COVID-19 Expert Reality Check

SARS-CoV-2 - electron microscope

As the media swarms the coronavirus story, most news articles focus on numbers of cases and deaths, new locations of cases, etc.

Lost in the shuffle are the important public health insights about how viruses work and humans respond. To help improve understanding of an emerging outbreak’s complex dynamics, GHN has reached out to some of the world’s most respected global health experts for their quick "reality checks" on key issues related to the outbreak.



Will most of humanity be infected by the new coronavirus?

It is likely that eventually it will become endemic, and most of us will get infected. But one question is super important: How long will it take for that to happen? If it happens in a few months, every hospital will be overwhelmed and people will not be treated for coronavirus or other diseases. If it happens that fast, it will be an unprecedented disaster. However, if we do our best in terms of prevention by practicing social distancing, reducing travel, not going to work when we’re sick, we could slow spread of the disease. If the same 60-70% infection of the global population is spread over 3 years, then hospitals don’t get overwhelmed, people can get treated, and we have time to develop a vaccine—it’s a completely different story.The difference between it happening fast or slow is potentially the difference between a 1918 flu level event and a bad flu season level event. We have control over that.

Justin Lessler is an associate professor of Epidemiology at the Johns Hopkins Bloomberg School of Public Health.

How does a virus shift from zoonotic to human-to-human transmission?

When a virus passes from a nonhuman animal into a human, we call that moment of spillover a zoonotic transmission. It’s an ecological event. What happens next depends on evolutionary potential and chance. If the virus is adaptable, it may succeed in replicating and proliferating in the new human host. Maybe it kills the person and the line of transmission comes to an end there—as happens with rabies. But if the virus is even more adaptable, it may acquire the ability to pass from one human host to another, perhaps by sexual contact (as with HIV), perhaps in bodily fluids such as blood (as with Ebola), perhaps in respiratory droplets launched by coughing or sneezing (as with influenza or SARS). What makes a virus adaptable? The changeability of its genome, plus Darwinian natural selection. Those viruses with single-stranded RNA genomes, which replicate themselves inaccurately and therefore have highly changeable genomes, are among the most adaptable. Coronaviruses belong to that group.

David Quammen is the author of more than a dozen books, including Spillover: Animal Infections and the Next Human Pandemic, and hundreds of articles for publications including National Geographic, The Atlantic, Harper’s, Rolling Stone, and many others.

Is it possible to be reinfected with the novel coronavirus?

Reinfection is always a possibility with a viral infection, particularly if you have a subclinical infection and don’t mount much of an immune response against it. Reinfection is also possible within the window after the first infection and before you develop antibodies. That window can vary from a couple of weeks to a few months, depending on how much your immune system was triggered.

We’ve now got a good population of people who have recovered from the virus. Serum samples from those patients can allow us to time exactly when they begin to develop antibodies and when they develop sufficient titers and neutralizing antibodies. This will help us determine what the window is for protection.

Before your immune system returns to normal, you can be infected by not just this virus, but by regular colds and flu. A couple of months may be a reasonable window of recovery, based on what we know right now.

Rachel Graham, PhD, is an assistant professor in the Department of Epidemiology in the UNC Gillings School of Global Public Health. She began actively studying coronaviruses just prior to the SARS-CoV pandemic in 2002–2003.

Can the new coronavirus be transmitted via paper money?

Cash can be contaminated with potential bacterial pathogens, but there is little information about viruses on cash in general—and nothing about contamination with SARS-CoV-2, the virus that causes COVID-19.

SARS-CoV-2 is spread by person-to-person contact—not by touching fomites (objects that may be contaminated with, and help transmit, infectious organisms) like cash. And, it’s unclear how long COVID-19 remains viable on surfaces—ranging from a few minutes to hours to potentially days depending on the temperature, humidity and surface type. Switching from cash to plastic has not been proven more protective, either, except perhaps by reducing person-to person hand exposure.

Some countries are washing or disinfecting cash, but there is no data demonstrating how this process works. The best practice is social distancing: limiting person-to-person contact by shutting down schools, bars, and other crowded places. That is what will slow infections, prevent health care systems from overloading, and reduce deaths. That is why everyone should do their part and embrace social distancing rather than worrying about using money or credit cards.

Marilyn Roberts, PhD, MS, is a microbioligist and professor of Environmental and Occupational Health Sciences, an adjunct professor of Global Health, and an adjunct professor of Pediatric Dentistry at the University of Washington School of Public Health.

