The "Red Dawn" Group

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2020 (April 11) - NYTimes - "He Could Have Seen What Was Coming: Behind Trump’s Failure on the Virus"

An examination reveals the president was warned about the potential for a pandemic but that internal divisions, lack of planning and his faith in his own instincts led to a halting response.

By Eric Lipton, David E. Sanger, Maggie Haberman, Michael D. Shear, Mark Mazzetti and Julian E. Barnes

Published April 11, 2020 / Updated April 26, 2021 / PDF of source : [HN01NU][GDrive]

WASHINGTON — “Any way you cut it, this is going to be bad,” a senior medical adviser at the Department of Veterans Affairs, [Dr. Carter Evan Mecher (born 1956)], wrote on the night of Jan. 28, in an email to a group of public health experts scattered around the government and universities. “The projected size of the outbreak already seems hard to believe.”

A week after the first coronavirus case had been identified in the United States, and six long weeks before President Trump finally took aggressive action to confront the danger the nation was facing — a pandemic that is now forecast to take tens of thousands of American lives — Dr. Mecher was urging the upper ranks of the nation’s public health bureaucracy to wake up and prepare for the possibility of far more drastic action.

“You guys made fun of me screaming to close the schools,” he wrote to the group, which called itself “Red Dawn,” an inside joke based on the 1984 movie about a band of Americans trying to save the country after a foreign invasion. “Now I’m screaming, close the colleges and universities.”

His was hardly a lone voice. Throughout January, as Mr. Trump repeatedly played down the seriousness of the virus and focused on other issues, an array of figures inside his government — from top White House advisers to experts deep in the cabinet departments and intelligence agencies — identified the threat, sounded alarms and made clear the need for aggressive action.

The president, though, was slow to absorb the scale of the risk and to act accordingly, focusing instead on controlling the message, protecting gains in the economy and batting away warnings from senior officials. It was a problem, he said, that had come out of nowhere and could not have been foreseen.

Even after Mr. Trump took his first concrete action at the end of January — limiting travel from China — public health often had to compete with economic and political considerations in internal debates, slowing the path toward belated decisions to seek more money from Congress, obtain necessary supplies, address shortfalls in testing and ultimately move to keep much of the nation at home.

Unfolding as it did in the wake of his impeachment by the House and in the midst of his Senate trial, Mr. Trump’s response was colored by his suspicion of and disdain for what he viewed as the “Deep State” — the very people in his government whose expertise and long experience might have guided him more quickly toward steps that would slow the virus, and likely save lives.

Decision-making was also complicated by a long-running dispute inside the administration over how to deal with China. The virus at first took a back seat to a desire not to upset Beijing during trade talks, but later the impulse to score points against Beijing left the world’s two leading powers further divided as they confronted one of the first truly global threats of the 21st century.

The shortcomings of Mr. Trump’s performance have played out with remarkable transparency as part of his daily effort to dominate television screens and the national conversation.

But dozens of interviews with current and former officials and a review of emails and other records revealed many previously unreported details and a fuller picture of the roots and extent of his halting response as the deadly virus spread:

  • The National Security Council office responsible for tracking pandemics received intelligence reports in early January predicting the spread of the virus to the United States, and within weeks was raising options like keeping Americans home from work and shutting down cities the size of Chicago. Mr. Trump would avoid such steps until March.

  • Despite Mr. Trump’s denial weeks later, he was told at the time about a Jan. 29 memo produced by his trade adviser, Peter Navarro, laying out in striking detail the potential risks of a coronavirus pandemic: as many as half a million deaths and trillions of dollars in economic losses.

  • The health and human services secretary, Alex M. Azar II, directly warned Mr. Trump of the possibility of a pandemic during a call on Jan. 30, the second warning he delivered to the president about the virus in two weeks. The president, who was on Air Force One while traveling for appearances in the Midwest, responded that Mr. Azar was being alarmist.

  • Mr. Azar publicly announced in February that the government was establishing a “surveillance” system in five American cities to measure the spread of the virus and enable experts to project the next hot spots. It was delayed for weeks. The slow start of that plan, on top of the well-documented failures to develop the nation’s testing capacity, left administration officials with almost no insight into how rapidly the virus was spreading. “We were flying the plane with no instruments,” one official said.

  • By the third week in February, the administration’s top public health experts concluded they should recommend to Mr. Trump a new approach that would include warning the American people of the risks and urging steps like social distancing and staying home from work. But the White House focused instead on messaging and crucial additional weeks went by before their views were reluctantly accepted by the president — time when the virus spread largely unimpeded.

When Mr. Trump finally agreed in mid-March to recommend social distancing across the country, effectively bringing much of the economy to a halt, he seemed shellshocked and deflated to some of his closest associates. One described him as “subdued” and “baffled” by how the crisis had played out. An economy that he had wagered his re-election on was suddenly in shambles.

He only regained his swagger, the associate said, from conducting his daily White House briefings, at which he often seeks to rewrite the history of the past several months. He declared at one point that he “felt it was a pandemic long before it was called a pandemic,” and insisted at another that he had to be a “cheerleader for the country,” as if that explained why he failed to prepare the public for what was coming.

Mr. Trump’s allies and some administration officials say the criticism has been unfair. The Chinese government misled other governments, they say. And they insist that the president was either not getting proper information, or the people around him weren’t conveying the urgency of the threat. In some cases, they argue, the specific officials he was hearing from had been discredited in his eyes, but once the right information got to him through other channels, he made the right calls.

“While the media and Democrats refused to seriously acknowledge this virus in January and February, President Trump took bold action to protect Americans and unleash the full power of the federal government to curb the spread of the virus, expand testing capacities and expedite vaccine development even when we had no true idea the level of transmission or asymptomatic spread,” said Judd Deere, a White House spokesman.

There were key turning points along the way, opportunities for Mr. Trump to get ahead of the virus rather than just chase it. There were internal debates that presented him with stark choices, and moments when he could have chosen to ask deeper questions and learn more. How he handled them may shape his re-election campaign. They will certainly shape his legacy.

The Containment Illusion

By the last week of February, it was clear to the administration’s public health team that schools and businesses in hot spots would have to close. But in the turbulence of the Trump White House, it took three more weeks to persuade the president that failure to act quickly to control the spread of the virus would have dire consequences.

