We are living in strange times. The streets and highways that run through busy cities around the world are uncharacteristically empty. Schools are closed. Storefronts are boarded up. Many people are just trying to figure out how to survive the COVID-19 pandemic. Preparation is key, says epidemiologist Jennifer Nuzzo. But that doesn’t mean stockpiling paper goods and cleaning supplies. Each country needs to be prepared, and it is now clear that many were not.
Nuzzo’s work at the Johns Hopkins Center for Health Security has focused on pandemics and outbreaks. Less than three months before the earliest reported case of humans infected with COVID-19, Nuzzo and her colleagues published a WHO/World Bank-commissioned report about a “high-impact respiratory pathogen” that “would likely have significant public health, economic, social, and political consequences.” What we’re experiencing now, she says, exceeds “some of the grimmest expectations” highlighted in that report.
Still, Nuzzo sees a light at the end of the coronavirus tunnel. In our interview, she explained why vaccines aren’t the answer, how the novel coronavirus is unique, and what we can do to keep ourselves healthy. A supporter of social distancing, Nuzzo spoke to me from the protection of her home in Maryland, where she, like many of us, is balancing remote work with homeschooling two young kids.
Yvonne Bang: Because we sometimes encounter conflicting reports, I first have to ask: Is the COVID-19 pandemic serious? Are we overreacting or not reacting enough?
Jennifer Nuzzo: It’s very serious. We’re definitely not overreacting. I think we are not reacting enough in some areas.
It is very frustrating to watch how slowly the response has been going. It’s good that governments have finally taken seriously the need to try to prevent or slow the spread of infection. We’re finally seeing a call to expand testing. But we still haven’t made much progress on that front. People have been screaming about the shortage of personal protective equipment (PPE) at health facilities for weeks, and it’s just getting worse. I don’t really see a meaningful plan to get out of this very dire situation.
You were the lead author of “Preparedness for a High-Impact Respiratory Pathogen Pandemic,” a paper published just a few months before the first reported case of COVID-19. What conclusions or recommendations would you change? And which are more important than ever?
One of the overarching findings of that report was that respiratory pathogens have the potential to cause pandemics that can affect nearly every country at once. The usual mode of responding to infectious disease risk, like ones we may have seen in Ebola in the Democratic Republic of Congo or Ebola in West Africa, this idea that you could bring in outside resources to an area to try to slow the spread or contain it wasn’t going to be applicable in the context of a respiratory pathogen pandemic, because every country would be affected at once. Whatever resources exist at an international level would likely be insufficient, because everybody would need the same things.
That was an important thing that we wanted to stress. You can’t just assume that the World Health Organization is going to fix it. Essentially, every country’s going to be on their own, for better or for worse, and we need to think about scenarios in which we might all need the same things. That is very much true and, unfortunately, playing out right now, in ways that probably even exceeded what you could’ve described in September 2019 as being the grand risk area of conclusions. I mean we would’ve anticipated shortages in global supplies, but the extent to which they’re in short supply has exceeded some of the grimmest expectations.
What is happening now that you didn’t anticipate in your September 2019 report?
One thing that feels very different is that, here in the United States, I think we’re really suffering from weak national leadership. Somebody read our report and said to me, “You know, it’s almost as if you assumed there would be a functioning government.” Not to say that we don’t have a functioning government! It’s just that when you hear things like, “We’re leaving it up to individual states to acquire ventilators,” that’s not a unified response. That’s not acting on behalf of the union. That’s like The Hunger Games, in which you’re pitting 50 states against each other. So I think that is one unanticipated distinction.
We spent a lot of time focusing on national governments in our report, when clearly, right now, the important actors, out of necessity, are the state and local governments. They’re just not getting the kind of support they need from the federal government, and I think that’s really important. I don’t think that individual states should have to be trying to find their own ventilators or masks. I don’t think companies want to be negotiating with 50 different states. I think they want one single point of contact and one single point of influence. And that has to be the federal government.
While there is consensus about what we can do to protect ourselves from COVID-19, there is also more than a bit of confusion. For example, a recent report in the New England Journal of Medicine described COVID-19’s ability to remain “viable” in aerosols for up to 3 hours. Another report suggested that viral particles can linger in hospital hallways. So we’re not needlessly afraid of everything, what can we do to protect ourselves?