What is cryptic transmission, and what is its significance in the COVID-19 outbreak?

Cryptic transmission is the term that is used when there is no direct contact between person 1 shedding the virus and person 2 contracting it.

It is an important indicator of community prevalence of a virus. There is essentially enough circulating virus in a community to transmit the same strain of the virus between individuals who are not directly linked.

In the case of the COVID-19 outbreak, this term came into the lexicon after University of Washington researchers sequenced the COVID-19 genome from Snohomish County, Washington, which showed a direct genetic link from the first 2 cases in Washington though they had no known contact. This indicated there was significant community spread, and likely evidence the virus had been circulating for weeks by that point. As I noted on Twitter, the key takeaway is this is going to be a critical path for viral transmission given the potential infectivity prior to the manifestation of symptoms—and what will ultimately make it so hard to control the spread of the virus.

Ingrid Katz, MD, MHS, is Harvard Global Health Institute's associate faculty director, an assistant professor at Harvard Medical School, an associate physician at Brigham and Women’s Hospital, a research scientist at the Center for Global Health at Massachusetts General Hospital, and associate faculty at Ariadne Labs.

As COVID-19 symptoms mimic those of common cold and flu viruses, how do you know when you should seek testing or special care?

The symptoms of COVID-19—including fever, cough, and difficulty breathing—are similar to those of other cold and flu viruses. At this moment, the decision to test for COVID-19 in the US depends on both the patient’s clinical status and what is happening in a particular geographic location. A history of travel, especially international travel to one of the most affected areas, is still important, but this is evolving as the outbreak develops domestically. Close contact with someone who traveled to those areas or with someone who has been diagnosed with COVID-19 are other considerations.

The evaluation of cold and flu symptoms will often include testing for routine respiratory viruses as well, especially influenza. In general, if you do not have symptoms and would not ordinarily seek medical care based on how you feel now, you do not need evaluation or testing for COVID-19.

Preeti N. Malani, MD, MSJ, is the chief health officer and a professor of Medicine in the Division of Infectious Diseases at the University of Michigan.

What are the special risks of COVID-19 to pregnant women?

Infection rate and progression to severe disease in pregnant women is similar to that in nonpregnant adult women. The same protective measures against transmission of the virus apply to both.

So far, no transmission from mother to fetus has been described. Vaginal delivery should be encouraged when both the mother and the baby are not severely sick. Strict protective measures (facemasks, hand hygiene) must be observed to protect the newborn and the personnel during and after childbirth.

Separation of the mother and baby and breastfeeding should be discussed on a case-by-case basis with the mother. The newborn should be protected from infection by the mother as much as possible. If the mother wishes to express her milk or breastfeed, disinfection of the breast should be added to the protection methods mentioned above.

We have launched an international registry for women exposed to COVID-19 and welcome any medical center and maternity to join. (If you are a patient interested in sharing your data, please suggest that your doctors contact Dr. Baud.)

David Baud, MD, PhD, is head of obstetric service in the Department of Woman-Mother-Child at Lausanne University Hospital, where his research team studies emerging infections in the OB/GYN field.

Given that coronaviruses can cause the common cold, does that mean humans likely have some protection against this new virus? Or are we immunologically "naive"?

Although it’s possible we could have pre-existing immunity if we were previously infected with "common cold" coronaviruses, there is no evidence that this is protective in people exposed to SARS-CoV-2 (the virus that causes COVID-19).

Unless I see data otherwise, I’d assume that most of us are immunologically "naive." However, although we don’t know if it’s relevant to COVID-19 epidemiology, it has been shown that antibodies against SARS-CoV can block infection of cells with SARS-CoV-2 in vitro, so there is the possibility of protective cross-reactive immunity from closely related coronaviruses.

Angela Rasmussen, PhD is a virologist on the faculty at the Center for Infection and Immunity at the Columbia Mailman School of Public Health. She specializes in using systems biology approaches to study how a host responds to a virus infection and how this response contributes to disease severity and clinical outcome.

How do you go about creating a vaccine against a new virus?

Every virus has its unique challenges. In the case of n-coronavirus, the vaccine challenges are 2-fold. First, you have to interfere with the virus’s ability to dock with a specific receptor in the lungs called ACE2.