When Dr. Robert Kadlec, the top disaster response official at the Health and Human Services Department, convened the White House coronavirus task force on Feb. 21, his agenda was urgent. There were deep cracks in the administration’s strategy for keeping the virus out of the United States. They were going to have to lock down the country to prevent it from spreading. The question was: When?

Dr. Robert Kadlec with the Department of Health and Human Services ran an exercise with the White House Task Force in February that helped convince some in the administration to push for taking more urgent action against the virus. Credit...T.J. Kirkpatrick for The New York Times [HN01NW][GDrive]

There had already been an alarming spike in new cases around the world and the virus was spreading across the Middle East. It was becoming apparent that the administration had botched the rollout of testing to track the virus at home, and a smaller-scale surveillance program intended to piggyback on a federal flu tracking system had also been stillborn.

In Washington, the president was not worried, predicting that by April, “when it gets a little warmer, it miraculously goes away.” His White House had yet to ask Congress for additional funding to prepare for the potential cost of wide-scale infection across the country, and health care providers were growing increasingly nervous about the availability of masks, ventilators and other equipment.

What Mr. Trump decided to do next could dramatically shape the course of the pandemic — and how many people would get sick and die.

With that in mind, the task force had gathered for a tabletop exercise — a real-time version of a full-scale war gaming of a flu pandemic the administration had run the previous year. That earlier exercise, also conducted by Mr. Kadlec and called “Crimson Contagion,” predicted 110 million infections, 7.7 million hospitalizations and 586,000 deaths following a hypothetical outbreak that started in China.

[Note - First mention of this exercise in the newspapers is on March 20, 2020 : https://www.newspapers.com/image/679283129 ]

Facing the likelihood of a real pandemic, the group needed to decide when to abandon “containment” — the effort to keep the virus outside the U.S. and to isolate anyone who gets infected — and embrace “mitigation” to thwart the spread of the virus inside the country until a vaccine becomes available.

Among the questions on the agenda, which was reviewed by The New York Times, was when the department’s secretary, Mr. Azar, should recommend that Mr. Trump take textbook mitigation measures “such as school dismissals and cancellations of mass gatherings,” which had been identified as the next appropriate step in a Bush-era pandemic plan.

The exercise was sobering. The group — including Dr. Anthony S. Fauci of the National Institutes of Health; Dr. Robert R. Redfield of the Centers for Disease Control and Prevention, and Mr. Azar, who at that stage was leading the White House Task Force — concluded they would soon need to move toward aggressive social distancing, even at the risk of severe disruption to the nation’s economy and the daily lives of millions of Americans.

If Dr. Kadlec had any doubts, they were erased two days later, when he stumbled upon an email from a researcher at the Georgia Institute of Technology, who was among the group of academics, government physicians and infectious diseases doctors who had spent weeks tracking the outbreak in the Red Dawn email chain.

A 20-year-old Chinese woman had infected five relatives with the virus even though she never displayed any symptoms herself. The implication was grave — apparently healthy people could be unknowingly spreading the virus — and supported the need to move quickly to mitigation.

“Is this true?!” Dr. Kadlec wrote back to the researcher. “If so we have a huge whole on our screening and quarantine effort,” including a typo where he meant hole. Her response was blunt: “People are carrying the virus everywhere.”

The following day, Dr. Kadlec and the others decided to present Mr. Trump with a plan titled “Four Steps to Mitigation,” telling the president that they needed to begin preparing Americans for a step rarely taken in United States history. [HN01O2][GDrive]

But over the next several days, a presidential blowup and internal turf fights would sidetrack such a move. The focus would shift to messaging and confident predictions of success rather than publicly calling for a shift to mitigation.

These final days of February, perhaps more than any other moment during his tenure in the White House, illustrated Mr. Trump’s inability or unwillingness to absorb warnings coming at him. He instead reverted to his traditional political playbook in the midst of a public health calamity, squandering vital time as the coronavirus spread silently across the country.

Dr. Kadlec’s group wanted to meet with the president right away, but Mr. Trump was on a trip to India, so they agreed to make the case to him in person as soon as he returned two days later. If they could convince him of the need to shift strategy, they could immediately begin a national education campaign aimed at preparing the public for the new reality.

A memo dated Feb. 14, prepared in coordination with the National Security Council and titled “U.S. Government Response to the 2019 Novel Coronavirus,” documented what more drastic measures would look like, including: “significantly limiting public gatherings and cancellation of almost all sporting events, performances, and public and private meetings that cannot be convened by phone. Consider school closures. Widespread ‘stay at home’ directives from public and private organizations with nearly 100% telework for some.”

The memo did not advocate an immediate national shutdown, but said the targeted use of “quarantine and isolation measures” could be used to slow the spread in places where “sustained human-to-human transmission” is evident.

Within 24 hours, before they got a chance to make their presentation to the president, the plan went awry.

Mr. Trump was walking up the steps of Air Force One to head home from India on Feb. 25 when Dr. Nancy Messonnier, the director of the National Center for Immunization and Respiratory Diseases, publicly issued the blunt warning they had all agreed was necessary.

But Dr. Messonnier had jumped the gun. They had not told the president yet, much less gotten his consent.

On the 18-hour plane ride home, Mr. Trump fumed as he watched the stock market crash after Dr. Messonnier’s comments. Furious, he called Mr. Azar when he landed at around 6 a.m. on Feb. 26, raging that Dr. Messonnier had scared people unnecessarily. Already on thin ice with the president over a variety of issues and having overseen the failure to quickly produce an effective and widely available test, Mr. Azar would soon find his authority reduced.

The meeting that evening with Mr. Trump to advocate social distancing was canceled, replaced by a news conference in which the president announced that the White House response would be put under the command of Vice President Mike Pence.

Vice President Mike Pence visiting a Walmart distribution center in Gordonsville, Va. this month. He was put in charge of the coronavirus task force after Mr. Trump clashed with Alex M. Azar II, the health and human services secretary. Credit...Anna Moneymaker/The New York Times [HN01NX][GDrive]

The push to convince Mr. Trump of the need for more assertive action stalled. With Mr. Pence and his staff in charge, the focus was clear: no more alarmist messages. Statements and media appearances by health officials like Dr. Fauci and Dr. Redfield would be coordinated through Mr. Pence’s office. It would be more than three weeks before Mr. Trump would announce serious social distancing efforts, a lost period during which the spread of the virus accelerated rapidly.

