Updates on the COVID-19 Crisis from April 3, 2020

Good morning or good afternoon. We have an incredible guest with us. I know there is absolutely positively no shortage of questions when it comes to coronavirus. And so we have brought one of the world's leading experts onto the call today to answer many of your questions. So I'm thrilled to be able to share the screen with Dr. Larry Brilliant. If there was ever a person who is able to help lead us in better understanding the dynamics of a global pandemic, I assure you it is Larry. For those of you who do not know, he's a leading epidemiologist who helped eradicate smallpox, the only human disease ever to be successfully eradicate, eradicated. So, you know, he's got that going for him. He's a technologist, he's a philanthropist. He's the author of Sometimes Brilliant, and he has made Time magazine's list of the 100 most influential people in the world. He's also currently the chairman of the board of Ending Pandemics, a nonprofit focused on finding outbreaks faster in emerging disease hotspots. And he is a salesforce.org board member.

So.

So he is a very close member of the Ohana. If any of you saw the movie Contagion, that was all of his work. And it's certainly having a resurgence of popularity. I wonder why. So, anyway, today this is going to be all Q and A. Thank you for all of you who submitted your questions in advance. We're going to try to get through as many of them as we can. And so, Larry, welcome. Thank you. Thank you so much for joining us. So let's just kind of start off at the top. Can you give us all an overview of where we are at right now with this pandemic and how did we get here?

Well, first of all, in my introduction, the number one part is that I am part of the Salesforce Ohana and thrilled to be it, and thrilled to be a friend of Mark an fom, as we say. So we are now at. I mean, yesterday was a day that will live in infamy. I think we passed 1 million cases of the disease, 55,000 deaths. A quarter of all the cases are in the United States. The countries with the leading number of deaths right now, Italy, 13,000, 14,000, Spain, 11,000, the US 6,000. We have other countries, other states that are increasingly at risk. On a state by state basis, New York, with 5,000 deaths, already is at the top of the list, followed by New Jersey with three, and then Michigan, where I was born, 1,000 deaths. If we look at it from a Satellite, you know, or some kind of a time machine. The next three weeks for people in California, the next two weeks for people everywhere else in the United States, and probably about the same time for Europe, for our personal health and our family's health, these are going to be the most important weeks in our life. The first crest, the first wave, the first of many waves in this rolling tsunami, which we call a pandemic, will crest, according to the modelers, on April 15th, and that's two weeks away. And since it takes a little time to incubate the disease, perhaps six days, five days, could be as long as two to 14, but realistically around a week. And then it takes a week to get sick. What you're most worried about is will my sickness intersect with the peak demand in my hospital for an ICU bed, good medical care, a ventilator if you need it? And so that's the moment we're at right now. Anybody who gets sick now is going to run into traffic when they try to get medical help. So if you've been socially distancing, double down for the next week or two or three, if you haven't been, as much of the world has not been, or if you've been practicing Swiss cheese social distancing with big holes in it, or laissez faire social distancing, as they did in Italy and in Louisiana and New Orleans. This is not the time for joking around. You can joke around after three or four weeks, maybe begin to think about writing a joke. But this is not a joke. And why it's not a joke is that