Then, you need to reduce the problem of antibody-dependent enhancement. ADE means that some respiratory virus vaccines can actually make things worse. There are multiple ways to solve this problem. One option is creating a vaccine that only uses parts of the pathogen to stimulate the immune system. One approach is to do this by producing recombinant protein subunit vaccines.

We have found that these vaccines that use a part of a protein of the virus (the spike protein) and known as the receptor binding domain (RBD) are optimal for 2 reasons: Recombinant proteins are a standard technology that has resulted in other licensed vaccines, including the hepatitis B and HPV vaccines; and it’s possible to produce this vaccine in abundance and at low cost.

Moreover, this approach, unlike many others, reduces ADE and has a potential for being safe.

Peter Hotez, MD, PhD, is dean of the National School of Tropical Medicine at Baylor College of Medicine and Co-Director, Texas Children’s Hospital Center for Vaccine Development.

How does this particular coronavirus compare with other coronaviruses like SARS and MERS?

"We are learning more about the virus every day. On the continuum of the common cold to SARS, it’s now clear that the novel coronavirus is more contagious than SARS, but less deadly. We don’t yet know how much more contagious, or how much less deadly. The number of confirmed infections with nCoV has already far outpaced the total number of suspected SARS cases."

Tom Frieden is President & CEO of Resolve to Save Lives, an initiative of Vital Strategies, and the former Director of the US CDC and Commissioner of the New York City Health Department.


There have been news reports that the coronavirus epidemic will last for 18 months or longer and come in multiple waves. If so, how long will social distancing be necessary in that situation?

This pandemic will last until most people are immune, whether through vaccination or from having gotten the illness [COVID-19] and recovered. The 18-month figure comes from reports that we won’t have a vaccine in less than 18 months, but that would be in unprecedented, in record-breaking time. We’ll eventually have a vaccine, but that may be in 18 months or 5 years from now.

I think there will be waves of the epidemic across the US. What’s happening now in Seattle and New York, and to a lesser extent in San Francisco, will happen in Baltimore and Dallas at different times. Each wave will last a couple of months—from valley to peak to valley. As we begin to relax social distancing efforts—which we will have to do because society can’t stay like this—the disease will start to come back. The hope is that it will return more slowly because there are fewer susceptible hosts, we’ll have more ubiquitous testing, and more [targeted] interventions instead of the sledgehammer we’re using now.

Eric Toner, MD, is a senior scholar at the Johns Hopkins Center for Health Security at Johns Hopkins Bloomberg School of Public Health, with expertise in health care preparedness for catastrophic events, pandemic influenza, and medical response to bioterrorism.

What’s the worst-case scenario for this pandemic?

There is already evidence of widening transmission of SARS-CoV-2 across the Southern Hemisphere, though the virus is currently taking its primary toll in the North. It is likely that 60-65% of Northern Hemisphere populations will be infected with the virus by July or August.

As the epidemics seem to diminish later in the summer, action will shift to the South, with COVID-19 sweeping across Latin America, Africa and the South Pacific, similarly infecting upwards of 60% of populations. And then by December, it will make a slow return to the Northern Hemisphere, creating a North/South cycle that will persist for years.

Adding additional fuel to the South’s fire will be high HIV infection rates, with more than a third of HIV-infected Africans, in particular, unaware of their status and therefore not on suppressive medication, and immunocompromised.

Laurie Garrett is a former senior fellow for global health at the Council on Foreign Relations and a Pulitzer Prize winning science writer.

How much will mortality rates vary from country-to-country given differing levels of health system preparedness and response resources?

Mortality rates will vary by country according to several factors. First, it will depend on the age structure of the population; Italy has the second oldest population in the world, which may partly explain the high mortality observed.

Health care availability (in terms of the number of hospital and intensive care beds) and accessibility (free versus paid) will also influence mortality. For example, low death rates in Germany and South Korea are partially attributed to the relatively high number of hospital beds per capita. Moreover, disparities in death rates between Hubei province—the location of Wuhan, where the outbreak first emerged—and other parts of China are thought to be due to the rapid case rise and resulting strain on health care resources in Hubei.

Lastly, a country’s testing policy will be an important determining factor. If there is widespread testing of community as well as hospital-based cases, mortality will be lower than if testing was solely focused on hospital cases.

