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>> Good afternoon, and welcome to a special presentation about Coronavirus Virus Disease 2019, or COVID19.  Today, we're going to answer some common questions about the outbreak.  I'm Loretta Lepore, and today I'm representing CDC's Emergency Partners Information Connection, the EPIC Team.  We have Dr. Jay Butler with us today.  Dr. Butler is CDC's Deputy Director for Infectious Diseases.  In this capacity, he provides leadership to the efforts of CDC's three infectious disease national centers and helps advance the agency's crosscutting infectious disease priorities.  Welcome, Dr. Butler. 
>> It's a pleasure to be here, Loretta.
>> Before we begin, I wanted to point out that Dr. Butler and I are sitting six feet apart.  We're doing this because we're comporting with CDC's guidance on social distancing.  And we would ask all of you out there watching to embrace the same guidance.  We've got a lot of questions to get down to today, so let's get started with today's questions.  Are you ready, Dr. Butler? 
>> I'm ready. 
>> Okay, I thought it might be helpful to begin by providing an overview to our viewers of the current outbreak, both domestically and internationally. 
>> Well, the outbreak is something that started only three months ago.  And it's an important part of the discussion to recognize that we are talking about a virus and a disease that we didn't even know existed only three months ago.  So, it's really remarkable how much has advanced and how much has changed over that brief period of time.  The emergence of this new Coronavirus occurred in Central China.  And for the first few weeks, it spread within China.  But more recently, it has really spread globally.  About three weeks ago, we began seeing a significant number of cases occurring outside of China that were reflecting local transmission.  And at that point, we began to see each day more cases outside of China than in China.  During the past few days, we've actually exceeded now the total number of cases occurring globally.  Less than half have occurred in China.  So, we're seeing significant transmission really all around the world.  Some of the hottest spots right now are South Korea.  Also, the Eastern Mediterranean area, Europe, including the United Kingdom and Ireland, and also now in the United States and Canada. 
>> So, there was one phrase in there that you used.  You used local transmission.  Could you, could you explain that to our viewers? 
>> Sure.  So, when the epidemic first started, a lot of the approach to slow the spread and even prevent the entry into the United States for as long as possible focused on containment measures. 
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And that focused primarily on travelers.  Early on, the cases that occurred outside of China occurred either in people who were exposed in China, traveled out, became ill after they returned home, or in their household contacts.  In some situations, there's been further spread within communities.  And this is not unexpected.  This is what we would expect to see say in an influenza pandemic where there's a new virus to which the community, and indeed the human population around the world, has little or no immunity.  As we've progressed, we've seen now over 180,000 cases worldwide.  Here in the United States, we've seen over 6,000 cases so far.  Unfortunately, about 100 people have lost their lives to this infection.  The people who are most at risk for these severe infections are people who are older and people who have chronic underlying heart, lung, or kidney disease, and those with diabetes. 
>> So, there are two things I want to follow up on.  As of today, how widespread is the outbreak in the United States? 
>> We've now had cases reported from all 50 states.  Also from Puerto Rico, the U.S. Virgin Islands, and Guam.  So, as we talk about where we are in the pandemic, it's important to recognize it is a global pandemic now.  So, while we'll talk more about travel I'm sure, it's important to think about what's happening in our own communities. 
>> One of the questions I wanted to get back to was about you mentioned the elderly.  And this is a population that is at risk and is vulnerable to this disease.  Can you explain a little bit more about that and how families should be interacting with their elderly relatives at this point in time? 
>> Yes.  And this really was, is something that's been observed since the beginning of the epidemic in China, and we're now seeing it in the United States as well.  The people at highest risk of severe infection are those who are older, particularly those who are over age 80.  More than half the deaths that we've seen in the United States have been among people who live in longterm care facilities.  But then also people who have chronic heart conditions, lung disease, kidney failure, or diabetes.  For families, what that means is that it's important that we practice social distancing, particularly with our elders, but also with people who have those underlying conditions.  Just as we're sitting six feet apart with a virus between us, it's important to do as much communication as possible virtually, such as what we're doing with our audience now, for families interacting with elderly relatives, grandparents, this is probably not a good time for the grandkids to run and give grandma and grandpa a big hug and a kiss.  This may be a better time for a phone call, for a video chat.  If those type of technologies are not available, even coming by, if possible, and waving through the window, just to be able to maintain that social contact, is important.  One of the challenges when we talk about social distancing is we don't want social isolation.  And it can be very challenging, because we know particularly for our elders, having that connectivity with family is very important to mental health as well.  But at least for a period of time, it's important that we do things a little differently and make sure that we keep our elders safe.  It also is probably a good time to reconsider visiting elderly people who live in longterm care facilities, because those seem to be situations that are at particular risk.  And most important is if you have any symptoms of a respiratory illness, please do not be in contact with people who are elderly or have underlying heart, lung, kidney disease, or diabetes. 
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>> And it's probably a good time for us to point out that CDC has guidance for nursing homes on our website.  And folks can relevance that for further information. 