Over nearly three weeks from Feb. 26 to March 16, the number of confirmed coronavirus cases in the United States grew from 15 to 4,226. Since then, nearly half a million Americans have tested positive for the virus and authorities say hundreds of thousands more are likely infected.

The China Factor

The earliest warnings about coronavirus got caught in the crosscurrents of the administration’s internal disputes over China. It was the China hawks who pushed earliest for a travel ban. But their animosity toward China also undercut hopes for a more cooperative approach by the world’s two leading powers to a global crisis.

It was early January, and the call with a Hong Kong epidemiologist left Matthew Pottinger rattled.

Mr. Pottinger, the deputy national security adviser and a hawk on China, took a blunt warning away from the call with the doctor, a longtime friend: A ferocious, new outbreak that on the surface appeared similar to the SARS epidemic of 2003 had emerged in China. It had spread far more quickly than the government was admitting to, and it wouldn’t be long before it reached other parts of the world.

Mr. Pottinger had worked as a Wall Street Journal correspondent in Hong Kong during the SARS epidemic, and was still scarred by his experience documenting the death spread by that highly contagious virus. [HN01NY][GDrive]

Now, seventeen years later, his friend had a blunt message: You need to be ready. The virus, he warned, which originated in the city of Wuhan, was being transmitted by people who were showing no symptoms — an insight that American health officials had not yet accepted. Mr. Pottinger declined through a spokesman to comment.

It was one of the earliest warnings to the White House, and it echoed the intelligence reports making their way to the National Security Council. While most of the early assessments from the C.I.A. had little more information than was available publicly, some of the more specialized corners of the intelligence world were producing sophisticated and chilling warnings.

In a report to the director of national intelligence, the State Department’s epidemiologist wrote in early January that the virus was likely to spread across the globe, and warned that the coronavirus could develop into a pandemic. Working independently, a small outpost of the Defense Intelligence Agency, the National Center for Medical Intelligence, came to the same conclusion. Within weeks after getting initial information about the virus early in the year, biodefense experts inside the National Security Council, looking at what was happening in Wuhan, started urging officials to think about what would be needed to quarantine a city the size of Chicago.

An I.C.U. ward at Papa Giovanni XXIII hospital in Bergamo, Italy last month where critical Covid-19 patients were hospitalized.Credit...Fabio Bucciarelli for The New York Times [HN01NZ][GDrive]

By mid-January there was growing evidence of the virus spreading outside China. Mr. Pottinger began convening daily meetings about the coronavirus. He alerted his boss, Robert C. O’Brien, the national security adviser.

The early alarms sounded by Mr. Pottinger and other China hawks were freighted with ideology — including a push to publicly blame China that critics in the administration say was a distraction as the coronavirus spread to Western Europe and eventually the United States.

And they ran into opposition from Mr. Trump’s economic advisers, who worried a tough approach toward China could scuttle a trade deal that was a pillar of Mr. Trump’s re-election campaign.

With his skeptical — some might even say conspiratorial — view of China’s ruling Communist Party, Mr. Pottinger initially suspected that President Xi Jinping’s government was keeping a dark secret: that the virus may have originated in one of the laboratories in Wuhan studying deadly pathogens. In his view, it might have even been a deadly accident unleashed on an unsuspecting Chinese population.

During meetings and telephone calls, Mr. Pottinger asked intelligence agencies — including officers at the C.I.A. working on Asia and on weapons of mass destruction — to search for evidence that might bolster his theory.

They didn’t have any evidence. Intelligence agencies did not detect any alarm inside the Chinese government that analysts presumed would accompany the accidental leak of a deadly virus from a government laboratory. But Mr. Pottinger continued to believe the coronavirus problem was far worse than the Chinese were acknowledging. Inside the West Wing, the director of the Domestic Policy Council, Joe Grogan, also tried to sound alarms that the threat from China was growing.

Mr. Pottinger, backed by Mr. O’Brien, became one of the driving forces of a campaign in the final weeks of January to convince Mr. Trump to impose limits on travel from China — the first substantive step taken to impede the spread of the virus and one that the president has repeatedly cited as evidence that he was on top of the problem.

In addition to the opposition from the economic team, Mr. Pottinger and his allies among the China hawks had to overcome initial skepticism from the administration’s public health experts.

Travel restrictions were usually counterproductive to managing biological outbreaks because they prevented doctors and other much-needed medical help from easily getting to the affected areas, the health officials said. And such bans often cause infected people to flee, spreading the disease further.

But on the morning of Jan. 30, Mr. Azar got a call from Dr. Fauci, Dr. Redfield and others saying they had changed their minds. The World Health Organization had declared a global public health emergency and American officials had discovered the first confirmed case of person-to-person transmission inside the United States.

The economic team, led by Treasury Secretary Steven Mnuchin, continued to argue that there were big risks in taking a provocative step toward China and moving to curb global travel. After a debate, Mr. Trump came down on the side of the hawks and the public health team. The limits on travel from China were publicly announced on Jan. 31.

Email sent among federal government physicians and former senior pandemic advisers by Dr. James Lawler, an infectious diseases specialist and public health expert at the University of Nebraska Medical Center. [HN01O3][GDrive]

Still, Mr. Trump and other senior officials were wary of further upsetting Beijing. Besides the concerns about the impact on the trade deal, they knew that an escalating confrontation was risky because the United States relies heavily on China for pharmaceuticals and the kinds of protective equipment most needed to combat the coronavirus.

But the hawks kept pushing in February to take a critical stance toward China amid the growing crisis. Mr. Pottinger and others — including aides to Secretary of State Mike Pompeo — pressed for government statements to use the term “Wuhan Virus.”

Mr. Pompeo tried to hammer the anti-China message at every turn, eventually even urging leaders of the Group of 7 industrialized countries to use “Wuhan virus” in a joint statement.

