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COVID-19: Expert Guidance and Q&A

The Japan American Society of Chicago November 17, 2020

Michael Lin, MD MPH Associate Professor, Division of Infectious Rush University Medical Center Agenda

• COVID-19: current trends • : symptoms and outcomes • : Risks • Treatment Update • Vaccines

• Question and Answer Japan: 119,557 cases, US: 11,200,879 cases, 1,883 deaths 247,175 deaths

Johns Hopkins COVID-19 map (accessed 11/16/2020) Region Comparison

Japan USA Cook County Population 126.7 million 328.2 million 5.15 million COVID cases 119,557 11,200,879 251,101 Rate (/100k) 94 3,413 4,876 = 36x Japan rate = 52x Japan rate

Japan Daily Cases US Daily Cases

(Corrected US map) Johns Hopkins COVID-19 map SARS-CoV-2

• SARS-CoV-2 = • COVID-19 = disease

• Belongs to the family, named for the crown-like spikes (spike protein)

• (4 types) are known to cause common colds in humans • Starting in 2001, 3 novel coronaviruses have emerged: SARS-CoV (2002), MERS-CoV (2012) and SARS-CoV-2 (2019) Novel Coronaviruses of 21st Century SARS-CoV (2002) MERS-CoV (2012) SARS-CoV-2 (2019) Disease Severe acute respiratory Middle East Respiratory Coronavirus Disease 2019 syndrome (SARS) Syndrome (MERS) (COVID-19) Location of emergence, China, bats → palm civet Saudi Arabia, bats → camel China, bats → pangolin? animal origin Symptoms Fever, cough, shortness of Fever, cough, shortness of Fever, cough, shortness breath breath, renal failure of breath Status Eradicated Sporadic cases Infected cases 8,096 2,553 55 million + Case fatality rate 10% 34% 1-3% Asymptomatic No No Yes transmission Peak viral shedding Late, >10 days Late, >10 days Early R value 1.7 – 1.9 0.7 2-3

Zhu Z et al. Respir Res 2020; Liu et al. JTM 2020; Petrosillo N et al. Clin Micro Infect. 2020. COVID symptoms Symptom Percentage Fever OR cough OR shortness of breath 70 (flu-like illness) Fever 43 Cough 50 Shortness of breath 29 Muscle aches 36 Runny nose 6 Sore throat 20 Headache 34 Diarrhea 19

Loss of smell or taste 8

Stokes et al. MMWR 2020; 69(24):759-765 Risk Factors for Severe COVID-19 Hospitalization risk increases with age

Garg et al. MMWR 2020; 69(15): 458-464 Other risk factors

• Cardiovascular disease • Diabetes mellitus • Hypertension • Chronic disease • Cancer • Chronic kidney disease • Obesity • Smoking • Organ transplant https://www.cdc.gov/coronavirus/2019-ncov/need-extra- precautions/people-with-medical-conditions.html Droplet versus

Influenza; SARS-CoV-2 , How does COVID-19 spread? • Respiratory transmission is dominant • Classic droplet transmission (close proximity) more important than transmission (spread over distance/time) • Evidence: • Contact tracing studies: proximity (<6 feet) is most important • Reproduction number (R0) ~2 suggests predominant droplet transmission; airborne transmission would have resulted in many-fold more cases • Medical masks equally protective as N95 respirators, based on meta-analysis of trials

• Aerosol transmission is uncommon and associated with: • Enclosed spaces with poor ventilation and with groups performing expiratory exertion (e.g., singing)

• Less important: direct contact and • No evidence of transmission: fecal-oral, sexual, or bloodborne routes

1. CDC Scientific Brief: SARS-CoV-2 and Potential Airborne Transmission (Last update Oct 5, 2020) 2. Meyerowitz et al. Annals Int Med. 2020 Sep 17. Which community activities are potential risk for COVID? 14 CDC study: Half of Household Contacts Became Infected

Grijalva, Carlos G. "Transmission of SARS-COV-2 infections in households— Tennessee and Wisconsin, April–September 2020." MMWR. Morbidity and Mortality Weekly Report 69 (2020). Restaurants May be Risk for COVID-19

Fisher et al. MMWR 2020;69(36):1258 Another Study Implicating Restaurants

Chang et al. Nature. 2020 Nov 10:1-8 (in press) Duration of Infectivity (and limits of PCR testing)

• Period of infectiousness begins ~2 days prior to symptoms, peaks at about day -1, and then disappears after day 7 • Viral RNA detection (PCR) lasts much longer (up to 12 weeks) and is not associated with live virus or contagiousness • Current CDC guidance: “10/1” day rule for mild-moderate , “20/1” day rule for severe infection or immunocompromise

Meyerowitz et al. Annals Int Med. 2020 Sep 17. Which test to get?

Test Active Past Turn-Around Time Notes Infection Infection 1-2 days Nucleic Acid (e.g.,PCR) X Most accurate (best) (ID NOW: 15 min)

Antigen Test X 15 minutes Rapid, but not accurate

Only helpful for diagnosing Antibody Test X 1 day prior infection; accuracy varies widely Treatment

https://www.covid19treatmentguidelines.nih.gov/ therapeutic-management/ Vaccines

Adapted from O’Callaghan KP et al. JAMA 2020

• Vaccine approval for each vaccine candidate will eventually come from FDA and will be based on results from Phase III trials

“Vaccines don’t save lives. save lives.” – Walter Orenstein Upcoming Vaccines

Pfizer/BioNTech Moderna Technology mRNA mRNA Status US Phase III trial complete US Phase III trial complete Interim efficacy (press release) >90% 94% Dosing 2 doses, 21 days apart 2 doses, 28 days apart Storage −70° C −20° C (once thawed, 30 days at 2-6° C) Distribution Through public health dept Through public health dept

Priority for (CDC ACIP): 1. Healthcare personnel 2. Workers in essential and critical industries 3. People at high risk for severe COVID-19 illness due to underlying medical conditions 4. People 65 years and older What to do for winter surge:

• Universal approach to COVID-19 prevention (e.g., universal masking, , hand hygiene) remains key strategy • Treatment of COVID-19 patients is improving (dexamethasone, remdesivir antiviral, anticoagulation, and provider experience), as long as there are enough hospital beds • Vaccines: will not likely factor into winter surge response All 11 Illinois regions move to Tier 3 mitigation on Friday morning (Nov 20, 2020) Thank You

Michael Lin, MD MPH [email protected]