>> Yes, there's quite a bit of information on the CDC website.  I think we have now over 450 different guidance documents out there.  And so it's arranged in a tabular form.  Also, Google can be useful for finding those documents.  But this can be accessed at cdc.gov/covid19.
>> Great.  We talked a little bit about the elderly and their risk to COVID19.  How severe is COVID19 for the general population? 
>> For most people, we're talking about a mild illness.  The vast majority of people will not require an interaction with a healthcare provider or certainly not an admission to the hospital.  And particularly for younger people, and especially children, the illness may be very mild.  So, it's one of the challenges in controlling it is that the spread may occur from people who have really minimal symptoms.  There's even some evidence that it may spread from people who have no symptoms at all, or who have not yet developed a symptom.  So, that can be a major challenge.  And one of the reasons why social distancing may be the right thing to do right now, because it's easy to say if you're sick, stay home.  But it is possible that people who are not yet sick may be able to transmit the virus as well.  I think it's safe to assume that if you're sick, you are, and have COVID19, that is the person who is most infectious.  But there may be more to it than that. 
>> And there's just so much we still don't know.  I mean, as you said, this has only been, this outbreak has only been, you know, three months in.  And scientists, our scientists are still learning so much more about this on a daily basis. 
>> Yes, and this is a new Coronavirus.  I frequently hear people say, well, Coronavirus is not new.  And the family of Coronaviruses is not new.  So, oftentimes, household disinfectants will say that it deactivates Coronavirus.  That's correct.  But there's several Coronaviruses that have been known for years that cause relatively mild symptoms.  The other end of the spectrum, there's always the Coronaviruses that cause SARS and one that causes Middle East Respiratory Syndrome, something called MERS.  Those are more severe illnesses.  So, there's a lot that we know about Coronaviruses have those diseases.  But we're learning a lot because this is a unique Coronavirus that we've never seen before.  It's also important to recognize there's a whole world of Coronaviruses out there that infect other animals.  And, for instance, if you've ever looked closely at your veterinary bill, you may have seen a charge for Coronavirus vaccine.  That's actually a vaccine that is for a different type of Coronavirus.  So, there's no evidence that those type of vaccines would provide protection against the COVID19 virus. 
>> So, specifically, speaking of COVID19, how, how does this disease spread?  How does this particular virus spread? 
>> Well, it appears that the vast majority of infections are transmitted by respiratory droplet.  And what I mean by that is that the virus infects the respiratory tract, including the upper respiratory tract. 
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So, if I cough or sneeze, the spray that's produced will contain the viruses, and they will fall as they travel away from me.  That's why we're six feet apart.  Maybe this is a good time when the virus between us should drop to the floor, because that's what would happen in real life.  But it's also possible that it can survive on surfaces.  And there's, there's some laboratory evidence that its survival in the environment is not unlike the SARS virus.  So, it's also important to be able to clean surfaces with standard household disinfectants, particularly frequently touched surfaces.  So, that's things like doorknobs and phones and even tabletops, because the virus may be able to survive for a period of minutes, even hours.  And that provides opportunity for the hands to become contaminated.  And there's where we get to some of the basic recommendations.  It's important to wash your hands for at least 20 seconds with soap and water, or use an alcoholbased hand cleaner that contains at least 60% alcohol.  It's also important to break the habit of putting your hands to your face, because that is one of the ways, if your hands are contaminated, you can then inoculate yourself with not just COVID19, but any number of respiratory viruses. 
>> I think we don't think on a daily basis how often we touch our faces.  And with this outbreak, you become much more cognizant of that, and have to be more cognizant of that.  One of the things that I've heard just, you know, anecdotally, the way that people are determining how long to wash their hands is they sing happy birthday twice. 
>> Yes. 
>> And that, that's a sufficient, and that's a great way to teach children how long they should be washing their hands with soap and water under warm water.  So, just a little trick for our viewers out there. 
>> Right, or the alphabet.  A colleague in Louisiana said wash your hands like you're at a crawfish boil and you need to take your contacts out. 
>> Okay, love that one.  That's regional.  So, one of the big questions that we get often, and is probably one of the most difficult questions for our subject matter experts to answer, is about when the outbreak will end.  Can you help inform that discussion a little bit? 
>> Well, there's a lot of variables that will drive when this epidemic, pandemic will end.  And in many ways, I think we would like it to end as soon as possible, particularly those of us who have been involved in it for several months now.  The end couldn't come soon enough.  But there's actually, I want to say something maybe surprising to many people, is that in many ways, we want the pandemic to spread out over as long a period as possible.  And I think many people have heard discussions about flattening the curve.  And this means that we want the pandemic to affect as few of people as possible at any given period of time.  In other words, if we had say 10,000 people in a community who became sick, if they all get sick over a twoweek period, that could overwhelm the healthcare system and really shut everything down for a period of time and put lives at risk.  If it's 10,000 cases over a period of three to four months, that may be something the community can manage, society can continue, and also the healthcare system could be robust to be able to take care of people who might have more severe symptoms.  So, when will it run its full course?  You don't know for sure. 