Others, including aides to Mr. Pence, resisted taking a hard public line, believing that angering Beijing might lead the Chinese government to withhold medical supplies, pharmaceuticals and any scientific research that might ultimately lead to a vaccine.

Mr. Trump took a conciliatory approach through the middle of March, praising the job Mr. Xi was doing.

That changed abruptly, when aides informed Mr. Trump that a Chinese Foreign Ministry spokesman had publicly spun a new conspiracy about the origins of Covid-19: that it was brought to China by U.S. Army personnel who visited the country last October.

Mr. Trump was furious, and he took to his favorite platform to broadcast a new message. On March 16, he wrote on Twitter that “the United States will be powerfully supporting those industries, like Airlines and others, that are particularly affected by the Chinese Virus.”

Mr. Trump’s decision to escalate the war of words undercut any remaining possibility of broad cooperation between the governments to address a global threat. It remains to be seen whether that mutual suspicion will spill over into efforts to develop treatments or vaccines, both areas where the two nations are now competing.

One immediate result was a free-for-all across the United States, with state and local governments and hospitals bidding on the open market for scarce but essential Chinese-made products. When the state of Massachusetts managed to procure 1.2 million masks, it fell to the owner of the New England Patriots, Robert K. Kraft, a Trump ally, to cut through extensive red tape on both sides of the Pacific to send his own plane to pick them up.

The Consequences of Chaos

The chaotic culture of the Trump White House contributed to the crisis. A lack of planning and a failure to execute, combined with the president’s focus on the news cycle and his preference for following his gut rather than the data cost time, and perhaps lives.

Inside the West Wing, Mr. Navarro, Mr. Trump’s trade adviser, was widely seen as quick-tempered, self-important and prone to butting in. He is among the most outspoken of China hawks and in late January was clashing with the administration’s health experts over limiting travel from China.

Peter Navarro, Mr. Trump’s trade adviser, warned that a pandemic could cost the United States trillions of dollars and put millions of Americans at risk of illness or death. Credit...Doug Mills/The New York Times [HN01O0][GDrive]

So it elicited eye rolls when, after initially being prevented from joining the coronavirus task force, he circulated a memo on Jan. 29 urging Mr. Trump to impose the travel limits, arguing that failing to confront the outbreak aggressively could be catastrophic, leading to hundreds of thousands of deaths and trillions of dollars in economic losses.

The uninvited message could not have conflicted more with the president’s approach at the time of playing down the severity of the threat. And when aides raised it with Mr. Trump, he responded that he was unhappy that Mr. Navarro had put his warning in writing.

From the time the virus was first identified as a concern, the administration’s response was plagued by the rivalries and factionalism that routinely swirl around Mr. Trump and, along with the president’s impulsiveness, undercut decision making and policy development.

Faced with the relentless march of a deadly pathogen, the disagreements and a lack of long-term planning had significant consequences. They slowed the president’s response and resulted in problems with execution and planning, including delays in seeking money from Capitol Hill and a failure to begin broad surveillance testing.

The efforts to shape Mr. Trump’s view of the virus began early in January, when his focus was elsewhere: the fallout from his decision to kill Maj. Gen. Qassim Suleimani, Iran’s security mastermind; his push for an initial trade deal with China; and his Senate impeachment trial, which was about to begin.

Even after Mr. Azar first briefed him about the potential seriousness of the virus during a phone call on Jan. 18 while the president was at his Mar-a-Lago resort in Florida, Mr. Trump projected confidence that it would be a passing problem.

“We have it totally under control,” he told an interviewer a few days later while attending the World Economic Forum in Switzerland. “It’s going to be just fine.”

Back in Washington, voices outside of the White House peppered Mr. Trump with competing assessments about what he should do and how quickly he should act.

The efforts to sort out policy behind closed doors were contentious and sometimes only loosely organized.

That was the case when the National Security Council convened a meeting on short notice on the afternoon of Jan. 27. The Situation Room was standing room only, packed with top White House advisers, low-level staffers, Mr. Trump’s social media guru, and several cabinet secretaries. There was no checklist about the preparations for a possible pandemic, which would require intensive testing, rapid acquisition of protective gear, and perhaps serious limitations on Americans’ movements.

Instead, after a 20-minute description by Mr. Azar of his department’s capabilities, the meeting was jolted when Stephen E. Biegun, the newly installed deputy secretary of state, announced plans to issue a “level four” travel warning, strongly discouraging Americans from traveling to China. The room erupted into bickering.

A few days later, on the evening of Jan. 30, Mick Mulvaney, the acting White House chief of staff at the time, and Mr. Azar called Air Force One as the president was making the final decision to go ahead with the restrictions on China travel. Mr. Azar was blunt, warning that the virus could develop into a pandemic and arguing that China should be criticized for failing to be transparent.

Mr. Trump rejected the idea of criticizing China, saying the country had enough to deal with. And if the president’s decision on the travel restrictions suggested that he fully grasped the seriousness of the situation, his response to Mr. Azar indicated otherwise.

Stop panicking, Mr. Trump told him.

That sentiment was present throughout February, as the president’s top aides reached for a consistent message but took few concrete steps to prepare for the possibility of a major public health crisis.

During a briefing on Capitol Hill on Feb. 5, senators urged administration officials to take the threat more seriously. Several asked if the administration needed additional money to help local and state health departments prepare.

Derek Kan, a senior official from the Office of Management and Budget, replied that the administration had all the money it needed, at least at that point, to stop the virus, two senators who attended the briefing said.

“Just left the Administration briefing on Coronavirus,” Senator Christopher S. Murphy, Democrat of Connecticut, wrote in a tweet shortly after. “Bottom line: they aren’t taking this seriously enough.”

The administration also struggled to carry out plans it did agree on. In mid-February, with the effort to roll out widespread testing stalled, Mr. Azar announced a plan to repurpose a flu-surveillance system in five major cities to help track the virus among the general population. The effort all but collapsed even before it got started as Mr. Azar struggled to win approval for $100 million in funding and the C.D.C. failed to make reliable tests available.

The number of infections in the United States started to surge through February and early March, but the Trump administration did not move to place large-scale orders for masks and other protective equipment, or critical hospital equipment, such as ventilators. The Pentagon sat on standby, awaiting any orders to help provide temporary hospitals or other assistance.

