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'Science Over Stigma'

Feb 21 , 2020

Interview with Dr. Soumya Swaminathan,

Chief Scientist, World Health Organization,

on the outbreak of COVID-19

February 18, 2020

An audio recording is available here

 

COVID-19 icu.jpg

Introduction

The China Current continues its special coverage on the outbreak of COVID-19. Go to our social media @thechinacurrent and our website, for interviews, videos, and podcasts. I’m James Chau. Thank you.

James Chau:

When Dr Soumya Swaminathan was appointed Chief Scientist of the World Health Organization, she became the first-ever person to achieve this role. In the COVID-19 outbreak, she offers not only the skill and experience from 30 years in clinical care and research, but the ability to translate that into impactful programs shaped by equal parts of science and compassion. Last week in Geneva, she gathered the best in global science and R&D funders at a WHO meeting – as part of a wider action plan for the people of Wuhan, and beyond. But, as the weeks speed up, is there enough time to make a lasting difference? I called her in Geneva.

Dr. Soumya, thank you very much for interrupting your day to do this. I want to jump straight to the global research meeting you just put together at very short notice, but a very big and important turnout. Who came and what skill sets were you seeking to engage?

Dr. Soumya Swaminathan:

Thank you, James. Yes, even I was surprised by the kind of response and turnout that we had for this meeting. As you know, we planned it in less than 10 days, because we really wanted to ensure that the scientists and researchers around the world could help to tackle this outbreak. And so we had over 400 people that were invited. About 250 came in person and the rest were connected through WebEx, including a number of colleagues from China, and the head of the China Center for Disease Control and Prevention, George Gao, was connected for most of the meeting and made very important points.

So the whole idea was really to get this group of people together from all over the world, experts in different disciplines, including epidemiology, social science, vaccines, virologists, they came together here. The idea was really to first of all, look at the state of the art, what do we know about this disease or similar diseases? Secondly, what are the knowledge gaps? And thirdly, to really prioritize the research questions in order of importance, and which ones should be addressed urgently as opposed to which ones can be more medium to long-term. And then finally to discuss a governance mechanism, so that this global coordination and optimal use of resources to generate the answers that we need.

James Chau:

We're still at the early stages. But many weeks have begun to go by. What more do we know about the epidemiology of this virus, and how's that going to help us?

Dr. Soumya Swaminathan:

We're learning a little bit every day. And I think what we know now is that this virus... it belongs to the family of the SARS-related corona viruses. But it seems to be more transmissible human to human, than SARS or MERS corona viruses, but perhaps has a milder clinical course. So what we know now from 44,000 patients that were analyzed in Wuhan and presented just recently, that about 80 per cent of infections are mild, so you have symptoms like fever, headache, cough, fatigue, and then you recover. So a flu-like illness. About 15 to 17% can be quite severe, and about 5% end up with critical illness in ICUs, and there's a very high mortality among those who end up in the ICU with acute respiratory distress syndrome. But that's a small minority of patients. So we're learning more about clinical course, we yet don't understand fully the epidemiology, in terms of how easily it spreads. A number called the R-zero (R0) or the R-nought, which is how many people can be infected by one infected person, and the initial estimates were between two and three. And we're still going with those estimates.

But of course, this changes with the conditions with implementation of certain measures, etc. But you know, how it spreads... children are relatively less affected, only about 1% of people affected so far are children under 15, and they have a relatively milder course. So again, why? The older you are, the more the other diseases you have, the more dangerous this is because then you're likely to get more severe disease.

We of course don't know the source of this virus, which animal it came from, when it came, and when it jumped. The virus is closely related to several bat corona viruses that have been isolated from that region in China, southern China. And corona viruses, the bats have many, many types. So, it's likely that this originated in a bat. But then whether it jumped directly to humans or through an intermediate animal, and what animal that is, there have been many suggestions made, but no conclusive results on that. That's an important area of research. Unless we know that, we can't prevent further events from happening, spill over events.

And then clinical management: this was really highlighted by Dr. Gao. The two areas he highlighted as being of very urgent interest to the Chinese are trying control this outbreak, is a rapid diagnostic test, so that you can use the test out in the community, out in primary health care centers, and really diagnose people earlier. And the second was optimal case management. What's the best way? What's the standard way of managing people who end up in hospital? what combination drugs and supportive treatments? So these were two very urgent issues highlighted. And we're working on also a clinical severity score so that we can have a standardized score, which scientists across the world [and] clinicians could use to classify how people are doing in terms of being from asymptomatic all the way into severe illness and death. So that there's a standard way of looking at things.

We have a standard case report form that is up on our website. We're encouraging all doctors to use that case report form and submit the data to the World Health Organization, so that we can then gather a database and learn more from that. Then in the more medium-term are the clinical trials for both for drugs, for therapeutics, and even longer is for vaccines. Because therapeutics… there are a few protease inhibitors and antivirals, which in the lab seemed a good activity against this virus. And so there's a drug called lopinavir-ritonavir, which is an antiretroviral drug that's in clinical trials, and another experimental drug called Remdesivir, which was tried for Ebola, which was not very effective for Ebola, but which is now being tested in another clinical trial in China.