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As we look at influenza pandemics, oftentimes they begin to abate after 12 to 18 months.  You also raise a question that you haven't asked, but I bet many of our viewers are wondering because they've heard about it, is is this an infection that will go away in the summertime.  We know that influenza generally does go away.  We know from the pandemic of 2009, although the virus first emerged and there were many infections late in the springtime, there was then a lull through the summer months.  We don't know about this Coronavirus yet.  So, while it would be optimistic to think we're going to get a break in the summertime, we'll have more time to prepare for what may come in the fall, it's important to recognize, as we've said earlier, this is a virus that we didn't know existed three months ago.  And we really don't know yet how it will be influenced by the warmer months in the northern hemisphere. 
>> One of the points you raised was about the stress on the healthcare and the structure of our nation.  And while we do have one of the best systems in the world, heavy, a heavy burden on that infrastructure could present some problems.  And so I wonder if you might address when people should visit an ER, when people should visit a doctor's office, and should they call ahead to their doctor before going into the office.  I think that would be helpful for folks at home, but also be helpful to the healthcare providers that are triaging these cases. 
>> Yeah, well, first of all, I think it's important to acknowledge just the heroic job being done by healthcare providers all over the country right now, particularly in those communities that have been most heavily impacted.  In parts of the country, the healthcare system is already stressed to the breaking point.  And people are working long hours, under very difficult conditions.  In terms of the healthcare system and how we can best keep it resilient, it's important that plans are put in place, which are generally there in each hospital.  I mean, many hospitals have done tabletop exercises of what to do in a flu pandemic.  Those plans are still very useful in this situation, even though this is a virus that's very different from influenza.  So, things like elective procedures or office visits that might be able to be deferred until particularly several weeks or months down the road, this is the right time to do that.  So, for the general public, that involves some patience and flexibility to understand if an elective surgery is being rescheduled or a visit to your provider is being bumped further down the schedule.  Understand that this is part of how we keep the healthcare system robust, to be able to take care of those people who do get very sick with COVID19.  In terms of people who become ill with respiratory illnesses, two thoughts on that.  First of all, we are still in the flu season.  So, most likely, it will be something other than COVID19.  If it is COVID19, the vast majority of people will have relatively mild illness.  So, it's important that just everybody with a runny nose doesn't come running into the Emergency Department.  It's wise, though, to be on alert for the more severe symptoms.  So, a very high fever, shortness of breath, tightness or fullness in the chest, those are the kind of things that may reflect that there's a more serious manifestation.  And if those develop, pick up the phone, call either your provider or the Emergency Department in advance so you can get instructions on how to come into the healthcare system in a way that will minimize the risk of exposure to others who may not have COVID19.  Of course, if there are symptoms of a lifethreatening problem, whether it be COVID19 or the tightness in the chest is a heart attack, call 911, because those things are still going to happen.  And that's an important component of why maintaining the robust responsiveness of the healthcare system is important, because COVID19 will not prevent people from falling down the stairs and breaking bones.  It will not prevent automobile accidents.  There are going to continue to be traumatic events that occur, and acute illnesses that occur that have nothing to do with the pandemic that will require care in the healthcare system. 
>> So, a good reminder that our healthcare professionals and ERs across the country are also triaging a host of other medical conditions in addition to COVID19. 
>> Absolutely. 
>> I'm going to shift gears just a little bit here, because we've got a lot of questions.  The next question we have is should Americans be concerned about traveling to other countries, or about travelers from other countries coming from the United States? 
>> Well, I think in general, let me just start by saying this is not the best time to travel.  And at the CDC website, cdc.gov/covid19, you can find links then to advice to travelers.  There are a number of countries where we recommend that anyone who is considering travel seriously consider delaying it unless it's somehow essential travel.  China has been in that category for a couple of months now.  But that's expanded now to include South Korea, Iran, really all 26 nations of the European Union, United Kingdom, and also Ireland.  Also, people who travel anywhere in the world, we recommend if you are at risk of more severe COVID19 illness, and that would be people who are older, people with underlying heart, lung, kidney disease or diabetes, it's going to be best to defer that travel.  We also recommend that no one should be traveling on cruise liners right now.  Our experience to date has been that once COVID19 is onboard a cruise liner, it can spread very rapidly, and attack rates can be much higher than we're seeing in communities. 
>> So, for individuals coming back into the country, we've seen some new advisories go up recently.  We've heard a lot about transmission in the European Union.  And those flights coming back into the United States.  Could you, could you, for a moment, just address for those folks, Americans and legal residents that are coming back into the United States, how that process is working and what role CDC is playing with that? 
>> Right.  So, if you're traveling back from one of these areas where the travel advisories are in place, we recommend, first of all, that you not travel if you're sick.  When you reenter the United States, there will be a process of a brief assessment of your health.  You'll be directed through one of thirteen airports in the United States if you're traveling from one of the Asian countries involved, or from Europe.  And you may be directed to talk to one of the CDC quarantine doctors who are there.  There will be an interview and an assessment.  And if you've developed symptoms during the flight, you'll be advised and directed to where to get medical care.  If you're well, you'll be allowed to continue on with your domestic itinerary. 