I think there have been a lot of reports that have misinterpreted some findings of data. The majority of the transmission is going to occur via respiratory droplet. That means if somebody who’s sick sneezes or coughs or touches their nose and eyes and mouth, these droplets that contain virus can be expelled from their body and fall to the ground within about a six-foot radius. They may fall to a surface, and then if you touch that surface and then touch your eyes, nose, or mouth, you can become infected. This droplet mode of spread is going to be the predominant one.
I think some studies have found that it hangs in the air for three hours, but that’s a result from experimental conditions that don’t exist normally. It’s only in a hospital setting, where you have a ventilator or some kind of aerosol-generating procedure that can put individual virus particles into the air, where there are small enough particles that they can hang in the air and not be too heavy where they’ll fall, like droplets do.
People are going crazy, like washing their produce and washing their stuff. I mean it’s not to say that there’s zero risk from all of these things, but we have to be focused on the main mode here, which is droplet infection.
So what do you do to protect yourself from droplet infection? Well, first of all, you definitely don’t go out if you have any level of respiratory symptoms. I mean, nobody’s going out now! They shouldn’t be right now because there is very much an acute need to social distance. But if you are someone who has any respiratory symptoms, stay away from your family. Isolate yourself from your family as best as you can so you don’t spread it to them. Clean the surfaces in the house so that if viral droplets get on the surfaces, other people don’t pick them up on their hands and then touch their faces.
Those are the main things. The hand hygiene and cough hygiene, not shaking hands and washing your hands and coughing into your sleeve, those are all important things. That’s the most you can do. Obviously, staying out of crowds right now is important. Staying away from people, maintaining a physical space of six feet is important. All aimed at reducing that droplet spread.
I think the other category of things that people can do to protect themselves is taking care of their general health. We may be stuck like this for a while—a month, a couple months. Although we are all equally capable of becoming infected with this virus, it is clear that not all of us are equally likely to contract severe disease or die. Which is not to say that previously healthy people don’t get severely ill and die with COVID-19—they certainly have. But for the majority of deaths and severe illnesses, it’s people with underlying health conditions or people with advanced age. Often, underlying health conditions go along with having advanced age. You accumulate those conditions later in life.
So, it’s a good time to get blood pressure in check and get diabetes controlled and have heart-healthy diets. Maintain exercise and take care of yourself. It seems small and not immediate, but, I think, if we should learn anything from this pandemic, it’s that our health is the most important thing that we have. If people have ever needed an excuse to take care of themselves and to get their health in check as best as they’re able, being able to survive a pandemic is a pretty good reason.
The measures that we’re taking now, they’re hopeful. Like we’re hoping that they will slow the occurrence on any one day of new cases so we can reduce the strain on health systems. They’re not a fix for this. They’re not going to get us out of this pandemic. It’s more like a pause button to try to slow things down a bit. There will have to be a next phase, when we think about releasing some of these measures when we get our numbers down to a certain point. But for now, you know, the hope is that as many people as possible can stay home and stay away from others. That’s mostly what we’re doing right now, right? Hand hygiene, droplet protection, social distancing.
Why is it respiratory illnesses, for the most part, that cause pandemics and wreak global havoc?
It’s about how these viruses spread and the kind of non-specific symptoms that they cause. So, this report was commissioned by the Global Preparedness Monitoring Board. The secretariat is housed at the World Health Organization. This is a kind of independent monitoring board that was set up to ask, “How prepared is the world for a variety of events?” Part of the reason why they wanted us to write and focus on respiratory pathogens was that a lot of the other background papers were very Ebola focused, because that was the global crisis that we most recently experienced.
Respiratory viruses are different than Ebola. I mean Ebola is quite deadly, much more deadly than this virus that we’re dealing with now, but it’s not that transmissible. People don’t usually transmit until they’re fairly ill, and it’s pretty obvious at that point that they’re ill. This virus and other respiratory viruses, people can transmit before it’s fully clear that they’re ill. And their symptoms can look very non-specific.
So, that just creates disease control challenges that other pathogens don’t have. Respiratory viruses also have very short incubation periods (the period from when you first are exposed to the time you exhibit symptoms). And when the incubation periods are short, the time between generations of cases is also short. So, that means that the little window of time when you can intervene to stop transmission is smaller. So that’s another challenge.
One of the biggest epidemics in recent history, as measured by the number of deaths caused, was H1N1. And I’ve read that that epidemic is really the best one to compare this current pandemic. Is there an epidemic or pandemic that we can compare our COVID-19 experience to? Or is it truly so unique that it is unprecedented?