James Chau:

Should we be looking to innovate on an existing therapy, rather than starting from the ground up with a completely new vaccine in a sense?

Dr. Soumya Swaminathan:

Exactly. So what is needed now is a therapy to save people's lives and to prevent for the spread of infection. The vaccine as you mentioned, is a longer-term product that we might need if indeed this becomes an endemic disease in humans and if it becomes a disease like flu, which flares up every year, then people do need a vaccine to prevent this. But right now, the vaccine isn't going to come fast enough to have any impact. So what can have impact are the public health measures, the quarantine, etc., that China is already doing, and secondly, better treatments for people who end up in hospital with severe illness and that's where these clinical trials... there are over 80 clinical trials by the way that have already begun in China, that are registered in the registry, and despite all the pressure they're under they've been able to really initiate quite a lot of very useful research. We should get in a few weeks or months the results of some of these studies to show us [whether] some of these drugs are useful and protective.

James Chau:

My natural urge wants to ask you questions like, when are we going to reach a peak of the outbreak? Or how close are we to human trials for any candidate vaccines? Or how similar is this to becoming the new 'flu' going toward? But obviously we're not at that stage to answer those kinds of questions now. The speculation around those types of very broad, open questions, how far is that distracting from your work as a scientist and as the Chief Scientist at WHO?

Dr. Soumya Swaminathan:

I think those are all excellent questions, James, and that's why we're trying to focus on what is important now - versus what is important but interesting to know, but is not going to have an immediate impact. So what is important now is best ways of protecting people from getting the infection including healthcare workers. We've seen a huge number of healthcare workers get infected in this outbreak. It's really unfortunate. And we must find the best ways of protecting healthcare workers, and of course, family members and friends from getting infected.

In terms of when is the peak, I think we have to wait for a few more days or weeks. What we do see now is that the number of new cases in Wuhan has stabilized. For many, many days now, we've seen a slow reduction in the number of cases being reported daily. The number of deaths is still quite high. It's too early to say whether this is the beginning of the downside curve of the outbreak, we have to wait. But we're hoping this would be a good sign. Of course, we also don't know what's going to happen in all the other countries where this virus has already entered, and whether the containment efforts, heroic containment efforts, being put in place now would keep it limited.

James Chau:

What are those "heroic containment" efforts you refer to?

Dr. Soumya Swaminathan:

Many countries have set up quarantine facilities, and anyone with a history of travel is being quarantined and tested, and then there's contract tracing: people who come into contact with people with diagnosed virus infection are being actually traced, and found and tested. And most countries where cases have been reported, have done it. Africa is one continent where we've only seen one case being deported from Egypt so far [as of February 18, 2020]. Labs across Africa, about 17 labs, are now equipped to detect this infection, and testing has started, but probably not as widely.

They're not covering as wide a net as some of the high income countries are doing. In terms of whether we will ever need a vaccine - again, that question cannot be answered today because we don't know the trajectory that this outbreak is taking. This virus, maybe like SARS, in that we're able to contain it and it doesn't come back. Or it could become a lingering human infection that just stays. Many of these viruses do change their characteristics. Once they become established in humans, it could get milder, it could just become another virus that causes a common cold, or it could still continue to cause severe illness. So a lot of open questions which will be answered with time.

James Chau:

Dr. Tedros, the Director-General of WHO, declared a public health emergency of international concern precisely for the reasons of protecting countries with weaker health systems, and also to exercise the ability of PHEIC, which is to monitoring engage your member states, so that they take appropriate levels of action. Are we seeing solidarity in science across those fronts?

Dr. Soumya Swaminathan:

We're seeing absolutely unprecedented global solidarity, James, as far as the desire to do something to tackle this new virus. I think that the world's scientists have really taken it upon themselves as a collective challenge to their skills and their resources. And so what we saw at the two day meeting here in Geneva, and subsequently we've had the research funders, we had about 25 research funders here, health research funders, and they all agreed to coordinate and collaborate in terms of funding the high priority questions, and also in terms of sharing what they're doing, who they're funding. The other thing, the [science and medical] journals around the world have responded by opening up preprint servers. So that manuscripts are being put on the server well before they are peer reviewed or published, and this was a call that went out from WHO post-Ebola outbreak because scientists were keeping data to publish later. This time it's been very different.

James Chau:

You're the central funnel, so to speak, where all those [scientific] papers are now going through, am I right? And I understand that paywalls also coming down on coronavirus-related content in journals like 'Lancet' and 'Nature'.

Dr. Soumya Swaminathan:

Yes, exactly. Paywalls have come down. Most of these journals have a page devoted to coronavirus, open access. We have access to all the preprints manuscripts that are being submitted. And there are many now pre-print servers around the world. Even the 'WHO Bulletin' put out a call saying we will encourage publication on this topic to be sent to us, so that we can put it on a on a on a server for open access. And it's not only that open sharing of data.