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And it's important for people to realize this is different than what was done initially for travels coming out of Hubei Province in Central China where there was quarantine facilities set up in different parts of the country.  Our emphasis now, because of the continued spread of the virus, and the breadth of the pandemic, is that you quarantine at home for a period of 14 days.  And this is to reduce the risk of spread from these other countries into new communities in the United States.  And this is part of that overall process of how we spread the curve out.  Even as we see some transmission in the United States, some communities see quite a bit.  This is a way to prevent additional transmission in the United States and to slow the progress of the pandemic. 
>> Should we be concerned about travel within the U.S.?  We've seen some highprofile leaders like Dr. Fauci, for example, from NIH, indicate that at his age and his preference would be not to travel at this point in time.  What is the CDC recommendation on travel within the United States? 
>> Well, Dr. Fauci is in line with the CDC recommendations.  And while Dr. Fauci is quite robust and incredibly intelligent, he has also been around a long time.  So, we do recommend that people who are older not travel right now if there's any way to avoid that.  And also the people who have chronic heart, lung, or kidney diseases. 
>> Perfect.  The next question that we have is what should people consider to avoidhow should people consider avoiding stigmatizing particular groups or products? 
>> Yeah, so, let's address the two questions there separately.  First of all, it's, through history, there's been blame placed on different groups of people for different types of diseases.  And it's important to recognize that this COVID19 is now a global disease.  It affects everyone.  So, there really is no justification to stigmatize anyone, particularly any racial or ethnic group related to COVID19.  For people who have traveled, while social distancing may be important, it's also important to not be socially isolated, and certainly not to shun people, and certainly not to shame people either.  There's very little evidence that that's going to lead to additional healthy behaviors.  Now, the question about products relates back to our earlier discussion about transmission.  There were a lot of questions early on about products that were made in Central China.  Of course
>> The supply chain. 
>> China is, plays a very important role in the global supply chain, as does the European Union and the United States.  And there was concern, well, is the virus being transmitted via these products, or by mail even?  And while under laboratory conditions the virus can survive on paper or cardboard products for a period of time, the epidemiology does not indicate that that is what has spread the virus.  If this were a virus that were transmitted through the mail, we would have seen more hotspots hopping up all around the world very early on.  What we saw instead, as cases occurred outside of China, they were occurring initially in travelers who came out of China and were well during their time of travel, during the incubation period, before illness onset, and then became ill after arrival.  If there was subsequent transmission, it was most often to their household contacts, the people they were most closely associated with.  So, we really don't think that mail or products that have come out of any part of the world have played a significant role in spread of this infection. 
>> Since this outbreak began, there have been a number of new words, terminology introduced into America's lexicon.  Some of the most common are the words quarantine, isolation, and social distancing.  I think sometimes people get confused between what quarantine means versus what isolation means. 
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So, could we start with that?  We've addressed a little bit about social distancing, and I'll ask you to go into more detail on that in a minute.  But I think the differentiation between what it means to be quarantined versus being in isolation, there's a difference there.  And let's clarify that for our viewers. 
>> From, there certainly is.  And while these may sound like technical terms, they may even seem like they could be used interchangeably.  And unfortunately, oftentimes are.  They mean very different things.  So, quarantine means separating someone who has been exposed to infectious agent from people who are unexposed.  It's not a tool that's been used very often recently in public health.  And it's oftentimes more challenging to do, because you're basically taking people who are healthy and feel good, separating them from their loved ones sometimes, and that can be a challenge.  But it's a tool that has been used really for centuries with varying degrees of success.  Isolation is much more commonly used.  And it's used every day in hospitals all around the country.  Isolation means taking someone who is sick and infected with a specific organism and separating them from people who are well.  So, you're trying to prevent transmission of the infection to the people who are well.  And there's various types of isolation.  There are specific guidelines for respiratory droplets, such as what we were talking about earlier.  There's also specific guidelines for airborne pathogens, which we don't see a lot of evidence that this virus is commonly transmitted by the airborne route.  Even though under laboratory conditions, we can get it into the air and show that it can be there for a while, this is not like tuberculosis or measles where we think it's common that the transmission is through the air.  Quarantine achieves the goal of being able to prevent transmission that may occur early in the course of the illness.  Isolation achieves the goal of preventing transmission throughout the course of illness. 
>> And we should mention that you had spoken about the early flights, for example, of repatriated Americans from Hubei Province, some of the passengers aboard the Diamond Princess, the cruise ship, they were in quarantine, many of them, and the resilience of the American people was demonstrated in those situations because by and large everybody was very grateful to have, we've received notices from many of them, they were compliant, they were, they understood the complexity of the outbreak and were very willing to respond to recommendations.  And so I think as just, as a point of reference, just to acknowledge that when Americans know what's happening and they're asked to rise to the occasion, they are doing so, and that we're all in this together.  If you wanted to put an emphasis on that, I'd be happy to
>> Will, first of all, we recognize that none of us wants to have our freedom of movement restricted.  So, it's always a challenge to strike that balance between our individual freedoms and liberties and what's good for the larger community.  My heart particularly goes out to people on the Diamond Princess, many of whom were quarantined onboard the ship for a period of time.  And then because there was evidence of ongoing exposure, had to again be quarantined upon return to the United States.  That was a long period of time to be oftentimes separated from family and other, other loved once.  So, that's, that's not a tool, quarantine is not a tool that we take lightly by any stretch.  I will add, though, in terms of the resilience of the American people, I've had some reports of the first group of repatriated American citizens coming out of Wuhan in China, they landed for refueling in Anchorage, Alaska.  And when the CDC official from the quarantine station went onboard and was really unsure what the reaction would be.  But I'm told that when he said welcome to the United States, there was laughter and a round of applause.  People were very glad to be home.  And I think that's important for us to remember, that our fellow citizens were very glad to be home again. 