Antonia Ho, MBChB, PhD, MRes, MSc, is an infectious disease physician and clinical senior lecturer and consultant in infectious diseases with the Institute of Infection, Immunity, and Inflammation at the MRC-Centre for Virus Research at the University of Glasgow.

When does an outbreak become a pandemic?

The word pandemic literally means "all people" in Greek. But clearly not all people become sick even in the worst pandemics. Epidemiologists typically mean an infectious disease epidemic that has spread or is spreading globally.

Usually we refer to a pandemic only when it involves a new disease. So, for example, we talk about an influenza pandemic when there is a new strain of flu spreading around the world. In contrast, we do not refer to the global outbreak of seasonal influenza as a pandemic because the strains are not new.

There is no strict definition of when an epidemic becomes a pandemic—but usually it means that the disease is actively spreading on several continents with likely continued spread to other continents.

Eric S. Toner, MD is a Senior Scholar with the Johns Hopkins Center for Health Security and a Senior Scientist in the Johns Hopkins Bloomberg School of Public Health, Department of Environmental Health and Engineering. He is an internist and emergency physician.

Why are wild animals believed to be the source of this outbreak?

About 60% of newly emerged and re-emerging pathogens share a common origin: the bodies of animals. Genetic and epidemiological evidence suggest that the novel coronavirus, like SARS, may have emerged from a so-called "wet market," where wild species that would rarely encounter each other in nature are crammed together, allowing microbes to spread between species and into humans. China claimed to have cracked down on these markets after the SARS outbreak, but when I visited a few years later, it wasn’t hard to find one.

But such markets are only part of the problem. The loss of wildlife habitat around the world more generally is forcing wild species to cram into closer proximity to human settlements. Bats, for example, have been fingered as the source of Ebola, SARS, and a host of other pathogens. When we cut down the forests where they live, they come roost in our backyards and farms instead. It’s this kind of novel, intimate contact that provides opportunities for the microbes that live in their bodies to spread into ours.

Sonia Shah is a science journalist and author of Pandemic: tracking contagions from cholera to Ebola and beyond. Her new book, The Next Great Migration: the Beauty and Terror of Life on the Move, will be published in June 2020.

How do disease detectives find the source of an outbreak like this?

Once two or more people are identified, disease detectives (such as those in the CDC’s Epidemic Intelligence Service) look for what these people have in common. Do they live together? Work together? Shop at the same market? Points of overlap could indicate sources of the pathogen.

At the same time, infectious disease doctors and scientists try figure out what the pathogen is. In the case of the novel coronavirus, scientists isolated and genetically sequenced the virus, revealing its close relationship to SARS, which originated in bats but was transmitted to humans through another species.

Pinpointing the precise animal species will take time and a lot of testing: It took more than a year to identify civets as the intermediary host between bats and humans for SARS.

Michael Mina, MD, PhD, is an assistant professor in the Center for Communicable Disease Dynamics at Harvard T.H. Chan School of Public Health and associate medical director of Clinical Microbiology at Brigham and Women’s Hospital and Harvard Medical School.

What are super spreaders and how can they affect the trajectory of an outbreak?

Rather than using the term super spreaders (a person who infects a large number of people), we should think of them as super spreading events. Maybe a person is at the right time of infection and at the mall. Typhoid Mary infected many people because she was a cook.

Part of the reason we stopped SARS is that a lot of super spreading was happening in health care settings and when people really got their act together in terms of infection control and biocontainment, it nipped the epidemic in the bud.

Super spreading events have the largest influence an outbreak’s trajectory early on. If there’s only a few cases and one person then infects 10 others, it can make it start strong. Once an epidemic gets going and has 100 to 200 cases or more, the "law of large numbers" takes over—and it stops mattering so much.

Justin Lessler is an associate professor of Epidemiology at the Johns Hopkins Bloomberg School of Public Health.

What’s a reproductive number and what does it tell us about an outbreak’s future?

The reproductive number represents the average number of people that one infected person will infect. The reproductive number for a disease can change based on how infectious the pathogen is, the host population, and environmental factors.

To control an outbreak, the goal is to reduce a disease’s reproductive number to less than 1. If the reproductive number remains 1 or higher, the outbreak will continue. In the case of COVID-19, the estimated reproductive number is around 2.6, meaning the outbreak is expected to continue.