I think there are elements of a number of different things that we can look at. I mean there’s a little bit of an element of SARS (Severe Acute Respiratory Syndrome). The key difference is that SARS was more deadly but less transmissible. And it was largely transmitted later in the course of infection, such that people were feeling really lousy and not going about the community and, therefore, a lot of the transmission that occurred happened in health facilities. Once we got infection control practices up and running in health facilities, it was easier to contain, and we ultimately got rid of the virus. So, I think there were some important lessons from SARS that we should learn from.
H1N1 probably is the best example, but we kind of dodged a bullet with H1N1, in the sense that it wasn’t as severe as it could have been. Though I think there are some lessons in that it spread really quickly around the planet. It was one of the things I was reflecting on when I thought very early on that we were on the pathway to a pandemic, just understanding that this coronavirus was capable of sustaining an efficient human-to-human transmission. I fully expected to see it in multiple countries within a few months.
I think I’m probably more skeptical than others about looking at 1918, which ironically was also an H1N1 flu, in part because I don’t fully trust the data, the record-keeping, from 100 years ago. We didn’t have modern healthcare. There were no IVs or antibiotics or ventilators (though we’re now talking about those being in short supply). So, it’s just really hard for me to compare.
That said, I think some of the societal impacts of H1N1 that were reported in 1918—like morgues being overrun; and running out of coffins to bury the dead; and large absences among workers in critical areas. I mean those are all categories of impacts that we should also expect to see from any disease that’s capable of infecting and killing a large number of people.
Where do you think the virus came from?
I think it’s clear that it came from an animal. Probably started in bats. Whether it passed through another animal first is unknown. I think that most people think it likely did, probably some mammal, but we don’t know what. Some people are looking at pangolins now, but who knows?
There was a new study out by NIH [in March] concluding that this is likely how everything arose—and not, you know, a viral agent engineered by the Chinese. We have fairly strong beliefs that this was yet another case of a virus that spilled over from animals to humans. We don’t know when that happened, but likely earlier than we think—sometime before the first cases.
Animal-to-human transmission, interspecies transmission, that’s pretty rare, right? Would you say?
Well, I mean, not really. Anytime we have an emerging disease, about two thirds of them seem to have animal origins. Looking back at history, we have this coronavirus. We had also Zika, which has an animal interface with a sylvatic cycle. Monkeys are also involved in transmission. And Ebola’s also carried by bats. There was a big outbreak of plague in Madagascar a few years ago, spread largely by rodents.
So, we’re seeing lots of these events. We think new flu strains emerge by being passed between birds and mammals and then adapting to humans. This animal-human environmental interface is an important driver for the spillover of viruses into the human population. Colleagues of mine who work on these issues have looked at what important determinants are, and one thing that rises to the test is that land use change seems to be an important driver. It puts humans into contact with animal species that they may not have had contact with before. Or it changes where animals wind up living.
This is important because the frequency with which these events are occurring is increasing. There’s some good data on that. And the majority of these events are of zoonotic origin.
We’ve seen examples of different responses to the COVID-19 pandemic: South Korea, China, Italy, and ours, among many others. Which response, just from your perspective, seems to be effective, and why has it been effective for that country?
At the top of my list of interesting places to look at are South Korea, Singapore, Taiwan, and Germany. South Korea is credited for doing the most per-capita tests. They were very aggressive at finding cases and also doing contact tracing of cases.
Singapore didn’t do any of the kind of social distancing measures that we’re doing. They didn’t cancel schools. They didn’t implement any kind of community lockdowns. But they were very aggressive at finding cases and then doing contact investigations with those cases. They didn’t do the level of testing that South Korea did, but they did very dogged epidemiologic investigations. And they were very transparent about it. They’ve put all the data out for people to see, which was extraordinary.
Germany also has done a lot of testing and contact investigations. They seem to be doing fairly well compared to others.
And Taiwan did a mix of social distancing and also case identification and contact investigation. They haven’t had that many cases. I think when you’re an island, it’s a little bit easier, and the impact of the travel screening and travel restrictions is probably greater for island countries like that. I think there are snippets of each country’s response that we can learn from.
Are there actions that we could have taken that might’ve changed the course we’re on now? Or was what is happening now—shuttered businesses and schools, stay-at-home orders— inevitable?
No, I don’t think it was inevitable. I think the fact that we are all sitting here sheltering in place is the result of a lack of preparedness and a lack of appropriate response once we saw what was happening in China. I mean we have a third of the population of China, and we had several months lead time. Yet we now have more cases than China ever had. In my mind, that’s failure.