>> That's right.  And that's a nice segue for us, because you were the former public health leader in Alaska at one time.  And our next question has to do with what can state and local health departments do to prepare for those that perhaps haven't yet had a big outbreak within their jurisdiction, what can they prepare for, and how can they respond to this outbreak? 
>> Well, I think it also ties into another question that we're frequently asked, is are we prepared.  And preparedness is not an all or none phenomenon.  I think we are more prepared now than we were 20 years ago.  So, we'd say a progress.  And it's an ongoing process that is a progression.  For instance, every state has gone through some type of pandemic exercise, planning how do we work together, and, you know, who are the people that need to be in touch.  There's an old saying that an emergency is a terrible time to start exchanging business cards.  But, of course, there's also the old expression that no battle plan withstands the stress of combat.  So, these, these exercises help us to prepare, but they don't answer all the questions.  So, in terms of the ongoing response of preparedness for what's next, we try to stay in close touch with our state, local, and tribal public health leaders and provide technical advice.  And fortunately, thanks to some appropriation from Congress, we've been able to provide some funding locally as well.  The local jurisdictions have been pulling together.  I think practically every state has activated an emergency operation center, which provides a center of operations, because this is, while it is at its foundation a health issue, the impact is much broader than just health.  It impacts education.  It impacts commerce.  It, you know, really, transportation is heavily impacted.  So, it really requires everybody working together to be able to respond and be prepared for what's next.  In terms of knowing what's next, that's where the national data that's aggregated by CDC can be very useful, to look at where the hotspots, what are some of the travel connections that might help you anticipate when the virus is coming in.  The WHO website is also very good to get some visibility on what's going on all around the world. 
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>> So, you mentioned some funding that's been approved by Congress to help local and state governments build their capacity.  Could you speak a little bit about that so that folks watching understand what locals are actually doing, what the states and the local health departments will be doing with that funding to build capacity?  What does that mean to build capacity?  Where's that, what does that mean? 
>> Well, it's really intended to be flexible for the state or local agency involved, because we recognize that the needs being different in different parts of the country.  Some of the state public health labs are fairly robust in terms of being able to scale up and process a fairly large number of specimens.  Others have more challenges.  And to be honest, some state public health departments have had to struggle with declining funding in recent years.  So, it's, it's been a challenge for preparedness.  There's an old saying that at the airport you don't wait until there's a plane crash to buy a firetruck.  Unfortunately, we do have some of our partners who are really struggling with the response.  And that's where funding can be very helpful, to gear up however it's needed, whether it's public health nurses to be able to be out and do case investigations, health educators to help get good messages that are appropriate for the community, epidemiologists to be able to study the data that's being collected locally.  It's really intended to be flexible.  The public health funding, though, is specifically not designated for treatment centers.  And there are other streams of funding that will help support those aspects of the response.  There's also now funds that are available more broadly as part of a disaster response, which will assist locally in terms of being able to provide emergency care facilities as needed.  >> You mentioned just a moment ago some of the community ripple effects of an outbreak and an emergency response, whether it was transportation or other things, business, commerce.  Specifically, there are a lot of businesses that interface with customers, have contact, close contact with customers on a daily basis.  What is CDC's guidance for those businesses? 
>> Well, for details, I don't know if I've mentioned cdc.gov/covid19 yet, but I will mention it yet. 
>> Can't do enough of that. 
>> Yeah.  But there are specific guidelines for businesses.  Briefly, that involves some of the basic concepts around social distancing as much as possible.  But also hand hygiene.  And for management of employees, making sure that you have policies in place so that people who are sick cannot come into work.  So, looking at sick leave policies, and making sure that people are able to take time off if they are sick so that they don't potentially expose your customers are important.  In terms of hand hygiene, not everybody can install a sink in the lobby, say if you're a bank, but you can make hand gel available.  You can also make sure that your employees at say the teller window have the ability to be able to sanitize their hands as often as possible.  So, there's a number of steps there in terms of how to keep not only your employees safe, but also your customers.  And finally, there's alternative ways to do business, which are being implemented in very many parts of the country right now.  For instance, restaurants are being encouraged, in some areas, required to provide only takeout services, to be able to minimize that persontoperson contact. 
>> And the social distancing, to keep people
>> Exactly. 
>> In proximity, the proper level of proximity. 