The reproductive number can be reduced by altering transmission dynamics—with social distancing, home isolation, quarantine, and use of personal protective equipment in health care settings. Over time as people are infected and recover—or if a vaccine becomes available (which may take months or years)—immunity in the population also reduces the effective reproductive number of a disease.

Michael T. Osterholm, PhD, MPH, is the director of the Center for Infectious Disease Research and Policy (CIDRAP), and a professor for the University of Minnesota’s School of Public Health, College of Science and Engineering, and Medical School. He is also the author of the 2017 book, Deadliest Enemy: Our War Against Killer Germs, and a member of the National Academy of Medicine and the Council of Foreign Relations.

What does successful risk communications look like?

When you think of containing an epidemic, from Ebola to coronavirus, labs and disease surveillance are often top of mind. Risk communications, however, is a key aspect in shaping the course of an epidemic, and how prepared people are to combat it.

People need timely, accurate and easy-to-understand information that encourages protective behavior without inciting panic. Information based on the changing risk of transmission and not politics, fear or stigma is critical.

As coronavirus spreads, government, media and others need to elevate accurate information sources and built community trust while combatting misinformation.

Amanda McClelland is the Senior Vice President, Prevent Epidemics at Resolve to Save Lives an Initiative of Vital Strategies, and has more than 15 years of experience in international public health management and emergency response.

What are some of the major challenges to global cooperation in this coronavirus outbreak?

Data transparency and political sensitivity are two of the most critical challenges to effective global cooperation on the COVID-19 outbreak—and they are deeply entwined.

China has a history of concealing, delaying or refusing to share data and information (this happened with SARS in 2002-2003 and in 2018, when China reportedly refused to share samples of a bird flu with pandemic potential). Leading global health agencies have praised China’s response to COVID-19, while other experts doubt the accuracy of the reported data. Data transparency is key to building much-needed trust—and preventing the misallocation of resources, which could slow the response.

Some countries in Asia—where China holds significant economic and political influence—have carefully crafted their public coronavirus responses, aware that criticizing China could hinder cooperation. And all stakeholders face a difficult task: balancing effective disease response with the political sensitivity necessary for a successful, cooperative, global response.

Sarah McCool, PhD, MPH, MHA is a clinical assistant professor of Health Policy & Behavioral Sciences at the Georgia State University School of Public Health in Atlanta, GA.

Could export goods transmit SARS-CoV-2 infection around the world?

The likelihood of getting infected with SARS-CoV-2 (the virus that causes COVID-19) through export goods originating from China or elsewhere is quite low. Although SARS-CoV-2 can survive on surfaces from 2 hours to 9 days, it is vulnerable to heat, changes in pH, and common disinfectants. Since SARS-CoV-2 is an enveloped virus (meaning it has a fragile outer layer), it is less stable and more susceptible to disinfectants. Therefore, the risk of an infected person contaminating commercial goods is low—and so is the risk of catching the disease from a package that has been transported and exposed to different conditions (and temperatures).

So, feel free to order that dress from China or those leather shoes from Italy. While you are at it, wash your hands and maybe wipe the surface with a disinfectant because informed preventive measures are what we need to stop both COVID-19 and the fear epidemic from spreading.

Sulzhan Bali, PhD, MS, is a public health specialist with an international financing institution. She has over a decade of work and research experience in health security, global response to epidemics, and infectious diseases. The views expressed here are personal.


Why will it likely take longer to develop a vaccine than a drug for COVID-19?

The development of vaccines and drugs for COVID-19 share common goals: to ensure safety and efficacy. These are often assessed through a series of studies, sometimes beginning with animal experiments, progressing through human phase 1, 2 and 3 clinical trials with increasing numbers of participants. However, it often takes much longer to develop and rigorously assess a vaccine. First, vaccines are usually targeted to healthy people, in contrast to drugs administered to people with disease. Larger and longer studies are often needed to ensure the safety of vaccines. Second, the outcomes of interest often take much longer to be measured. Vaccine efficacy and immunogenicity can take many months to measure accurately, whereas whether or not a treated patient improves can take days. And some vaccines require multiple doses spread out over months whereas drug treatment regimens typically are days to weeks. Once developed, it can also take longer to manufacture and deploy vaccines.

William Moss, MD, is executive director of the International Vaccine Access Center and a professor of Epidemiology at the Johns Hopkins Bloomberg School of Public Health.

What’s the most important thing that WHO can do in the fight against COVID-19?