And I think one of the huge limits in our response was that we waited too long to start testing in the way that we would’ve needed to. For a very long time, until just a few weeks ago, we were only testing people who traveled from China, from Wuhan specifically. If you didn’t travel to Wuhan, but you traveled to broader China, you had to be sick enough to be hospitalized to get tested. And we maintained these criteria even after we implemented the travel restrictions, even after China itself implemented exit restrictions.
So, even after the travel from those areas was essentially cut off, we never updated our testing criteria. That meant that we weren’t looking for cases. And by that point, tens of thousands of people had traveled from the affected area to the United States. There were many other countries that were reporting cases. And so, it was highly probable, if not almost a certainty, that there were cases in the United States. We just weren’t looking for them. We basically didn’t tune in to our epidemic until it became painfully obvious that it was happening.
Had we done that early, had we started at the beginning, we could have recognized that there was a problem with our approach to testing, such that we could’ve developed the workarounds that we’re having to try to develop now. I think we could have caught local outbreaks more quickly and potentially contained those local outbreaks, and better understood where we are. Right now, we’re trying to play catch-up, and we don’t even know how many people have been infected. We now have all of these cases in front of us, and we’re already overwhelmed in being able to respond to them, and we don’t have enough supplies to test. And now we’re running out of personal protective equipment and reagents and all sorts of other things, which further hinders our ability to test. We’re competing with the rest of the world for all of these things. We basically lost three months of preparedness, of time to prepare.
In the next phase, are there policies that we can enact that might help us return to some sort of normalcy?
I think vaccines are not going to be a realistic solution for years. The 12-to-18 month timeline that you’ve likely heard assumes that the science works in our favor. But it will take years to get the quantities that we need. I don’t see vaccines being a viable solution for a long time.
I think what’s going to happen now is that we will, through these crippling social distancing measures, eventually slow our incidents to a more manageable point. And then we’ll have to think about relaxing the social distancing measures very slowly. But in order to be able to do that, so that we don’t wind up back where we started, we’re going to have to do what Singapore and South Korea did. We have to test widely in order to very rapidly identify cases, and then we will have to isolate those cases as soon as we find them, so they can’t transmit their disease to others. We have to identify their contacts, so that we can figure out if those people too have been infected. And we will have to monitor cases of transmission for a period of time—test and isolate so they don’t transmit.
We’re just going to have to keep doing that and doing that and doing that, until either the pandemic has peaked—and hopefully we’ve spared the health system from crashing—or until we have other tools, like maybe therapeutics that could treat people who become infected, so that they don’t require intensive care or ventilators.
As the director of the Outbreak Observatory, can you explain why the work is especially important in a post-coronavirus world?
We started the observatory a few years ago because we wanted to try to learn how better to prepare for outbreaks. And we felt that an important way to do that is to learn from those who are on the front lines of outbreak response, what lessons they’re learning, what their experiences are, what resources they need, mistakes. And then we analyze that and publish it so that others can learn from it. We would talk to practitioners who were on the front lines. And they would have enormous knowledge in their heads, but it would never leave their heads because they would go from one crisis to the next.
We’re not trying to audit any particular response and tell people what they did wrong. We’re just trying to learn from them what others should know—either places that haven’t yet experienced that particular disease or outbreak or even more broadly. We increasingly find that there are broader preparedness lessons that transcend a particular pathogen or a particular geography.
It’s important to build the literature on this because there are very few operational research studies on outbreaks. There are plenty of epidemiological studies, and there are plenty of clinical studies, but there are very few studies about, “When this happens, what do you do?”
We publish a weekly blog called Outbreak Thursday. Every Thursday, we profile an outbreak that’s happening in the world. And on January 2, 2020, we wrote about the outbreak of viral pneumonia, which gave rise to the COVID pandemic. We are not doing any operational research on COVID-19 right now, but we have some projects in the works. We have some colleagues in Italy that we’re going to try to work with when things settle down. That’s one of our hopes.
And we also want to do more to analyze the data that has been collected globally, perhaps put some more context around it to try to understand why different places may have had the experiences that they did. Research is important, and we want to try and document as much as possible before it’s lost. But we also don’t want to get in the way. First, let’s save lives, and then we’ll figure out when to plug in!
You’re also co-leading the development of the first ever global health security index (GHSI). And this seems particularly relevant as we learn about the various ways different countries are responding. How will GHSI impact public health globally?