>> That's right.  So, driveby services actually are probably more important now than ever.  Services that can be delivered remotely or virtually, you know, even in healthcare, there's a role for telemedicine that's very important for people who don't require handson medical care. 
>> One of the other big areas of discussion obviously is guidance for K12 school systems.  Where are we with that guidance today? 
>> Well, last week, CDC posted some guidelines for school closures.  And the decision to close schools is a very complex one.  So, it's important that health, as well as education, most importantly, the school administrators, or the school district superintendents, are involved in that discussion.  And while it's not unlike what decisions that have to be made when there's adverse weather conditions, whether it's black ice or after a big windstorm or an earthquake, this is different because the perception may be different.  There's more fear around the ongoing aspects of the pandemic.  But also school closure may be for a longer period of time.  So, when we talk about some of the pros, we're looking at social distancing again. 
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How do we separate kids from one another?  Of course, schools can be congregate settings, mass gatherings of a small scale.  And we want to be able to minimize that contact.  But there's also a number of downsides.  There's a large proportion of children who receive one, even two meals a day at school.  And how do we make sure that they're continuing to get nutritious food?  We also know that when schools are suddenly closed, that can stress the healthcare system because doctors, nurses, particularly if there's two parents working, somebody has to stay home to take care of the kids.  And it may not be easy to immediately set up that type of, that type of care.  Another consideration is who is going to take care of the kids.  If the, if grandma is 85 years old and the kids also have a respiratory illness, that actually could be a problem.  So, school closure is very complex.  That guideline is available at the CDC website, because nationally there are school closures in at least 37 states right now.  There are literally millions of kids who are home.  Homeschooling's never been more popular than it is right now.  We are working hard to develop some additional guidelines that people can review and consider as they look at the possibility of reopening down the road.  The last thing about school closure that I think is important for everyone to understand is right now we're in a time, in some ways a national timeout almost, in terms of seeing what the impact of this pandemic over the next one to two, three weeks is going to be.  It may be that schools will reopen fairly soon.  But as we progress, it's possible they will need to close again.  So, I think as we go forward, we continue to learn about how this virus behaves.  The recommendations may shift, because getting back to our opening comments, this is something that not only is it unique, but we didn't even know it existed three months ago. 
>> And I think it's important to point out with all of these recommendations CDC is making, that there's not a onesizefitsall approach for all jurisdictions across the country. 
>> Absolutely. 
>> That really local authorities have to make decisions predicated on their populations, on the considerations, the level of outbreak, et cetera, within their communities. 
>> Right.  And the possibility of doing any type of virtual distance delivered education is quite variable also.  I think all of us will be learning a lot more about distance delivered education over the next few months. 
>> Right.  And I'm going to get to that at the higher ed level as well. 
>> Yes. 
>> But, but one of the things I did want to go backtrack on very quickly is you had mentioned that there's a level of fear.  And I've heard you address this in the past about there's a difference between preparation and being scared.  And so if you could address that briefly, because I think it's important, since that's come up in our discussion, that folks understand, and we provide some level of calm and comfort to our viewers to understand, again, some of the topics you've talked about, that most of us, it will be a mild outbreak.  But if you could address that specific issue. 
>> Sure.  Well, let me start.  At the risk of sounding like a bumper sticker, the advice is be prepared, don't be scared, because we know that people who are motivated primarily by fear may do irrational things.  If you live in an area where it's prone to tornadoes, if there's a tornado warning, you don't go running down the street.  You seek shelter.  You take cover.  If there's an earthquake, you don't, you try to avoid things that may fall on you, you try to duck and cover.  And similarly, in a pandemic, it's important that we understand as much as we can about the disease and the steps that can help protect us.  And that's where we start the conversation with this particular virus at this point in the pandemic about social distancing, protecting others by staying home if you're sick, trying to avoid other people who may be sick as well, and looking out for the interests of those who may be at higher risk of a more severe illness. 
>> And I wanted to backtrack to the higher education piece, just if you wanted to add something onto that.  Is there different guidance for higher education, university systems, et cetera, versus the K through 12 guidance? 
>> Yeah, there are different guidelines.  They're not so much different guidelines as there's a different focus, because obviously kindergarten is very different from a graduate class in any discipline.  Universities are probably, in general, more well set up to be able to do distance delivered education.  So, a number of universities, universities have already made the decision for the remainder of this semester to not have inperson classes.  And this will also help with reducing the amount of travel.  Universities are also fairly unique in terms of the number of international students, as well as the amount of international travel, as students may want to go overseas or do a semester outside of the United States, they function a bit differently than primary schools.  So, there's both assets that are available at the university level, but also some unique risks, primarily because there's so much more travel associated with attendance at university. 
>> If ever there was a time to be kind to your neighbor, now would probably it, be it.  Are there recommendations for how individual neighborhoods, community groups, civic groups can be mindful at this particular point in time in helping one another through this period of transition? 
>> Yeah, it's important to know, more than ever, who your neighbors are.  If you can find out if they're people who need help, do that. 
