You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Phyllis Kanki, the Mary Woodward Lasker Professor of Health Sciences in the Department of Immunology and Infectious Diseases. This call was recorded at 11:30 am Eastern Time on Tuesday, May 5.
Previous press conferences are linked at the bottom of this transcript.
Transcript
PHYLLIS KANKI: I’ve been working in Africa, primarily Nigeria, but also Tanzania and Botswana on HIV for many years trying to roll out the treatment programs there. And then, of course, had to deal with a variety of emerging and reemerging infections that would crop up in West Africa. We have lots – in 2014 we had Ebola and because of the outbreak of SICA in the Americas. I started studies to work on seek of ours there so I spend a lot of time in Nigeria, maybe eight or nine trips a year. So, this is a new normal for me to have to work from my computer screen and try to manage our projects that are ongoing there.
Nigeria has been locked down for, partially locked down for about five weeks and some very serious lockdowns in some of the big, urban centers like Lagos and Abuja and a couple of other places that had lots of cases and they’re just coming out of that with the recognition that they couldn’t stay locked down, but they were just trying to limit the amount of transmission. They’ve got pretty robust contact tracing which they know how to do. They did very well in the Ebola outbreak, they only had 20 cases and people were really concerned that a population like Nigeria, about 190 million, would really blow up with one of these readily transmissible viruses. So, there’s a lot of concern. There’s a lot of government engagement.
I’m also working with Africa CDC, which is part of the African Union based in Addis, and they’re trying to coordinate the Africa response with 54 member states. They have lots of guidance different working groups dealing with testing or messaging. They have lots of brochures and educational tools and they’re well-coordinated with the WHO and do regular reporting. So, they’ve really taken on an important leadership role, they’ve done this in the past with things like Ebola and were very important in the DRC’s recent outbreak that is just sort of petered out recently. But they’ll take on a very important role for the COVID outbreak on the continent. They’re coordinating some massive contributions that initially came in from Jack Ma, who has provided a million tests for the 54 member states, and a lot of personal protective equipment, swabs, extraction kits, gloves, masks.
So, they were sort of jump started in that response. And I think that really helped, but it’s not easy to get everything to all the states. All of the states are in sort of different phases of the pandemic but South Africa, Nigeria have some of the larger numbers in the four or 5000s. And then there’s some countries that still have very small numbers, but they’re really limited in the amount of testing, they can do. So, I guess I’ll stop there.
MODERATOR: Great. Thank you so much, Dr. Kanki. First question.
Q: Hi, Dr. Kanki, I’m wondering if you can talk about your assessment of the progress of the COVID pandemic in Africa. I’ve hear a number of different theories of why the numbers are relatively low from a lack of testing to demographics with a large young population. And I wonder if you could just sort of give us your sense of where you think the African nations are in the course of this pandemic.
PHYLLIS KANKI: Yeah, I have also – obviously, the amount of testing is going to be important. I also think that the population structure being a larger proportion of young folks might make the transmission slightly different. And there are a lot of other health concerns and probably differences in cultural differences in what we call health seeking behavior, what people consider to be something that they need to go to the doctor or go to a hospital. Remember these are places that have significant endemic diseases, people regularly have malaria, there’ll be flu in some parts of the continent, and respiratory illnesses like flus though are probably not what we see in the West, where you see it in the winter seasons because Africa doesn’t have it.
So, there are a lot of different environmental and sociological differences in these populations that may make the epidemiology of the outbreak different. I mean, people wondered why there were not more cases because there was so much international travel going in and out of the continent. And what we did in fact see was not so much transmission from Asia but from Europe, and even the US. Those were some of the reported first cases that people have seen and then a pretty rapid response, I would say because they had the benefit of seeing what was going on in the rest of the world. Of contact tracing. They had emergency operation centers called EOCs that were activated in Nigeria, you know, in February you’d say, well, where they ready that the EOC was already activated because they’re tracking cholera and loss of fever, so you don’t have to eat. You’re already activated. You already have states around the country.