Dr. Carter Mecher with the Department of Veterans Affairs argued to colleagues in late February for so-called targeted layered containment (TLC) and non-pharmaceutical interventions (NPIs), which are measures like closing schools and businesses, to limit the spread of the virus. Mr. Azar and other public health officials came to the same conclusion around that time. [HN01O4][GDrive]

As February gave way to March, the president continued to be surrounded by divided factions even as it became clearer that avoiding more aggressive steps was not tenable.

Mr. Trump had agreed to give an Oval Office address on the evening of March 11 announcing restrictions on travel from Europe, where the virus was ravaging Italy. But responding to the views of his business friends and others, he continued to resist calls for social distancing, school closures and other steps that would imperil the economy.

Pandemic experts, including Mr. Trump’s own former homeland security adviser, Thomas Bossert, compare notes via the Red Dawn email group, after Mr. Trump’s March 11 announcement that he is limiting travel from Europe. [HN01O5][GDrive]

But the virus was already multiplying across the country — and hospitals were at risk of buckling under the looming wave of severely ill people, lacking masks and other protective equipment, ventilators and sufficient intensive care beds. The question loomed over the president and his aides after weeks of stalling and inaction: What were they going to do?

The approach that Mr. Azar and others had planned to bring to him weeks earlier moved to the top of the agenda. Even then, and even by Trump White House standards, the debate over whether to shut down much of the country to slow the spread was especially fierce.

Always attuned to anything that could trigger a stock market decline or an economic slowdown that could hamper his re-election effort, Mr. Trump also reached out to prominent investors like Stephen A. Schwarzman, the chief executive of Blackstone Group, a private equity firm.

“Everybody questioned it for a while, not everybody, but a good portion questioned it,” Mr. Trump said earlier this month. “They said, let’s keep it open. Let’s ride it.”

In a tense Oval Office meeting, when Mr. Mnuchin again stressed that the economy would be ravaged, Mr. O’Brien, the national security adviser, who had been worried about the virus for weeks, sounded exasperated as he told Mr. Mnuchin that the economy would be destroyed regardless if officials did nothing.

Soon after the Oval Office address, Dr. Scott Gottlieb, the former commissioner of the Food and Drug Administration and a trusted sounding board inside the White House, visited Mr. Trump, partly at the urging of Jared Kushner, the president’s son-in-law. Dr. Gottlieb’s role was to impress upon the president how serious the crisis could become. Mr. Pence, by then in charge of the task force, also played a key role at that point in getting through to the president about the seriousness of the moment in a way that Mr. Azar had not.

Dr. Deborah Birx eventually helped convince Mr. Trump that stricter measures needed to be taken. Credit...Anna Moneymaker/The New York Times [HN01O1][GDrive]

But in the end, aides said, it was Dr. Deborah L. Birx, the veteran AIDS researcher who had joined the task force, who helped to persuade Mr. Trump. Soft-spoken and fond of the kind of charts and graphs Mr. Trump prefers, Dr. Birx did not have the rough edges that could irritate the president. He often told people he thought she was elegant.

On Monday, March 16, Mr. Trump announced new social distancing guidelines, saying they would be in place for two weeks. The subsequent economic disruptions were so severe that the president repeatedly suggested that he wanted to lift even those temporary restrictions. He frequently asked aides why his administration was still being blamed in news coverage for the widespread failures involving testing, insisting the responsibility had shifted to the states.

During the last week in March, Kellyanne Conway, a senior White House adviser involved in task force meetings, gave voice to concerns other aides had. She warned Mr. Trump that his wished-for date of Easter to reopen the country likely couldn’t be accomplished. Among other things, she told him, he would end up being blamed by critics for every subsequent death caused by the virus.

Within days, he watched images on television of a calamitous situation at Elmhurst Hospital Center, miles from his childhood home in Queens, N.Y., where 13 people had died from the coronavirus in 24 hours.

He left the restrictions in place.

  • Mark Walker contributed reporting from Washington, and Mike Baker from Seattle. Kitty Bennett contributed research.

  • Eric Lipton is a Washington-based investigative reporter. A three-time winner of the Pulitzer Prize, he previously worked at The Washington Post and The Hartford Courant. @EricLiptonNYT

  • David E. Sanger is a White House and national security correspondent. In a 38-year reporting career for The Times, he has been on three teams that have won Pulitzer Prizes, most recently in 2017 for international reporting. His newest book is “The Perfect Weapon: War, Sabotage and Fear in the Cyber Age.” @SangerNYT • Facebook

  • Maggie Haberman is a White House correspondent. She joined The Times in 2015 as a campaign correspondent and was part of a team that won a Pulitzer Prize in 2018 for reporting on President Trump’s advisers and their connections to Russia. @maggieNYT

  • Michael D. Shear is a White House correspondent. He previously worked at The Washington Post and was a member of their Pulitzer Prize-winning team that covered the Virginia Tech shootings in 2007. @shearm

  • Mark Mazzetti is a Washington investigative correspondent, and a two-time Pulitzer Prize winner. He is the author of "The Way of the Knife: the C.I.A, a Secret Army, and a War at the Ends of the Earth." @MarkMazzettiNYT

  • Julian E. Barnes is a national security reporter based in Washington, covering the intelligence agencies. Before joining The Times in 2018, he wrote about security matters for The Wall Street Journal. @julianbarnes • Facebook


New York Times Red Dawn emails ( made available via NY Times )

Source is available (downloadable) ss a text file (see [HN01Y9][GDrive] ) or as a PDF (see [HN01YA][GDrive] )