^M00:43:59
And that can be done virtually.  There really are advantages of some of the online neighborhood groups.  I saw one recently where someone offered if someone needs groceries, let me know, I'm a retiree, but I'm, I'm a young retiree, I'm healthy, I'll be glad to make that run.  All I'm asking is reimbursement for the amount on the receipt.  And, you know, look out, we do need to look out for one another.  So, it's not a time to stand handinhand, but it is a time to stand together, although six feet apart. 
>> Right.  We all have a role to play in this.  You mentioned early on the issue of transportation.  And there have been a lot of questions about public transportation.  And should individuals who have regular commutes on public transportation, or children that commute to school on public transcription, should they be doing this at this time, or is there a recommendation that maybe they opt for a different mode of travel? 
>> Yeah, public transportation really is a major challenge, because oftentimes these conveyances can be quite crowded.  There's a lot of hightouch surfaces, such as the bars we hang onto when the subway starts or stops.  So, we certainly are concerned about the risk of transmission in those settings.  The most important thing is, again, if you are sick, stay home, because you don't want to be going onto a bus or a subway with a cough and potentially infecting other people.  It's also highlighting the important role of business and encouraging teleworking, to be able to lighten the load on the public transit system.  And then if the load can be lightened enough, that might provide an opportunity for more social distancing aboard the public transportation routes as well.  It's important, it's probably good if you can get some of the small pocketsized hand gel containers.  I understand in many parts of the country, they're hard to get.  But that's a great thing to be able to have to do hand hygiene.  If you've been onboard a subway, for instance, and holding onto the bar, think about that touch surface, and be sure and practice hand hygiene as much as possible.  Keep your hand away from your face. 
>> So, we've had some guidance this week about mass gatherings as well. 
>> Yes. 
>> When we talk about mass gatherings, we're referring to things like public events, whether they're sporting events, or whether they're conferences, business conferences, all types of events of that nature.  There's been new guidance.  Can you speak to the new guidance that's come out this week with respect to mass events?  And also to social gatherings? 
>> Yeah, and the newer guidance is based on some of the observations of how the virus has been transmitted, excuse me, to a relatively large number of people in some settings where people are gathered together.  So, it may be time that we abandon the term mass gathering.  Excuse me.  And focus instead on gatherings in general.  A question that's come up often is, well, how many people should that be?  And as you can imagine, that might be really variable, depending on the type of event.  Here in this room, there's five us.  We're the closest of the five people who are here.  So, this is probably a lowrisk gathering.  On the other hand, if we were sitting next to one another across the front here, that might be a higher risk gathering.  So, at this point in time, the recommendation is to minimize those gatherings altogether.  Gatherings of more than 10 people I think have been particularly called out as of concern.  And we realize that that's very disruptive, because now we've gone beyond just large faithbased gatherings or business conferences, but really we're talking about things like weddings and family gatherings.  So, it's not easy.  Of course, sporting events have been canceled.  Live audience TV shows have either gone without audiences or have been canceled altogether.  So, we do recognize that it's disruptive.  But this is an important part of how we at least start social distancing until we know more about how this pandemic is going to progress and what we can do to slow it. 
>> So, at the outset of our conversation, we talked quite a bit about the healthcare setting and some of the challenges presented to them today and potentially in the future.  One of the questions that's come to us is about, is it safe to go to a hospital.  And I think it might be important to share where CDC provides technical advice in this respect, both to, you mentioned, how you enter a room, a visitation room, and how to not disturb and affect others in the room.  But also about infection control in general in healthcare settings.  Could you speak to both of those issues? 
>> Well, first of all, if you have a lifethreatening condition, or have been in an accident, it is important to seek care still. 
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So, we're not telling people don't go to the hospital.  But we are encouraging people to delay unnecessary visits.  And also to limit visitation to individuals who are in the hospital.  Again, this is part of social distancing.  CDC has some very specific guidelines for healthcare providers to protect themselves, as well as to protect the people that they're caring for.  One of the challenges, though, that we have to acknowledge is that the global supply chain for personal protective equipment is quite strained right now.  And so in some parts of the country, the protective equipment is running thin.  So, CDC is also looking at ways to be able to work with the materials that we have available so that the healthcare system can be flexible during this very challenging time. 
>> So, when we talk about protective equipment, so kind of break that down for our viewers, we oftentimes use shorthand.  We talked about PPE or protective gear.  And what does protective gear encompass?  And what are the most significant parts of protective gear for the healthcare community? 
>> Right.  So, we're talking about things like masks, goggles to protect the eyes, gloves, you know, very broadly, in terms of the COVID19, when particular issues have surrounded masks.  And there's two types of masks.  And, of course, there's more than just two, because we see them increasingly in the community as well.  But from a healthcare standpoint, they're the types of masks that actually filter the air.  N95 is a term people have heard quite a bit lately.  And that's to prevent inhalation of the, of viruses, particularly airborne viruses.  It is possible that we believe that this virus could become airborne in certain hospital situations where aerosols are generated by medical procedures.  On the other hand, surgical masks provide more broadly some protection against respiratory droplet type infections.  And also sometimes we'll put a respiratory, we'll put a surgical mask on someone who is ill with a respiratory illness, if you will, as a splatter shield, so that if they cough or sneeze, those droplets are contained within the mask.  So, surgical masks have both a protective role for people who are not sick and for people who are sick to prevent spread. 