WHO has reiterated to all countries that with early and aggressive measures, they can stop transmission and save lives. WHO must be the first entry point for reliable information on the virus and its spread. It also has the unique mandate to provide evidence-based guidance to help countries and individuals to assess and manage their risk and make decisions. This is even more critical now as countries should be preparing for sustained community transmission.WHO must also be able to support the most vulnerable countries.The world requires a comprehensive and coordinated approach as outlined in the Strategic Preparedness and Response Plan that WHO has issued: Establishing international coordination and operational support; scaling up country readiness and response operations; and accelerating priority research and innovation.That turns the question on its head: One of the most important things countries and financial organizations must now do is support WHO in order to protect us all.

Ilona Kickbusch, PhD, chair, Global Health Centre, Graduate Institute of International and Development Studies, Geneva, and member of the Global Preparedness Monitoring Board.

What does "preparedness" in a country really mean?

Preparedness starts with funding. That’s how everything else gets done—by having resources available to prepare for these kinds of rare but highly impactful events.

Public health departments would use that money to ensure expertise in emergency and pandemic planning. That’s key not only for the public health preparedness, but for preparedness in hospitals and long-term care facilities as well.

The money could also be used for supplies. In the US, we’ve heard a lot of about the Strategic National Stockpile which contains critical medicines and supplies needed during public health disasters. Having the resources to ensure we have extra supplies on hand is crucial.

Preparedness also means having policies and guidance ready to pull off the shelf during crises, rather than starting from scratch. That could include telework policies at an institutional level, or advance thinking on actions like the triggers that would indicate a need to close or reopen schools.

Caitlin M. Rivers, PhD, MPH is a senior scholar with the Johns Hopkins Center for Health Security and an assistant professor in the Environmental Health and Engineering department of the Johns Hopkins Bloomberg School of Public Health.

In the absence of approved treatments, what can health care providers do?

Even without approved treatments, there are several key ways health care providers can care for people with COVID-19 and keep them alive:

  1. Control their symptoms: Give them medications that make having COVID-19 more tolerable—ones that control fever, cough, and other commonly associated symptoms.
  2. Provide intensive support to the body of a sick person as their immune system battles the infection: We see that some patients may become critically ill with this disease, hence they may need mechanical ventilation or urgent dialysis. There may be a role for technologies such as extracorporeal membrane oxygenation to help their lungs recover from acute respiratory distress syndrome.
  3. Treat other infections that COVID-19 patients may get, such as concurrent bacterial pneumonia because their lungs are not functioning as well as they can. In this case, clinicians will use antibiotics to help them recover.

Nahid Bhadelia, MD, MALD, is the medical director of the Special Pathogens Unit at Boston Medical Center and an associate professor in the Section of Infectious Diseases, National Emerging Infectious Diseases Laboratories, at Boston University School of Medicine.

What should the average person in a non-outbreak area be doing to prepare?

The CDC believes it is likely that COVID-19 will cause a pandemic, but there are steps that the public can take to protect and prepare themselves.

First, it is important to stay informed and follow instructions issued by your local or state health department and the CDC. Basic infection control measures still apply in this scenario. Practicing good handwashing techniques or using hand sanitizer, avoiding people who are ill, and staying home when you are sick are all effective measures.

A pandemic could interrupt supply chains and result in closures at local businesses, meaning it may be prudent to stock reserves of critical supplies. Examples include extra prescription medications, asthma relief inhalers, over-the-counter anti-fever and pain medications, non-perishable food items, household cleaning supplies, and toiletries. However, do not hoard - this could create shortages.

Michael T. Osterholm, PhD, MPH, is the director of the Center for Infectious Disease Research and Policy (CIDRAP), and a professor for the University of Minnesota’s School of Public Health, College of Science and Engineering, and Medical School. He is also the author of the 2017 book, Deadliest Enemy: Our War Against Killer Germs, and a member of the National Academy of Medicine and the Council of Foreign Relations.

Does the COVID-19 pandemic automatically mean setbacks for ongoing global health programs?

Consider the limitations or strain already on health systems in many of the countries where global health programs operate. Whether related to health services, surveillance, or supply chains, meeting public demand can be an ongoing challenge at baseline. To add an outbreak response in those settings could spur an outright collapse of essential resources. And that could have a ripple effect for people in need of care across a range of issues, not only those exposed to a novel disease.