There’s 36 states that are reporting these diseases and that’s a real jumpstart you may not have all of the tests, but they had testing centers with kits, you know, in February. Not a lot, they had four, now they have 20. And they’ve ramped up their testing to the extent that they can. It certainly will never be like the state of Massachusetts, but they’ll have to do with what they can and I think they’re showing a lot of resilience and patience in trying to get there.
Q: Are you anticipating, you know, a coming surge like we’ve seen in other places, or do you feel that it’s kind of being managed? I mean, are you looking forward to a peak or are we on a plateau, any sense of that?
PHYLLIS KANKI: I think some countries will probably see something like a surge and the countries I would worry about would be something like South Africa or even Nigeria that have, you know, 5000 cases. There’s still countries that have very limited amounts and if they’re able to really identify those cases and isolate them, they should be able to limit it so that it will be, you know, like some of the states we have here in the US where they have very few cases. And it looks like with border control and public health measures, they’re going to be able to maintain that status.
Q: Yeah. Very good. Thank you.
MODERATOR: Next question.
Q: And thank you so much for your talk. I wanted to see, and I think the previous question has touched on this a bit, what is the role of how, can we call it ‘literacy around pandemics’ or epidemiological literacy among populations in Africa, populations that know what the impact of an epidemic is, that have either suffered or have dealt with various kinds of epidemics in the past. I mean yesterday, for example, I was looking at the paper and I see a bunch of people in Central Park hanging out one next to another, as though what’s happening in New York isn’t happening to them. Do we find that these countries can teach Americans a bit as to the importance of having community understandings as to the gravity of these diseases?
PHYLLIS KANKI: Yeah, that’s an excellent point because, I do think that many African nations, as I was trying to allude to our sort of dealing with outbreaks on a regular basis and so their literacy is quite high. And, in general, I would say they’re fairly responsive to public health measures. Obviously, you have problems like in the DRC where you had an Ebola outbreak, but you still had military that were attacking the healthcare facilities and creating a situation where patients were afraid to go to be tested and treated, so there are exceptions, of course, but I would say overall because many of these countries are regularly experiencing outbreaks and understand the consequences. HIV of course is another example. It’s a different kind of disease, but the whole continent was overwhelmed with people who were dying of a very dangerous viral disease.
So, I think that history has taught those people quite a bit about how to respond. And I think their health care system, while it may not be as sophisticated as the West, they do sit on a pretty firm foundation of public health, which serves them well because they have limited resources.
Q: Just as a follow up to that. I mean, it, it seems fairly obvious that most African countries can’t follow say the Chinese model where you’re going to have zero transmissions nor can they really follow the European or American model where you can really ramp up your health systems to the point where you can survive this way or the next waves. But it does strike me that there’s a potential for protecting vulnerable populations. Is that the way to go? If not, what other strategies are available with countries that have these limited resources?
PHYLLIS KANKI: Well, I think early responses and the easy responses that they can do early are important. So, you know, they started in February and March to put handwashing stations in these rural areas, for instance, because they didn’t feel that there was adequate handwashing and they’ve started in urban centers very early to have basically lockdowns which they will ease back and then they’ll roll through in other places. So, it’s those are things that they can do.
It’s a sacrifice for the folks that have to be locked down because many of them are on, you know, hand to mouth so they’re going without but they won’t be able to maintain a lockdown situation immediately. They closed borders very quickly, and they’re setting up a big isolation areas, much as what was done in in convention centers and things like that in Europe and the US. So, they will begin to isolate. My experience with them during the Ebola outbreak, they had one case that came in from Liberia that that spread on to be 20 cases. They locked down that transmission in the one hospital where the initial patient was seen. His personal assistant moved it to Port Harcourt, but it was basically a lockdown in Lagos, and what was important there was that they actually did about 900 contact tracings and a huge amount of education in the community to avoid stigma, etc. So, they were able to mobilize quite a bit over 20 cases in and I’m really not sure that could have been done so readily even in a place like Boston.
Q: Just last follow up. I’m sorry. We’re looking at several models of transmission in the United States, in Europe, of course, there’s the model in which you have a first wave and then a huge second wave that comes later. What kind of modeling has been done for Africa? And what’s the model that you think is most likely to take place over the next year or so?