>> In individuals, you know, we saw a rush at the outset of the outbreak for individuals to buy masks and so forth.  It's important to know that we need to preserve those for our healthcare workers that are treating those who may come down with COVID19. 
>> That's right.  And CDC does not recommend use of masks in the general community.  And that's not a new recommendation.  That's been a standing recommendation for some time.  Primarily because there's not a lot of evidence that there's benefit.  We also are concerned about the exposure of hands to the face, as we mentioned earlier.  I've just, anecdotal observation, not true scientific data, I have watched people in public who are wearing the mask, and how often they put their hands in their face to adjust the mask, or to push it away from their eyes.  It really makes me wonder if it actually may have a negative benefit on the risk of infection as well. 
>> How can people in their communities stay plugged in and continue to be informed about COVID19?  Obviously, we've talked about the CDC resources quite a bit.  But in their local area, how can they best get connected to what's happening there? 
>> Well, in addition to the WHO and the CDC websites, each state has a COVID19 website.  And many cities and counties do as well.  So, that's probably your best choice to be able to find out what's going on in your area, as well as what some of the specific recommendations are.  Because while every state has been involved, the intensity of involvement is quite variable around the country.  Some countries, some cities are seeing quite a bit of activity right now.  Other areas, it's more like spots where the disease pops up and there does not seem to be as much community transmission yet. 
>> So, I know that you're a grandfather.  I'm a mother.  My children ask me questions on a daily basis about this outbreak and what they should be doing, what their friends should be doing.  Their school life has been turned over.  What should we be telling our children about this outbreak at this time? 
>> Well, I think it's important to be honest with children.  We shouldn't, you know, say things that are untrue or overly reassuring.  But at the same time, there's no reason to scare kids.  And a lot of the things that we can all do are things that we already tell our kids in terms of washing their hands, covering their cough.  It's more important now than ever.  And explaining things about why schools have closed, that may be a little tougher. 
^M00:54:34
But I think it's okay to frame it in terms of, well, schools sometimes close if there's snow or if there's a storm or if there's earthquake damage.  I mean, these are all things that can be scary.  But they're things that we've experienced in the past.  So, being able to relate to experiences that a child has already had so they can be more confident that this is something that we'll get through as well I think can be very helpful.  And, of course, it's going to be different for every kid.  Just like adults, some are more easily scared than others. 
>> Right, right.  So, age group, I'm sure the message needs to be massaged a little differently. 
>> Right.  And in every family, each kid may be different.  So, that does highlight the important role that parents and grandparents play in being able to deliver those messages in a way that's the right message for each kid. 
>> Right.  And a lot of grandparents have lived through outbreaks.  Right?  So, they were, in their youth perhaps, exposed to measles, and other disease outbreaks, and they can share what that time was like, they can speak from firsthand experience. 
>> That's right. 
>> Which is quite different.  I wanted to thank you for all of your time so far.  We have a few more minutes.  I'd like to take a couple questions if we have time. 
>> That would be great. 
>> In these last remaining minutes that we've received from the public. 
>> Great. 
>> One of the questions, the first questions I'm going to pose to you, is about vaccine development and therapeutics.  How quickly could a vaccine be available to Americans? 
>> Well, first of all, thank you for that, very broadly for that question, because we've talked a lot about hand hygiene and social distancing, quarantine and isolation.  These are some of the important tools in our toolbox.  But some of our tools that we're most accustomed to using, such as, in influenza, such as antiviral drugs or vaccines, are not there yet.  So, there's ongoing work to develop antiviral drugs, or to look at different types of antibodies that can be used in treatment of the infection.  At this point in time, treatment is really symptomatic.  So, it's important to recognize that this isn't like an influenza where there's availability of Tamiflu.  We have no tools like that right now.  A vaccine will ultimately be the best way to protect the entire population against this Coronavirus.  Unfortunately, it will probably be at least a year to a year and a half out.  We are at the point where there is a candidate vaccine that's entering into some human trials.  And these are very early on.  And this includes assessment of what's the best dose of the vaccine, how safe is it, and then it needs to move through the next phase so that it can be evaluated in terms of how effective it is, and how often are there any rare side effects that we need to consider.  The overall goal is we want to make sure that any vaccine that's recommended for the general public, that we can be confident that it's safe and that it is going to be protective as much as possible. 
>> Dr. Butler, thank you so much for your time today.  You have been very gracious with your expertise and the commitment of time that you've given to us this afternoon.  We are taking, we are going to be approaching the top of the hour.  And so we're going to close out today's discussion with a couple of reminders, some things that we've pointed out earlier in our discussion.  If we did not address your questions today, please visit cdc.gov/covid19.  We are also encouraging you to visit the website for your state and local health departments so that you can learn the latest information about COVID19 in your area.  And if you're looking for global information, please visit the World Health Organization's website at who.int.  Thank you for joining us today, and have a great day. 
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