening in Italy right now is that the health system is collapsing under the pressure of the people that are infected. And what our state and also our community is doing to prepare?

JIM DOBBINS: That's a good question. I don't know if you can all hear. The health system in Italy is overwhelmed by cases-- sick cases that need--

AUDIENCE: Which [INAUDIBLE] it means respirators.

JIM DOBBINS: Yeah, they need palliative support. There's no drugs. But they need-- they need support breathing. Same thing happened in China. China actually built a huge hospital in 10 days. And I think it's still empty. By the time they finished, just in those 10 days, the cases in Wuhan had diminished enough. So they're just going to have to gut it out and then the case numbers will go down. By the time they do anything serious, the cases will be back down.

AUDIENCE: So what the US is doing to prepare for the--

JIM DOBBINS: What would we do here?

AUDIENCE: Yeah. Do we have enough number to support the possibility of an outbreak?

JIM DOBBINS: That I can't answer. It's not-- that's out of my area of expertise.

AUDIENCE: Because at the end it's this component that is killing the biggest part of the people.

JIM DOBBINS: This part-- yeah. It should be-- presumably they're getting those respirators. But they're not getting them from China, which is where they're probably made. So that the-- our hands are tied on a lot of this stuff. Yes.

AUDIENCE: About how long the virus [INAUDIBLE]? I received a letter from Italy and it made me pause whether or not I should be handling--

JIM DOBBINS: You should be fine. Yeah. The question was how long would the virus be on a letter that came from Italy? And did you read it with rubber gloves on?

[LAUGHTER]

Yes.

AUDIENCE: How will the international community respond-- the SARS outbreak and now MERS. Do you think the community is going to change at all? Are they actually going to take action or is this going to be like [INAUDIBLE] wait till 2030 and then the next big virus--

JIM DOBBINS: I'll go along with your last guess. See we did all this planning for the International Health Regulations of 2005. It didn't really have a big effect. It didn't have a big effect in China. It didn't have effect at all in Iran. All the other countries it has had an effect.
And those-- when I put that slide up with those red circles all over it, that is pretty good data except for a few countries. So I think we're iterating towards a much better system. But I don't think we'll ever completely get there. There will always be autocratic governments that don't want to talk about how poorly a job they've done. Yes.

AUDIENCE: I have another question. The number of-- In Italy, we have free health. So lots of the testing for the coronavirus [INAUDIBLE] are free. What about the US? There are-- I mean, do you think that the number of cases that are recorded here are under-evaluated?

JIM DOBBINS: They're way, way under. When I got back from Singapore, I tried to get tested. I had a cold. Developed it four days after I got back. I couldn't-- the State of Illinois refused to test me. I didn't have a fever. I wasn't really sick. They had only a few test kits. They supposedly have more test kits now, but they're still not testing. They want to test here in Champaign County. The health district wants to test. But they don't have permission from CDC to do that at this point.

AUDIENCE: So basically, we don't know if it is already here or not?

JIM DOBBINS: Bingo. We do know that there's nobody sick with the disease here in Champaign County. So if it's here, it's here silently. It's not causing disease. If somebody is in the hospital with serious atypical respiratory problems, it definitely would be tested. So it's a little bit of what you're saying. Other questions? Thank you all for staying here. I'm sure there's a class here after this.

[APPLAUSE]

[INTERPOSING VOICES]