Some of the individuals included in these emails
  • Surgeon General of the United States.
      • Dr. Jerome Adams
  • Homeland Security
      • Dr. DuaneCaneva,DHSChief medicalofficer
      • Dr. DavidS Wade, medicalofficer, Departmentof HomelandSecurity,previouslyon NSC
      • Dr. ThomasWilkinson,MedicalInformationOfficer DHS
      • Herbert O. Wolfedirector and actingchief of staff of the Office of the Chief MedicalOfficer at the U.S. Departmentof HomelandSecurity.
      • Dr. DavidTarantino,senior medicaladviser for CBP andcoordinator of the protectionpart of CBP's responseto the opioidcrisis.
      • Dr. GregoryJ. Martin,StateDepartment
      • Dr. Alexander L.Eastmansenior medicalofficer HomelandSecurity
      • Dr. SangeetaKaushikisanemergencymedicinephysicianat DHS
  • STATE Department
      • Dr.LarryG.PadgetJr. StateDepartment
  • Health and HumanServices and Centersfor Disease Control and Prevention
      • BrettGiroir,Assistant Secretaryfor Healthat the U.S.Departmentof Healthand HumanServices
      • [Dr Anthony Stephen Fauci (born 1940)], director of the National Institute of Allergy and Infectious Diseases
      • [Robert Peter Kadlec (born 1957)], Assistant Secretary of Health and HumanServices
      • Dr. RichardHunt,senior medicaladvisor
      • [Dr. Robert Ray Redfield Jr. (born 1951)] ,Director of the Centers for Disease Control and Prevention
      • ChristianHassellSenior ScienceAdvisor at U.S.Departmentof Healthand HumanServices
      • DanielDodgen,director of ASPR Divisionfor At-Risk Individuals,BehavioralHealth,andCommunity Resilience.
      • KristinL.DeBord,Director of StrategyOfficeof the AssistantSecretaryfor Preparednessand ResponseU.S.Departmentof HealthandHumanServices
      • RobertJohnson,Ph.D.,is the Director of the InfluenzaandEmergingInfectiousDiseasesDivisionof BiomedicalAdvancedResearchDevelopmentAuthority
      • KevinYeskey,M.D.currentlyserves as the PrincipalDeputy AssistantSecretaryto the Assistant Secretaryfor PreparednessandResponse(ASPR)at the Departmentof Healthand HumanServices (HHS).Theofficeleads the nationin preventing,respondingto andrecoveringfrom the adversehealth effects of manmadeandnaturallyoccurringdisaster and publichealthemergencies.
      • [Dr. Gary Leo Disbrow (born 1967)] is the Deputy Director (Acting)of the BiomedicalAdvancedResearchand DevelopmentAuthority
      • Dr. JohnT. Redd, a medicalepidemiologistwiththe U.S.Centersfor DiseaseControlandPrevention
  • Department of Defense
      • Col. Matthew Hepburn, M.D.,DARPA program manager, former director of Medical Preparedness on the White House National Security Staff.
  • Department of Veterans Affairs
  • ACADEMICS/PrivateSector/FormerGovernmentOfficials
      • EvaK Lee: American operations researcher who applies combininratorial optimization and systems biology to the study of healthcare decision making at GeorgiaTech
      • Tom Bossert former HomelandSecurity Advisor to U.S. President DonaldTrump.
      • Dr. Dan Hanfling, MD, Clinical Professor of EmergencyMedicine at GeorgeWashington University also with In-Q-Tel
      • [Dr. Ralph Steve Baric (born 1954)], Professor in the Department of EpidemiologyUNC, leader in the study of coronaviruses
      • [Dr. Richard Jones Hatchett IV (born 1968)] CEO Coalition for EpidemicPreparedness. Servedin the White Houses of PresidentsGeorgeW . Bush and BarackObama
      • [Dr. James Vincent Lawler (born 1969)], infectiousdisease doctor atUniversityofNebraska, served as a memberofthe HomelandSecurityCouncilfor PresidentGeorge W . Bush and as a memberof the NationalSecurity CouncilforPresidentBarack Obama.
      • + + Dr. DavidMarcozzi , formersenior advisorfor EmergencyPreparednessand Acute Care within the Centers ofMedicareandMedicaid Services andmemberofWhite HouseNationalSecurity Council.
      • + + + MichaelWargois vice presidentofemergencypreparednessat HCAHealthcare.
      • + + Herbert O . Wolfe ofPennState, formerNationalSecurity Councilstaff at the White House
  • STATE OFFICIALS
      • Dr. Charity A Dean, CaliforniaDepartmentofPublicHealth
      • David GruberTexas Departmentof StateHealth ServicesMobileAssociate Commissionerfor Regionaland LocalHealth Operations, BorderHealth, EmergencyPreparednessand the Texas Center for InfectiousDisease.
      • Dr. Jeffrey S . Duchin, Health Officerand Chief, CommunicableDisease Epidemiology Immunization SectionPublicHealth- Seattle and KingCounty Professorin Medicine, DivisionofInfectiousDiseases, UniversityofWashington