One other thing I want to mention is the sharing of the genetic sequences because that's been critical to this outbreak. If China had not shared the sequences of the first six genetic sequences we had on an open platform, the world would not have been as prepared. Because within a few hours of those sequences being shared, labs around the world were able to create diagnostic tests to test people in their own countries, and vaccine companies and academics working on vaccines were able to create constructs. So within a few days, we were hearing about vaccine candidates, which would never have been the case in the past, and it was all triggered by the early sharing of the sequence data.

James Chau:

We keep on hearing about the emergency hospital in China taking 10 days exactly to be built. That's incredible. But it took you only around that same amount of short time to get the best of the world into one room physically and virtually, to help lead them on an important discussion and a work plan. The question is what's going to be the legacy of those two days together? And also, what are your next steps in terms of your priority streams for this outbreak?

Dr. Soumya Swaminathan:

So we had nine workstreams during the meeting, so we had some plenary discussions and then we had working groups that went away and came up with a plan. The working groups were in topics like animal reservoirs, epidemiology, and transmission, infection prevention and control, therapeutics, vaccines, social sciences and ethics. So on Friday, which was two, three days after the meeting, we put up the initial summary of the meeting report on the website. By this Friday, so a week from then, we will have the full meeting report with all the working group priority research questions. And by the end of the month, by the end of February, we should have a research roadmap.

The research roadmap will lay out the priority research questions in each of these areas, and also address some of the cross-cutting issues. And that will enable both scientists and academics, but also funders, to converge around those topics, and set up collaborative research programs. Now it's absolutely key that we have Chinese doctors and researchers. So we ensure that each of the working groups will have several Chinese scientists and physicians from the ground because most of the research at this time is being conducted in China. So we have a timeline to produce the roadmap, and what we hope to do is guide research funders and direct them in areas where this global scientific community has agreed to come to a consensus on what the top priorities are.

James Chau:

Can we briefly touch on the naming of COVID-19. COVID obviously means ‘corona virus disease number 19’. I just want to ask you about a very important aspect of that, because naming of viruses are also linked to preventing unnecessary stigma. How does that work in this particular case?

Dr. Soumya Swaminathan:

Yes, that's a good question. In fact, that's why we took a little bit of time to name this virus. Because there are certain principles established for naming of diseases in the past we've had infectious diseases named after the city, or the place of origin, Ebola Zika, etc. and sometimes even bacteria etc, named after cities, stigmatize it. It does stigmatize a certain place, or a person, or a community. So that was to be avoided in all cases and it has to be factual, descriptive of the type of disease, and easy for people to understand and to pronounce, and short enough so you can record it. It's mainly for the International Classification of Diseases, so that when a diagnosis is made, you have a clear description, and it's coded.

So that's why we came up with 'corona virus disease' and then there's a 'hyphen 19' because this disease was first described in 2019. And there is a possibility that there will be more coronavirus, diseases, newer types of diseases that might be described later. If there are new corona viruses that end up causing human disease sometime in the future, you have the possibility of saying 'corona virus disease 25 or 30'. So, that's why the '19' was added on. The virologist named the virus and WHO names the disease. So there's a difference in the way that it's done.

James Chau:

I have to finish by asking you about bringing science to the people because that's what you do. You break down very complex ideas in ways that we can really understand and apply them to our own lifestyles. You went to the Munich Security Conference to carry not just a message of science, but you went there also to carry an urgent message for the protection of health workers and the communities that they serve. What's the last thing that you would want everyone listening and watching this to keep in mind going forward?

Dr. Soumya Swaminathan:

I would say that this is a new viral infection. We've known now for some time that the world is going to have more viral infections, and that most of these are going to from animal sources. And so we need to be prepared. I think it's a good test for us as a global community to prepare ourselves for these types of outbreaks, especially if they are through the respiratory route, and they can spread easily. But I think what's important is to avoid panic, to avoid fear, and most of all to avoid stigmatizing and stereotyping a certain groups or communities of people. Because these infections can affect anyone, anywhere, they can arise anywhere, it's a matter of chance that it came in China. This time tomorrow, it could be arising in some other country.

And so I think it's more and more important that we look at this as a test of global solidarity, global strength, and global preparedness. Because as Dr. Tedros often says that we are only as strong as our weakest link, and so it's not just enough to strengthen ourselves within our borders, we need to ensure the world is prepared, that everybody is equally well prepared. And so I think that's where we need to focus now perhaps more focus on the weakest areas in the lowest-income countries to ensure that they're protected against this outbreak, but also and very important, be prepared for what we described as a 'Pathogen X' - the unknown disease that is sure to come again one day. This COVID-19 turned out to be Pathogen X, but they're going to be more Pathogen Xs in the future. I think we need to pay heed to preparedness for that, both in terms of scientific preparedness, but also in terms of public health preparedness.

James Chau:

Dr. Soumya, thank you very much for applying your skill and experience to this very important response. And thank you to everyone at the World Health Organization - not just for being a technical agency, but also being the humanitarian one as well.

Dr. Soumya Swaminathan:

Thank you, James. Pleasure talking to you.

 

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