PHYLLIS KANKI: I think it’s going to be different for different countries based on how many cases come in and if those numbers can be maintained for long periods of time. In some of the harder hit countries, you’ll probably see some of these recurring waves, which is what people saw in the Spanish flu, but we really can’t say, and I don’t – I haven’t seen a lot about modeling in Africa. I’ve seen it based on international air travel, for instance, but I think most of the modeling that I’ve seen has been taking the Asia data and then trying to mirror that over to the US and Europe.
Q: Thank you very much.
MODERATOR: Next question.
Q: I have a few questions about the predictions and how reliable, you know those models that you was talking about. Because, you know, we’re talking about 30,000 deaths in America than 60,000 and you know 200 thousands. So how reliable those predictions on how we can trust the models that you know different research groups gave us?
PHYLLIS KANKI: I don’t, I don’t think we can – I mean, I personally don’t put a lot into models because there’s so many assumptions that you have to really get around. And I think frequently the data that supports the models just isn’t there, so I would be very hesitant to take model data that was based on one setting and then just referred over. What we can use models for is in interpreting what we’re beginning to understand about this new virus. So, how much asymptomatic infection there is. It appears that there’s quite a bit and that asymptomatic infection basically will provide a little bit of a buffer, a protection to the population so you won’t overtax your healthcare system and you’ll have, you know, two in three or three and five of all cases be exposed and perhaps partially protected, but they no longer become the susceptible.
I think the thing that I worry about because I come from a background of HIV is that you have huge numbers of people who have another disease. They’re being treated for it, but they may not always be taking their pills. So, they’re basically a little bit potentially immunosuppressed that’s not good. That might counteract the fact that you have more young people that might be a little less susceptible to infection. So, there’s a lot of differences about the continent. And, in addition, what I mentioned early on as the differences that they have in quote health seeking behavior. I think they may not go to hospitals as often, but they may be willing to social distance, wear a mask, wash their hands because it’s the only thing that they can do. I think those of us in the West frequently feel inconvenienced because you might have to put on a mask when you go to a grocery store. I don’t think that would be the overwhelming attitude in in some of these developing countries. They’re willing to do that.
Q: And my follow up question is that for right now, what is the most realistic model for the US in your opinion?
PHYLLIS KANKI: In terms of where you think –
Q: Yeah, the curve and where it will develop and when we see, you know – I saw a lot of different graphics and they’re all different, you know, in terms of the end or where the peak is. So, what is your prediction basically?
PHYLLIS KANKI: Well, I think you’ve seen some parts of the country, Washington state and California, that look like they’re over their peak. New York is getting there, also maybe Massachusetts and New Jersey. But they’ve had huge numbers. There are other parts of the country that you haven’t seen a peek and to the extent that that’s supported with lots of testing. They may stay that way if it’s because they haven’t been testing enough, they’re in danger, I would say, of having a peak, but just one that’s poorly recognized and that would be dangerous.
The problem is that, you know, I’m in Massachusetts, and I can drive 45 minutes and be in Maine and New Hampshire. And many people, you know, work in another state. So, you do have to wonder ‘well, what what’s going to happen if my state is basically over with our peak of but another state is just beginning.’ And you could have rolling peaks which would mean that the country as a whole is just going to be up and down. It’ll be Spanish flus going throughout the nation, and that would be a pretty frightening thought
Q: Thank you so much.
MODERATOR: Next question.
Q: Thank you so much for doing this Dr. Kanki. Last year there was some good news about the treatment of Ebola when scientists found that a couple of antibody drugs seem to be effective against the virus. I was wondering what you think of the efforts to develop antibody drugs for coronavirus. Some people are saying that they may offer the best hope for treatment, while we wait for a vaccine.
PHYLLIS KANKI: Yes, there’s been a lot of research on antibodies and it does appear that that’s another approach that the research field will take up and those are already in the works. We also already have a drug that’s gotten an emergency clearance that acts on the virus itself, Remdesivir. I think the thought is that you might need to have a combination of therapies, some that would act in different ways, sort of like what you use with cancer therapy, and that might be useful. I think antibodies in general have been very effective at bringing virus down
if you had high burden of infection and bringing that that level down, but it may not be prolonged and there will be limitations to how much you can give and how long.