This is something that was the product of three organizations: Center for Health Security at Johns Hopkins; The Nuclear Threat Initiative, which is an organization in Washington, D.C.; and the Economist‘s Intelligence Unit, which is a research arm of the Economist Magazine.
The index looks at the health security capacities of 195 countries, very much at the national level, and we look at it in six categories. The first three are things that are commonly measured in public health assessments—their ability to prevent, their ability to test, and their ability to respond to infectious disease risks that have a potential to spread across their borders. And there are different things measured in each of those three categories.
Then we look at the health system and at countries’ commitments and adherence to international norms. And then we also look at their risk environment. That’s one of the final categories. What’s the risk of diseases emerging and spreading? But also social, economic, and political risks, like corruption and governance, or people’s faith in their government. Countries can have capacities on paper, but if there is an ineffective government, then the likelihood that they can mobilize those capacities when needed is not high.
We looked at all of those categories and we published our findings in October 2019. The overarching finding of our study was that no country is fully prepared. This has not been misinterpreted. But, if you just look at the scores, the United States comes out on top. Clearly, just given current experiences, there is no evidence that the United States is the most prepared. We are way behind other countries on a number of fronts. And even though the president held up our index at a press conference and said, “Look, you know, Johns Hopkins found that the U.S. is prepared,” that’s actually not what we found. What we found was that no country is fully prepared, and many countries have deficit in their health systems. That is very much playing out across the globe right now.
Can we alter course at this point?
I think these social distancing measures, if people comply, will have an impact. If people aren’t going out and coming into contact with new people, the likelihood that they’re going to transmit is going to be lessened. If they become ill, they can isolate themselves at home. If their conditions worsen and require hospitalization, they should definitely seek care.
But if you’re mildly ill, you don’t need to be seen by a health professional. Right now is not the time. Let’s give them as much space as possible. I know it’s a delicate balance here. On one hand, I am saying we need to do more testing, and then, on the other hand, I’m telling you don’t go out and try to get tested unless you need it, which sounds like a contradiction, and it sort of is. We need to expand testing at some point. But right now, we don’t have the capacity in our health system for people to just show up to try to get tested—or show up to try to be seen. We have to preserve this very fragile system for people who truly require the resources of hospitals.
I hope it won’t always be that way. I hope we can get it to a point where it’s a bit more manageable, where we have ubiquitous testing that doesn’t cause a strain on already stressed health systems. I mean we have this problem right now where, even if we had unlimited testing, we don’t have enough masks for the people that’d have to take a specimen from you to test. That’s one of the limiting factors. There’s also a shortage of reagents, the chemicals they use to process the tests at laboratories. So, there are still bottlenecks that need to be resolved, and we need to resolve them before we can handle wide-scale testing. But I think it’s necessary that we get to the point where we can do that.
What qualities about COVID-19 make it more pernicious to a certain group, and is there any silver lining?
In terms of upper or lower respiratory tract, they’re finding the virus in both upper and lower respiratory tracts. We don’t fully understand those dynamics yet. It’s possible that that’s one of the reasons why people can transmit it more easily than SARS. SARS tended to be a more lower respiratory tract infection.
Everybody is equally at risk of getting it. With older folks, there might be some behavioral things. People may live in certain settings that make them more inclined to get it. That’s one thought about older individuals: that they tend to live more in group housing, like long-term care facilities.
But on an individual level, we don’t have any evidence that there’s any difference between a 20 year-old and an 80 year-old in terms of the risk of infection. That said, the majority of the severely ill cases and deaths have occurred in people who are of advanced age.
The tough thing is having underlying health conditions. I say it’s tough because there haven’t been studies that disaggregate age versus these underlying health conditions. So, if you’re an 80-year-old who has been lucky enough not to have high blood pressure or cardiovascular disease or cancer or any of those underlying health conditions, I don’t know that we can say that you are at a higher risk of severe illness or death. It’s just that, by the time you’re 80, usually you have one of those conditions. So, we don’t know about age separately from other risk factors.
That said, people with those risk factors, at any age, are potentially at risk. And people with none of those, young people, people who are previously healthy, can also die or experience severe illness. It’s just not as frequent as in people who have underlying health conditions and have advanced age—qualified with the fact that we don’t fully know what age means in this context.
As far as a silver lining, we don’t know for sure, but there isn’t an indication that the virus is that mutable. Let’s hope that it’s not. And let’s hope that we discover that infection confers durable immunity. We don’t know that yet, but that would be great.