Consider a woman who can no longer visit a local clinic to protect her from pregnancy complications. Or the person living with HIV, TB, or some other chronic condition who can no longer receive lifesaving medications, either because of a breakdown or diversion of the pipeline intended to provide those. Furthermore, these very populations are at greater risk of poor outcomes from a disease like COVID-19, creating a potentially vicious cycle.

That is why it's essential that policymakers and practitioners shore up resources that protect progress in other critical areas of global health, while preventing fallout from a new public health enemy. If we are vigilant, we can soften the blow.

Loyce Pace, MPH, is president and executive director of the Global Health Council.

How can public health advocates encourage citizens to trust their advice in countries roiled by attacks on science?

Today’s communication environment is a sea of rapidly changing "information," confusion and distrust. Events shift rapidly, and conflicting perspectives, opinions and statements and accusations of "fake news" are common. Science-based information, when inconvenient, can be contested as just another perspective while repetition is used to establish "facts." In this environment, presenting public health information so it is trusted, understood and acted upon is difficult but possible.

  1. Trust is built over time. Establish credibility by being a reliable source over time so when a crisis occurs, people will turn to you.
  2. Focus on what people want to know; not just on what you want to communicate. One person’s important facts can be irrelevant to others.
  3. Make information accessible. Provide the points and their basis and context clearly.
  4. Work with others. Similar information stemming from multiple sources strengthens believability and credibility.

Keiji Fukuda, MD, MPH, is a clinical professor and director of the School of Public Health of The University of Hong Kong. Previously, he worked for the US CDC and the WHO.

What is the best way to counter misinformation in the media?

The best way to counter misinformation in the media is with an aggressive onslaught of facts. During an outbreak, information may be shifting, guidance changing, and questions multiplying, but the process is guided by adherence to reality and logic. Uncertainty is not an excuse for entertaining arbitrary assertions offered in defiance of the need for evidence. They should be identified as such and dismissed.

Experts, in addition to relating facts, should also explain the evidence that supports their conclusions and how recommendations are rooted in that evidence. This is a daunting task, as it involves more than information dissemination. It requires attention to what counts as evidence and an understanding of how to evaluate competing claims—some of which are grounded in evidence and some of which clearly are not.

Amesh Adalja, MD, is a senior scholar at the Johns Hopkins Center for Health Security.

What is it like inside a hospital biocontainment room?

At first glance, patient rooms in the Johns Hopkins Biocontainment Unit look no different than any hospital patient room—until you see the doors. They’re color-coded for health care worker safety. The colors signify required safety procedures to gain entry to a room. Red, for example, might alert a provider to change their personal protective gear.

We work so hard to make sure we can safely care for any patient, at any time, and simple safety cues like our doors help us do just that.

The design of the 7,900 square-foot unit, including three patient rooms, an onsite lab, shower facilities and clean-in/clean-out anterooms, helps us care for patients safely while protecting our staff and our community. A patient might be feeling scared and disoriented, so making sure they are safe and cared for is the number one priority of our team.

Lauren Sauer, MSc, is the director of Research with the Johns Hopkins Biocontainment Unit and director of Operations with Johns Hopkins Office of Critical Event Preparedness and Response.

What’s the best way to respond to the coronavirus outbreak?

Early in a coronavirus outbreak, unknowns are a given. But the global health community can’t afford to wait to see if a best- or worst-case scenario unfolds. Some post-haste priorities:

  • Vaccine development: Make this is a top priority. Vaccines can dramatically slow disease spread though they can take at least a year to develop. Plans for large-scale production at different sites worldwide are also needed.
  • Find treatments: Test possible antivirals—such as flu and HIV medications—for treatment options.
  • Expand diagnostic capacity: Manufacture and distribute rapid diagnostic kits so cases can be identified quickly.
  • Boost hospital readiness: Strengthen infection control procedures, train health workers, and keep masks, gowns, and gloves stocked.
  • Communicate: Share facts (and unknowns) clearly with the public, and resist the temptation to withhold bad news.

If the virus is ultimately less lethal than feared, or more easily contained, the extra effort will pay off when the next one strikes.

Tom Inglesby, MD is the Director of the Center for Health Security of the Johns Hopkins Bloomberg School of Public Health. This perspective was adapted from a piece he wrote in Foreign Affairs.

What should a country like the US be doing to prepare when an outbreak like this begins to spread globally?