you've heard it called a novel virus. Novel means that nobody in the world is immune. Novel means it's not like a novella. It's not like the fictional virus that we made up for Contagion, the movie. It means that our immune systems, in the millions of years of evolution, the hundreds of thousands of years of human evolution, our immune system, have never faced this virus. Each of us has a little library, an archive of all the viruses that our ancestors ever encountered. We inherit that as part of our genomic heritage. And so we've got a tool in our toolkit to deal with every virus that our ancestors have ever inherited. We don't have one for this virus. That means that if there are 8 billion of us in the world, plus or minus, there is a potential that this virus will infect 8 billion people. Now. It won't. It won't because of the three things that govern its speed. The replication value, which we call affectionately r Naught. And unless you've seen Kate Winslet say R naught in contagion. If I say it, it's really wonky, but it means the number of secondary cases that each case creates. For this virus, it's somewhere between 2 and 3. 2.4 is widely quoted. There are people who say it's going to go down, people who say it's already gone up. But it is a movable, movable number, and it is the exponent. When we say that this virus is growing at exponential speed, the exponent of that exponential speed is this number. So it's one case goes to 2.4, and then you multiply that by 2.4. You go on and on like that. The second thing is, how often do you do that multiplication? And that's the disease interval, the generational interval. It's pretty much the same as the incubation period, which is probably five or six days. As I said earlier. Yes, it can be two days. Yes, it can be 14 days. Yes, there can be asymptomatic spread. Yes, you can get it by fecal contamination or by sexual intercourse or by blood. But those things are not of epidemiological importance. Neither is a case that gets infected in two days or 14 days. But focus on the big picture. This virus is spread exponentially at an exponent of 2.4 every week and then the next. And the most important part of that equation, for the quants, the most important part of that equation is the density of susceptibles. If you're in Manhattan and nobody's ever had the disease, then you've got a high density of susceptibles to begin with. So there's nothing to stop the virus from multiplying exponentially with an exponent of 2.4 and an interval of a week. That's why you see explosive growth in Manhattan. If you're in Manhattan and everybody's vaccinated, it doesn't matter that the virus wants to grow at an exponent of 2.4 or an interval of five days. It can't, because there are no susceptibles because everybody's been vaccinated. Likewise, if everyone practices social distancing, there are no susceptibles, even though it's a high dense population. Likewise, if everybody has had the disease and is immune, the epidemiologist's golden ring, and you reach herd immunity, then the density of susceptibles is zero. So whether you think of being able to take the exponent from 2.4 down to zero because everybody's vaccinated or everybody is at a Safe distance away with gloves and a mask, or everybody's vaccinated or immune from having had the disease before. That's how we stop this thing. And in fact, we really only have to take that exponent down to one. So this is all. It's either too wonky or, or too simple for you. I don't know, you know what your level of interest, paranoia, obsession, slash, you know, is right now. But that's sort of the math that's undergirding where we are right now. One million cases. It's not clear to me that there are enough speed bumps in the path to stop it from going to 1 billion cases. That'll depend on how quickly we get an antiviral that has vaccine like characteristics or a vaccine. I'll stop there and.