EMAILS: Carter Mecher <Sent: Tuesday, January 28 2020 9: 10 AMTo : Hepburn, Matthew J CIV USARMY (USA) > ;Caneva, Duane < CautionCaution-mailto > Lawler, James V > ;Wargo Michael< :Michael h > RichardHatchettbrian . HARVEY ,MELISSAWade, Dave S . EOP/NSC < > : LisaKoonin > ; Marcozz, iDavid WOLFE, HERBERTSubject: RE [Non-DoD Source] RE: 2019- (UNCLASSIFIED )Updatednumbers. Changed things around to better compare current outbreak to SARS andH1N1. From :Richard Hatchett -mailto Caution- :Sent: Tuesday, January 28 , 2020 2 26 PMTo: CarterCc: Hepburn , Matthew J CIV USARMY DOD JPEO CBRND (USA )Duane V > ; Lawler, JamesMarcozz, iDavidSubject: Re: [Non- Source] RE: 2019- UNCLASSIFIED)> ; Caneva> ; Lisa KooninCarterAm goingthroughan interestingexercisenow of the whatwillyou wish youwould have done if . withtwoscenarios:1) The virus lands in the range of 0. 1- 1. 0 % CFR , which seemsthemostlikelysevere scenario2) The virus turns out, likeH1N1, to be much more widespread than initially appreciated and thus be associated witha much lowermortality than initially thought ( the crying wolf scenario )In mycasethis boils down to three areas of concern:**Status ofvaccinedevelopmen: t how much ?Organizational reputation/accusationsofmismanagement of fundsPotentialpoliticalembarrassmentfor currentand future donorsGrapplingwith both horns of the dilemma here - wouldwelcomeyou wrapping your brain around how to proceedinthemost prudentwayRichard
-----------------------------------------------------------------------------------On 28 Jan 2020, at 18 :04, CarterMecher < > wrote :
The chatter on the blog sis thatWHO and CDC are behind the curve. I' m seeingcommentsfrom people askingwhyWHO andCDC seem to be downplayingthis. I' m certainlyno public health expert (just a dufusfrom the VA) , butnomatterhow I look atthis, it looksbebad. Ifweassumethesamecase ascertainmentrate as the springwaveof 2009H1N1, this looksnearly as transmissibleas flu (butwith a longerincubationperiod andgreaterRo) . Theprojectedsizeof the outbreak alreadyseemshard to believe,butwhen I think of the actionsbeingtaken acrossChina thatarereminiscentof1918 Philadelphia, perhapsthosenumbersare correct. Andifweacceptthatlevelof transmissibility,theCFR is approachingthe rangeofa severeflu pandemic. Butifweassumethe case ascertainmentrate is betterthanH1N1and transmissibilityis less than flu ( it is stillmuchmoretransmissiblethanSARS) , and theCFR goesaccordingly(1918pandemic ) . Andifweassumethe case ascertainment rate is evenworse than 2009H1N1, this is really unbelievable(higher transmiissssiibbiilliittyytthhaann flu . Anyway you cutit, this is going to bebad. Youguysmadefun ofmescreamingto close the schools. Now m screaming, close the collegesand universities.
Is CDC monitoring the blogs ? One thing ' m checking each day is availability of respirators on amazon and ebay (just curious since this is an indirect way of taking the temperature of the country ) .
From : Lawler, James V [mailtoSent: Tuesday, January 28 , 2020 8 :56 PMTo: Hepburn, Matthew J CIV USARMYDODJPEO CBRND (USA)Hatchett Carter MecherCc: Caneva , Duane < v ; LisaKooninRichard> ; Marcozzi, DavidSubject: Re: [ Non- Source]RE: 2019- UNCLASSIFIED)GreatUnderstatementsin History:Napoleon' s retreatfrom Moscow - “ just a little strollgonebadPompeii - " a bit of a duststormHiroshima - summerheatwaveANDWuhan- bad flu seasonJames Lawler,MD, MPH, FIDSADirector, InternationalPrograms & Innovation GlobalCenter for Health Security , and Associate Professor ofMedicineDivision of Infectious DiseasesUniversity of NebraskaMedical CenterFrom : Hepburn , Matthew J CIV USARMY DOD JPEO CBRND (USA )Sent: Tuesday , January 28 , 2020 8 :37: 25 PMTo: Richard Hatchett > ; CarterMecherCc: Caneva, Duane v ; Lawler, James> ;Marcozz, iDavidSubject: RE: Non- SourceRE: 2019- (UNCLASSIFIED)Non-UNMCemailLisa KooninCLASSIFICATION: UNCLASSIFIEDTeam ,am dealing with a very similar scenario , in terms of not trying to overreact and damage credibility . Myargument isthatwe should treat this as the next pandemic fornow , andwe can always scale back if the outbreak dissipates , or isnot as severe .I alsohaveclinicianssaying ' it is like a bad year, butpeopledon' t overreactto that.' Mythoughtis thatmaybeweshouldbemoreaggressivewith flu as well. AND a bad flu year layeredunto a badflu is pretty awfulfor the world.MattOn Jan 29, 2020, at 8 :55 AM , CarterMecher > wrote:You are correct. All this stuff is complicatedandmessyand imperfectfor allthosereasons. The early datais also alittle goofy sincetheearly deathscouldhavebeenpicked up after somebodydied(meaningthattheywentback andlookedatrecentresp deathsand then confirmed the death postmortem) . As timegoeson things startto even outbutthe throughoutdynamicsof screeningandtestingare complicatedtoo just likeyou said.This really underscoreshow allthose tabletopexerciseswedo wherewehave a CFR builtintothem are really soartificia. l I wish therewas somebetterwayoffiguringthis outquicker. I justam notsmart enoughto seehow. Theuncertaintyandthe fog arelike the air aroundus is just a partofit all.suspectsomebodywho knowsqueuingtheory couldhelp unraveltheissues youraise. Theimpactsarenonlinear.(Considerhavingan answeringservicewith 10 operatorsto handle calls with an average calltimeof 3 minutesand avolumeof 200 calls perhour, whatamountoftimedo callersspendon hold waitingto getanoperator? Mostpeoplewould sayyou havejustenough, howeverwhenthenumberof channelsin thequeuebecomessaturated, waitingnatically . Weuse these concepts for clinic scheduling. Could do the samefor testing. Justneed toengage some smartmathematiciansto help you understandimpacts. That is atthe core of the problem you aredescribing. It is a nonlinearaffect that is huge. I would betthat Eva Lee could help unravel. )From : CarterMecher <Date: Wednesday, January 29, 2020 at 9 :04 AMTo: "Lawler, James V "Cc: "Hepburn,Matthew J CIV DOD JPEO CBRND (USA) " @mail.mil> , RichardHatchett "Caneva, Duane" @ . gov Lisa Koonin> "Marcozzi, David" umaryland.eduSubject: Re: [Non-DoD Source RE: 2019- UNCLASSIFIED)Non-UNMC emailDuanewaswatching Africa .Zambia justconfirmed a case.UAE also confirmed a case today .Sent from myiPhoneFrom : Carter MecherSent : Wednesday , January 29, 2020 10 :39 AMTo : Lawler, James VCc: Hepburn , Matthew J CIV USARMY DOD JPEO CBRND (USA ) ; Richard Hatchett; Caneva, Duane; Lisa Koonin ;Marcozzi, DavidSubject : RE : [Non - Source ] RE: 2019- (UNCLASSIFIED )Here is how explain all this to