"Beginning preparedness activities when an epidemics hits is too late. Although the US has a relatively strong health system, we need to be better prepared for an epidemic, particularly by strengthening state and local health departments and connections with health care providers and facilities. But we can’t protect ourselves only within our own borders. Our biggest vulnerability is spread in countries with weak health systems – viruses don’t need visas. The US should double down on support for countries in Africa and Asia so the health workers in these countries can find, stop and prevent epidemics. In the US and globally, there are important and simple things we can do that will prevent illness now and also protect against coronavirus: improve hand hygiene (handwashing), cough hygiene (cover coughs), don’t expose others if we’re feeling ill, and improve health care infection control."

Tom Frieden is President & CEO of Resolve to Save Lives, an initiative of Vital Strategies, and the former Director of the US CDC and Commissioner of the New York City Health Department.

Can travel restrictions and quarantines stem the spread of the coronavirus?

Travel bans can’t keep all cases of the virus out of a country. As the epidemic expands, cases may originate in any number of countries. We may already have unrecognized cases in the US.

Travel bans can actually make us less safe. They can make countries facing restrictions not want to share information about their outbreaks. They can disrupt the distribution of supplies needed to control the epidemic. Similarly, as we saw with the US’s Ebola response in 2014, quarantining returning travelers makes doctors and nurses less likely to volunteer to serve in affected countries.

This virus is likely past the point of containment. We need to focus on mitigating its impact by speeding the development of diagnostic tools, vaccines, and drugs to treat infections.

Jennifer B. Nuzzo, DrPH, SM, is an epidemiologist with the Johns Hopkins Bloomberg School of Public Health’s Center for Health Security.

Are strong national health systems all we need for pandemic preparedness?

Strong health systems are certainly a crucial foundation for preparedness. All countries, rich or poor, need to have a set of core national preparedness capabilities. For example, they need strong surveillance systems in place that can detect infectious diseases with pandemic potential, robust case detection, and effective contact tracing (i.e., identifying and reaching those who may have been in contact with an infected person).

But that’s only part of the story. By definition, pandemics cross national boundaries—they are global in nature and they require a global response, not just a national one. A whole set of "transnational" activities, called global public goods, is another critical plank in pandemic preparedness. These require collective funding by all countries. Such goods include developing medical countermeasures like pandemic vaccines, diagnostics, and treatments, stockpiling of medical supplies (including personal protective equipment), and ensuring that there is global "surge capacity" to rapidly scale up production and distribution of vaccines.

Gavin Yamey, MD, MPH, MA, is a professor of the practice of global health and public policy and director of Duke University’s Center for Policy Impact in Global Health.

What do frontline health care workers need most when they face an outbreak like this?

Health care workers are our first line of defense against disease, whether coronavirus or otherwise. In order to safely and effectively do their jobs they need to both have proper training and the right protective equipment. This keeps them safe from infection in "peace time" and during a large outbreak like we have now.

Health care workers are often the first affected by these types of outbreaks and to some extent can act as a canary in the coalmine for how infectious a new disease outbreak is. In the past, health care workers have died from infections and also amplified initial cases spreading the outbreak quickly. If we are to protect health workers and limit transmission, we must do more to ensure the right training and the right equipment are available all the time and not just once an outbreak has started.

Health workers are making heroic efforts in China, where they have converged on the epicenter. They can only protect us if they are protected.

Amanda McClelland is the Senior Vice President, Prevent Epidemics at Resolve to Save Lives an Initiative of Vital Strategies, and has more than 15 years of experience in international public health management and emergency response.

What are the ethical considerations of using quarantines?

The tools of public health during suspected infectious outbreaks include limits or restrictions on the movement of individual citizens, ranging from travel bans, to closure of businesses and schools, to isolation of individuals in their homes, to forced quarantine in medical facilities.

The goal in implementing public health measures during suspected outbreaks is to balance the freedom of individuals against the restrictions on freedom required to achieve legitimate protections of the public's health, with public and transparent justification of policy decisions.

Whatever restrictions are implemented should be the least restrictive to accomplish the stated public health goals. Quarantine is considered a measure of last resort given the severe restrictions it imposes on individual liberty, and when misused or ineffective can severely undermine trust in government.

Jeffrey Kahn, PhD, MPH, is the Andreas C. Dracopoulos Director of the Johns Hopkins Berman Institute of Bioethics.