Okay, I have like a million questions. Okay, let's pick up where you were just where you were just kind of ended there about the vaccine. How realistic is it that we're going to find a vaccine soon and then I guess once we find a vaccine, typically how long does it take before you can really slow it down?

I'm only aware of three important failures to make a vaccine really. I think hiv, AIDS, because the virus attacked the immune system itself and therefore undercut any effort to make a vaccine. Malaria, because you're dealing not with a virus, but you're dealing with a parasite inside of a mosquito. And when people get it, it's very difficult and has proven very difficult to make a vaccine against malaria in sars, the first type of the coronavirus that hit. And that's because we gave up because the SARS outbreak occurred. It died out except for Toronto, where Toronto had to be totally quarantined. The whole city. But other than that, SARS died out. And SARS died out. The same reason that mirs died out and same reason that Ebola usually dies out. The virus chose a evolutionary strategy that didn't work, which is to kill a lot of people. It is in the virus's best interest, if we think anthropomorphically, it is in the virus's best interest only to kill a number of people that get your attention, but not enough that stops its spread. So I see no reason why we won't have a vaccine. It's an RNA virus, it's large, it's about 0.3 microns and then it has this kind of sloppy membrane around it and an area of fat in between the membrane and the virus. And, and that is really good for making a vaccine. It's got these spikes which give it the name corona or crown. These spikes have recognizable points on it. The virus likes to latch in at a particular part in the cell which called the ACE2 docking site or the ACE2 receptor. We know all about that receptor. We make drugs to clog that receptor for hypertension and for antivirals. So this virus is not mysterious. I think if you remember how long it took us to make a vaccine against Zika, I think that's a reasonable thing to look at. Or Ebola for that matter, I guess. And we already have four or five good candidates that we're looking at right now. We will have a candidate good enough to put into trials and less than two months, maybe even less than that. Now comes the arduous challenge of finding out how can we prove that this virus is safe. You may remember the problem we had in 1976 with swine flu when the vaccine seems to have created Guillain Barre's disease. We can't do that. We can't make a billion doses of this vaccine and even a small number get neurological disease from it. So will it be safe? That'll take a bit of time. And then is it the effectiveness of vaccine A that we're trying better than the effectiveness of vaccine B? And are either one of them at a high enough level of effectiveness that'll stop the disease with herd immunity? So that's what's going to take 12 to 18 months now. Maybe we'll be faster. You know, God knows everybody is trying to do it. There's tons of money chasing it, smart people. I'm optimistic we will have a vaccine in a shorter time than ever before, but that's the length of time would take. And then I just wanna add on one more thing. The sun does not rise and the demons disappear the moment you have a vaccine. Vaccine distribution is not distributed evenly. We don't have very many vaccine manufacturing places in the United States. So there will be a bit of a great powers competition trying to get that vaccine. We have it and then once we have it and many people have been vaccinated and we can now see then because of vaccination, which will be available, testing which will be available then, then we'll be able to see where the hotspots are. Then we need to have a global program, hopefully run by who, which is like the smallpox eradication program or the polio program, to go and find every case and put a ring of vaccine around it and then begin the final phase of defeating this virus. So if people are telling you it's all going to be over this summer. They're misleading you or they're just misinformed. I am planning two years, maybe a little bit more. It doesn't mean the world won't come back to normal before then. We live in a fraught world all the time. We deal with dangers all the time. We are a very resilient species. We will figure out a way to live. There will be love in the time of COVID like there was love in the time of cholera. But that's going to take a little while yet.

Okay, so one of the things that you had said before, I am clearly no epidemiologist, but one of the things you had said before was that this was an RNA virus. And somewhere along the way I had heard that an RNA virus mutates really quickly. Do we think that we're dealing with multiple strains of this right now? And if that's the case, do you need multiple vaccines?

Yeah, terrific question. No, this virus doesn't mutate like the flu virus, which changes its entire genome 3 or 4 or 5% every day, which is one of the reasons why it's so hard for us to get a flu vaccine. You have to kind of guess. What did Wayne Gretzky say, the famous hockey player? He said, I don't go where the puck is, I go where the puck will be. Will be. The vaccine manufacturers have got to go where the virus, the influenza viral genome will mutate in six months when they start making their vaccine choices. This vaccine seems to be very stable. Of course, every virus, sorry, this virus, every virus mutates constantly. But this virus is not mutating in a way that is making multiple, importantly differentiated strains. That would give us pause that a vaccine would have to be multi antigen or change very often. Now you want the virus to mutate a little bit. And for those of you who are, you know, biologically inclined, this just means genetic shift or drift or it'll get into a mixing vehicle and reassort, which is much more dangerous. But you want it to do a little bit because that allows you to track where the person in front of you's disease came from. So you can actually see if you plot out the genome of four or five different patients, you can see which one came from the other, and you can see if there's a space missing that you've missed a whole different outbreak. We're not at that level of specificity now because we erred and didn't have enough masks, didn't have enough test kits. Most governments, maybe with the exception of Germany, have not been prepared well enough to give us a chance to practice the best epidemiology. We're now we're on our back foot because the. In the United States, because the federal government and in the UK have disappointed. But, you know, we've got a lot of tools, and I think that our side, if that's the case, if it's that metaphor, has really built up a lot of arrows in our quiver.

So what about. We're starting to hear a lot of talk about, like, this is going to come in waves, you know, that, like, we're going to. We're going to hit this peak in three weeks and maybe we'll come down from it, but then it's going to come back again in November. Can you speak a little bit about that?