One of the issues with the use of antibodies for Ebola is that you’d have to continuously give an intravenous therapeutic and that can’t be done. And you can also drive the virus into a reservoir, for instance, so that the idea is that it would be better if you had multiple types of their therapies that would try to basically cure the person.
Q: So antibiotic drugs might just be part of a, you know, I guess, a bigger toolkit or treatment approaches?
PHYLLIS KANKI: Yeah, I think that’s the conventional wisdom, yeah, and as you’ve probably seen cases come in, some with, you know, no symptoms, some with very severe acute symptoms, and you’d have to tailor those therapies, based on what you think is going on. If you have an assay where you can determine how much virus is there, you might say, ‘oh, let’s use an antibody here and Remdesivir or something else’ and then as the patient starts to get better, you may have to be dealing with other parts of that viral infection. Once the virus gets in there and you have you know a cytokines response, you might have to do something to deal with that response, which is almost indirectly a result of the viral infection.
Q: Thank you so much.
MODERATOR: I just wanted to have a quick question. As of a virologist, is there anything that stands out to you about this particular coronavirus, or is it very similar to other coronaviruses and it’s just how it’s affecting the body’s a little bit different? Do you have any thoughts on that?
PHYLLIS KANKI: Well, in the last month or so, I’ve done a lot of reading about coronaviruses and, you know, it’s a huge range of characteristics of these viruses in their infections in animals and people. It’s pretty frightening because it’s a virus, it’s able to mutate a little bit like flu and a little bit like HIV. And it’s also able to move from one host to another pretty readily and we’ve seen that with the original SARS virus in 2003 and the MERS virus 10 years later.
I think the lesson I take from that as a viral just is that there are these viral infections, not just coronaviruses, but there’s a huge number of coronavirus is sitting there, perfectly percolating along in different animal species with known mechanisms of being able to spill over into humans. And that is the whole area that biologists think about in terms of reemerging and emerging infections, we’re changing our environment and our access to some of these animal species more readily because we’re destroying their habitat for instance, or because we’re eating them and keeping them in the live market or whatever. But even domestic animals could serve as an intermediate host for something like a coronavirus and then you would have an outbreak. And these outbreaks of course the ones we think about the human ones, but we’ve had coronavirus outbreaks that have had devastating effects for the pork industry where you had huge numbers of pigs that were being killed by what appeared to be a spillover virus from bat into the pigs and created basically an outbreak in in the pigs.
MODERATOR: And I have one more question that I’ve been getting sometimes with various frequency in my inbox and that is mutations and how viruses mutate. Could you kind of put into perspective what a virus mutation can mean, that basically all viruses mutate and that is not necessarily a good thing or a bad thing, it’s just what viruses do. Could you talk about that a little bit?
PHYLLIS KANKI: They all can mutate but some do it better than others, and it’s just the nature of their how they replicate. So, these coronaviruses have an enzyme that reads their genetic material and creates another copy, so that the virus will live on. And sometimes there’s
in that replication cycle you can have the enzyme fail to read correctly and then you result in a mutation. And so, if you track this, you can see that in any given cycle, you’ll have so many mutations.
Now, that sounds bad, but it might not have a big effect because the virus – you can mutate a nucleic acid residue that won’t have any impact right and the virus is going to want to survive. So, the only thing that survives is what would actually allow the virus to replicate on, so there are measures by which that mutation doesn’t have impact. But you can also have a mutation that can say change the ability of the virus to transmit a little better. So, say you have the portion of the virus that contacts the receptor on the human cell, if you mutate that, you can either disallow the virus from getting in or you can make it get in better. And unfortunately, all those possibilities are there. Correct?
And so, I think that’s one of the things that we worry about when we’re studying these viruses is to recognize the tremendous potential these viruses have for doing things differently. In the retrovirus family, which is where HIV is, there are a whole set of viruses that cause cancers in different animals and one amino acid change, so that could be one nucleic acid residue different, can change the kind of cancer that that virus can cause. So, I guess it creates a certain anxiety as we sit here as a potential host to a virus infection, that there’s a lot of potential out there and that’s why there’s been so much work. One Health is another organization that’s concerned with the interface between animals and humans because there’s so many viruses that humans get that they get from animals.
MODERATOR: Right, thank you. Next question.
Q: So, I will ask an introspective question. So, as you know, in the wake of the 2003 SARS outbreak in China, some pharmaceutical companies try to develop both antibodies and the vaccine against the SARS, let’s call it the SARS-CoV1 as opposed to the SARS-CoV2, which is the one we’re facing now. So, some pharmaceutical companies with whom I got in touch, they said that they were trying to develop a vaccine that targeted the portion of the SAS -like family viruses, coronavirus, which is common to all coronavirus belonging for this family, so that the new system would recognize it, this common portion and basically deactivate the virus no matter of the mutations and, sort of, variables of the coronaviruses. And they said that eventually they need to develop further research because, as you know, the pandemic finished so there were no more infected people on whom they could have tested the effectiveness of this vaccine. And I was just wondering if a vaccine like that that was really targeting the common portion of all the SARS-like family of coronaviruses were developed back then in the past, would it be much easier now to resist this pandemic, may be using this virus at the start and then trying to upgrade it into a better vaccine which is better suitable for this new virus, SARS-CoV2?
PHYLLIS KANKI: Yeah, I’m not familiar with that vaccine candidate, but it certainly sounds like a great approach and it’s probably one that that people are looking at again. I think, unfortunately in many cases, what happens after an outbreak goes away and there’s no longer interest and there’s no longer cost benefit for a vaccine company the concept is dropped and it doesn’t go anywhere. We do know that if it was a vaccine that was specific to say CoV-1, it’s likely that that vaccine would not protect for CoV2 and the same thing is true with MERS.
But the idea of having a quote pan-coronavirus vaccine is certainly a good one and something I think people have thought about if they haven’t actually gotten it going now and there’s, you know, probably 50 candidates that are out there that that people are pursuing and companies are pursuing and trying to get into trials and get into people. You may end up having more of a situation like you have with flu, which is that you have to design a vaccine every year because the strain that’s infecting the populations is slightly different and last year’s vaccine will not protect from this year. It gives you some protection, but –
Q: Okay, well, just to follow up question. So, let’s say one year, two years, hopefully this new virus goes away. Then, I mean, if we keep using the same market-oriented mechanism we cannot be sure that the pharmaceutical companies will have enough of an incentive to sustain their research in a way that basically can develop a new version of the vaccine as they do with the with seasonal flu so that that we have a vaccine always ahead of it [INAUDIBLE].
PHYLLIS KANKI: Yeah, I agree with you. I just think that generally the way pharmaceutical companies and therapeutic companies operate is they have to follow the bottom line. And so if they find that something being prepared is not really in their business model, if you know what I mean. But I do think that this pandemic is going to change the way people think about things again and perhaps there’ll be a bigger push to not have such a short attention span about things just because they seem to have gone away now after one or two years. I mean, I know that after the Ebola outbreak – and I was working on it in the aftermath of it in Africa – the funding opportunities for me to get research funds for Ebola went away, and they basically were switched over and they had to use those funds to fund the research that was ramping up for Zika and I think now they’re those funds have gone away as well. So, there’s a short attention span and that’s unfortunate.
Q: So it’s a chicken/egg paradox?
PHYLLIS KANKI: Yeah.
Q: Thanks a lot. Thanks.
MODERATOR: Next question.
Q: I’d like to ask you another question, if you don’t mind. You were speaking earlier about immunity and issues around immunity. How much immunity you have, how long do you have it. Could you talk to us a little bit about how that plays into any discussions and debates around herd immunity, what constitutes herd immunity, etc?
PHYLLIS KANKI: Sure. So, the basic idea of the herd immunity is that you have a sufficient proportion of the population that has experienced the disease and has immunity. It’s generally thought of that that immunity is in the form of antibodies, but it could be cellular immunity and so that the pathogen entering that population just hits, you know, five times out of 10 or six times out of 10, it is confronted with someone who’s immune and it can’t enter the population. So those immune folks are protecting the smaller proportion generally of the population that have never seen the pathogen. So that’s the concept of it.