Yeah, it's inevitable. In 1918, great influenza had three such waves. And part of it is that even though you have succeeded in slowing down the virus by social distancing, and the curve begins to dip, you've not produced immune people. They haven't been sick enough to become immune, and they haven't been vaccinated. So what you're doing is you're pushing the epidemic curve to the right. You're delaying what would have been a very sharp peak. And I'll come back to that in a second. You're not actually reducing the number of cases that potentially would occur. So for those that you calculus, if you look at the area under the curve as an integral, and each of those squares is a case, when you change the shape of the curve from this to that, the area is the same. Why do we do that? Because if you move it out there, this is where you'll have a vaccine. And so those cases will actually never occur. So in that sense, yes, you're reducing the number of cases, but just the act of social distancing, it slows down and smooths out the curve. But why we do that is so that in this terrible period that we're facing, the only thing that kills people is the virus. And that means if we don't do that, I'll let that truck pass. It shouldn't be there. We're socially distancing. I don't know. They're gonna get in trouble.

They're messing with the wrong guy.

All right? So.

It'S okay. Just talk.

I think it's passing now. So by pushing it out, what you're doing is making sure the only thing that kills you is the virus kills people is the virus. Instead of if it's like this. Well, when you're at this point, every hospital is jammed and closing its doors to the person who's just been in a horrific traffic accident. So they're not going to get treated, they're going to die from their wounds. It's closing its doors to somebody who has a heart attack. They're not going to get treated. Cancer patients, women who are having a difficult labor, difficult childbirth, they're not going to be admitted in. People won't get chemotherapy. So all the normal things that we need, our health care system will be absolutely taken over by these peaks. Whereas if we smooth out the curve, then the hospitals have a chance to not only get better care, but to not reach the absolute congestion because we don't have surge capacity. I mentioned to Jodi earlier that I maintain a Twitter account. Larry brilliant. Larry, brilliant on Twitter. And I try to tweet out all these curves and all these graphs so that people can kind of, you know, we're going to have to develop a new vocabulary, a shared understanding. We're going to have to be kind to each other and love each other and be compassionate and have the same vocabulary so that we understand why we're doing this. We are not trying to flatten the curve because we think that we're not in denial of the fact that flattening the curve, it doesn't reduce the number of cases, it pushes out those cases until hopefully the cavalry arrives in the form of a vaccine or an antiviral that has vaccine life qualities.

Okay, I'm going to ask you one more loaded question and then I want to just rapid fire a few quick pointers for you. But the loaded one is just there's so much talk around testing and like how testing is being administered. And I'm just curious to hear your thoughts around the importance of widespread testing and also if there's going to be an ability to test people who may have already had it.

Right.

And they recovered from it and then I guess follow on to that even is that if that was the case, are you then immune to getting it again?

So let me take the last question and then move to the first. Yes, I believe that if you have this coronavirus, it will be the same as other coronaviruses, not the coronaviruses that cause colds, but the SARS and the mers. And I believe you will be immune. There's clearly anecdotal evidence to the contrary. There are some people who report case reports in literature of people who were sick. They were tested, they were positive, they were treated they were negative, they went home and they were tested and were positive again. Now, that could have been a test failure. That could be mistaken, or it could be that the virus persisted for a while. But I do not think that is of epidemiological importance. I offer as evidence the fact that we have had 1,052,990 cases and we have no evidence of that having occurred, certainly not in any number of epidemiological importance. So not worried about that. As far as having immune individuals who are badged with a coachella like wristband or a card with their photo ID on it or some other way of identifying them because they've had a serological test that shows that their body has made antibodies to this virus. The only way you can make antibodies is if you encountered the virus. And nine out of 10 times it's because you're immune. Unless your immune system is not adequate. We need to have that. That is more important than people think. Because for you and me, we're only going to begin to feel normal when a school teacher can go back and class, because they are not going to infect our kids. Or a nurse can go to the hospital, they're not going to infect the patients, or, you know, social workers or home healthcare providers can go see my mom and grandma and we're not gonna worry because they're badged. So it's just, it's a serological test.