What we don’t know about COVID, the COVID virus is how long after say you’ve been infected and you’ve survived the disease, how long does those antibody responses and T cell response, how long do they last and do they protect, and there’s unfortunately very little information about that. You could also say, well, what if I was one of the lucky people who was exposed and had asymptomatic infection, am I immune? We also don’t know that. We do know that those people probably have antibody responses, maybe two days after they were exposed – not great data about that – but we don’t know if those antibodies in a test tube will neutralize virus. That’s what you want to know. And we don’t know for instance, will you have that protection for, you know, more than a few weeks or a few months.
So, all of those parameters are important to sort of calculating the concept of herd immunity. Ideally, you would be in a situation where you have the infection or you have the vaccine and you have lifelong immunity, and that would protect you and it would help to protect those around you that that did not have it, but we don’t know that yet about this virus. And that’s partially because the test that used to diagnose COVID is based on the virus nucleic acid. And so, it’s not based on your immune response. And so, we have little data and as you probably know, there was the rollout of these antibody tests, but it was very late. And so, we don’t have good studies to say a patient who was exposed in a nursing home, 10 days later, how many people in that nursing home have antibodies and one month later, how many of those people have antibodies and importantly, how many of those healthcare workers, haven’t we don’t know anything and that’s really unfortunate.
Q: And in terms of populations, why is it that children seem to have a better response. I mean, in measles and other cases, we see under-fives are usually a vulnerable population. In this case it isn’t so much. And why is it that women seem to be responding better than men?
PHYLLIS KANKI: Good questions. I don’t know the answer to that. The age issue is an interesting one. We don’t know whether kids are exposed and infected and then have a milder course, or if they’re less susceptible and those are two different things, right? What we’re seeing right now is that men and older men are older population seem to have a more severe disease, but we’re really looking at sort of the tip of the iceberg because we’re only looking at sick people and we don’t know how many people are infected. Is it, you know, 100% of all kids that are exposed, are they protected or 50% of them are protected or do they get the infection but have a very mild course and so they’re never detected. And we just don’t know that, right?
Q: Okay, okay. And with regard to women and men. Is there any, are there any theories around that?
PHYLLIS KANKI: No, I haven’t heard much except that you probably in the analysis of the data have to really look at do you have the same number of men and women with pre-existing conditions like hype, you know, uncontrolled hypertension, or diabetes, or asthma, whatever. So those you have to say you have an equal number of that in both sexes and then determine, then you’ll see that the gender as an independent associated factor.
Q: Thank you very much.
MODERATOR: Alright, does anybody else have a question?
Q: Yeah, follow up the question by Gregory, you said that it will be difficult or even impossible to find out how many people in the nursing home have antibodies following a contagion from one in the nursing home – I don’t know if I have that right – but would it be possible to know that with serological tests?
PHYLLIS KANKI: Yes, and they’re starting to do those now. Here in Massachusetts, they’re starting to do, you know, the complete array of tests in these closed facilities that seemed to be such high risk. And they’re also starting to do that and healthcare workers, which is something that I think will be important for us to do all over the world because healthcare workers are really, have a higher risk of exposure.
Q: Yeah, I asked the question because in Italy, they estimate that at least 10,000 died in the nursing homes because they were denied access to the tests and care due to the thought that the hospitals were overwhelmed. So, of course, they tried to see the youngest and most healthy, so people in the nursing home were left alone and now they are trying to – there is some panic to provide the home care to these nursing homes. So, it’s essential actually to try to do serological testing in the nursing home to prevent further death.
PHYLLIS KANKI: Yeah, it’s really heartbreaking what’s happening in some of these health care facilities that people have.
Q: Okay, thank you.
PHYLLIS KANKI: Mmmhmm.
MODERATOR: Okay, looks like that was our last question. Dr. Kanki, do you have any other final words before we end the call for today?
PHYLLIS KANKI: No. I think we had some great questions and a good discussion, so thanks very much.
This concludes the May 5 press conference.
Michael Mina, assistant professor of epidemiology (May 4, 2020)
Marc Lipsitch, professor of epidemiology and director of the Center for Communicable Disease Dynamics (April 30, 2020)