Are people working? Are people thinking about that like, I.

Need a bracelet or just beginning, just beginning late. But we've got a really good committee now headed by Harvey Feinberg, which is a committee of the National Academy of Sciences in the United States that is now pushing the administration to be more science based with plus minus, but some good success. Tedris, the DG of who, who's an Ethiopian doctor is just absolutely wonderful. I know him very well. He's one of the. I would trust him with my life. He's a very good and special person. So we're getting to that. Now, the first question you asked when I worked on the Smallpox program, we could eradicate it because every single case had smallpox on their face. So finding them and knowing that that was smallpox was an easier task. So here first, you never have the disease on your face. You have a long prodrome, a period of time before you get sick enough to get either loss of taste or smell or the cough or the red eyes. Under that are the early indicators high temperature. So it's just the only way we know that you've had or do have the disease is a test. And if it's a simple test of do you have the virus for viral particles, that's the test that should be able to be done in five or 15 minutes. And while not yet at home as a home test, it's now available for, for use in point of care in medical institutions. Look, I think we should have in the United States 300 million tests because I think 100 million people are going to want to take them more than once. I think we should flood the zone with tests. In fact, the failure to do that is going to. History is going to look back on this administration and our response and say that was the single biggest failure, is not having tests that were you available. We are like a prize fighter in a ring with five kickboxers coming at us from different directions and we have a blindfold on.

Okay, great. A couple of quick questions because we're coming up to the end of our time here. Should we be wiping down our groceries when we bring them in the house?

So far, no evidence of spread from groceries. A lot of attention paid on it. It won't hurt. You know, get the wipes that are approved by the EPA or by the. By OSHA in the United States. By who outside the United States? I think wiping down things like the cart when you go shopping is really important. I think you should wear a mask when you go shop.

That was my next question. Should we all be wearing masks? Like just, just. If I go out on a walk, should I wear a mask?

Yeah. Well, on a walk, if you're six feet apart and you know, in the forest, I don't, I don't know that you need to do that there. But, you know, practice prudent measures. If you're going down into the city, if you're going to go shopping, if you go pick up your medicine at a drugstore, which should be the only reason to go out pretty much right now. Yeah, wear a mask. What I recommend is getting one of these reusable mask that you see that even protesters wear sometimes. They're not going to protect you from everything that comes in. They're mostly going to protect you from touching your face. So that if when you go out, you touch somebody or somebody does have droplet spread, it's going to be on your hand and then you put it to your face or your eye. The mask protects you from that. It telegraphs to people a little kind of, hey, I'm serious about this. Reminds you. And I would get two of them so that you can wash them. Reuse them. And while the other's drying, you're using the other one. If you don't do that, I would get disposable surgical masks. These are the three ply masks. The reason I say don't use the N95 is because they're in scarce supply and we want the people, health care.

Workers to have them.

But when the supply ends. When the supply. The supply problem ends. I would suggest that you use N95 when you're going out in an area that you could be exposed. Okay.

This has been incredibly helpful, and I am very, very grateful that you've joined us. And I would love to invite you to come back and speak with us again. Maybe as things keep progressing, you could come and update us. That would be great. Listen, everyone, I know this has been a lot to kind of digest and to take in. I think it's important that we have the right information, and we're getting it literally from the world's leading expert on this.

Could I.

Yes, please. Absolutely.

There is a magic medicine for the depression that we all face. Give some money to your food bank. People who are homeless, they can't afford to go out and binge and hoard. Think about somebody that you're mad at from high school, Call them and re establish relationships. And virtual hugs are really wonderful. Give them to everybody that you think is hurting. And you will find that that's a magic medicine. That's the. That's a much more powerful medicine than anything else on the shelves.

Well, Larry, this is my hug for you, man. I'm so glad that you're ohana. Thank you so, so much for being with us. And we will see you. Yeah, thank you. And we will see you again soon. Okay, thank you. Okay, bye.