myself (hope itmakes sense) using queuing theory and the example ofthe phonecallers , operators answering the calls , and number ofcallers on hold (and the amount of time they remain on hold ).Let' s assume that anyone who becomes infected immediately is triggered to pick up their phone and call Lisa' stelephone call center. The problem though , is the number works, butthe phones are notmanned (no operators arethere to take the call . Think of reaching the operator as confirmatory testing . These callers just remain on the line,listening to horrible elevator music , with a recorded message that intermittently says , "Please remain on the line, yourcall is very important to us. " So the callers just dutifully remain on the line, waiting for someone to answer. [ reality ,the phone lines are also being clogged with people who have not been infected buthave symptoms suggestive ofinfection — thatis why a simultaneousflu outbreaktakingoff will throw a monkeywrench into all of this (not to mentionthe usualbackgroundresp illnessand otherfebrile illnesseswesee withoutanotheroutbreak to consider) . If we lookat the % ofconfirmatorytests thatare negativewe can get a senseofhow importantthis groupis. Thesecallers tieup the operatortimeand prolong the amountof time infectedcallerswaiton hold.]Butevery two days the numberof infectedcallers on hold listeningto music doubles. someperiodoftime, adiagnostictest is developed thatmighttakeweeks, in which casethe numberof callers on hold is staggering,increasing 10 fold each week untilthe testisready and the operators are availableto answercalls) . The length oftimeon hold is pretty staggeringtoo. Someofthe callers hungup (diedor recovered). Whenthe operatorsbegin toanswer , they alreadyhave a massivebacklogand they don' t take the calls thathavebeenhangingon thelongest. They prioritizethose calls that seem to be themosturgent(the equivalentoftestinghospitalizedpatients, EReen waiting on the line for a very longtime, justlingeron hold).Andas theoperatorsbegin to rampup increasingmorecapacityandmorethroughpu),t the numberofpeoplecallingkeepsincreasingdoublingevery 2 days and increasingby an orderofmagnitudeof everyweek). Theoperatorhasto feellike a checkerworkingthe cashieratWalmarton Black Friday (nomatterhow hard they work, thelinekeepsgettinglongerandlonger). Even if you addmoreoperators, you willneedto increasethem atthe samerate as the epidemic(doublingthenumberofoperatorsevery 2 days, increasingtheirnumberby 10 eachweek, justto staywhereyou are). Now you begin to understandthedynamicsand the challenge. So as thoughtaboutit,there is nowaywe are workingdownanybacklog are growingthe backlogexponentially.Now think of how this translates to surge capacity for healthcare during an epidemic . The dynamics are totallydifferent from a single point event like a bombing , a mass shooting , an earthquake , etc . Large disease outbreaks(pandemics ) are in a class by themselves and they have dynamics that mostpeople do not appreciate .What found interesting during the 2009 H1N1spring wave in the US is that case ascertainment fell over time (thehardtimegettingourheadsaroundexponential growth and geometricprogression mindsare linear (just like peoplehavea timewith compoundinterest(whythey getinto debttroubleor are shockedwhattheypayfor ahouse over the lifeof a loan), orwhathappenswhen startwith a pennyanddouble it every day for amonth and realizehowmany$ thatbecomes, ortake a pieceofpaperand fold itin halfagain andagain ( 30 times) andhearhow thick it is , etc. ).From : "Dr. Eva K Lee"Reply-To: "Dr. Eva K Lee"Date: Friday, January31, 2020 at 3:48 PMTo: "Lawler, James VCc: CarterMecher , " Broadhurs, tMaraJ" < > , "Caneva, Duane"> , LisaKoonin Hepburn, Matthew J CIV USARMYDOD JPEOCBRND(USA)" , RichardHatchettSubject: RE: [Non-DoD Source] RE: 2019-nCoV (UNCLASSIFIED)Non -UNMC emailJames, some reports that for 2019 - has increased significantly from 1. 4 - 2 . 5 on Jan 1, 2020 to 3 . 3 -5 . 37 ( Jan30 , 2020 ). This huge value may be testing artifact as you mentioned . I did some lab experiments , when slightlyimproved the assay process time distribution in the lab processing model that I built , the testing efficiency improvesby 45 % under the samelabor availability . Hence suspect you are going to see rapid uptake in total infectivity andslower growth in death confirmed . As iti s now , with over 11,000 confirmed cases and over 220 deaths , CFR is still2 % , rather high , though much lower than 4 % in the initial guess by some. I think even 1 % is too much to bear .Whattroublesme-- believe there' s human- to -human goingon alreadyefficientlywithin china. I haveneverseenthosemeatmarkets(only been to China 3 times in mylife whenGTsentmeto PekingU ) , so everythingonmymindis justby imagination regardingthosemarkets. Can youbelieveover50 % of these cases comedirectly from animalcontact? I don't believeit. I wonderif theseanimals are live or dead to begin with . Themarketworkersdestroyedsomuch valuableinformation, itisa puzzle still. Butif it can transmitwith few casesinUS, then it is going totransmit.From : Dr. EvaK LeeSent: Monday, February 3, 2020 1: 45 AMTo: Krohmer, Jon (NHTSA) @ dot. govCc: Caneva, Duane @ .gov> ; CarterMecher > ; LisaKoonin> ; DavidMarcozzi umaryland.edu> ; Chaney, Eric (NHTSA)@ dot.gov> ; WILKINSON, THOMAS @hq.dhs.gov> ;Wargo Michael@ hcahealthcare . com > ; n @ uhc. com ; Cormier, Scott@medxcelfm. com > ; .edu; Firoved, Aaron @HQ. DHS.GOV> ; Quitugua ,Teresa @ HQ . DHS.GOV ; @ va.gov Eastman, Alexander@ .dhs.gov> ; HARVEY, MELISSA @ hq.dhs. gov ; CHRISTOPHER ALLEN@ msn. com > ; Luke, Stephen @ .govSubjec:t [EXTERNAL] Firstsetofresults- NationalED OvercrowdingStudy(NEDOCS) and theMedica/ lPublicHealthInformationSharingEnterpriseColleagues, I want to update you on the -nCoV analysis. Please see 7 itemsbelow1. Transmission mechanism : From myanalysis on the vector-host interplay , and confirmed by a localinvestigator ,the realtransmission is probably jumped from bats (carrier) to other animals that are easier to transmit to human . Inmy calculation , about 80 -88 % of the reported cases are human-human transmission (by that, it includes directdroplets and indirect surface). News is that there' s possibility offecal-oral infection .We can't confirm since so littledata is available .2 . Incubation: The currentmean incubation is 5. 2 days and 95th percentile 12 .5days, based on on- the- ground data .[ [shared by a localinvestigator. ]]3. Testingkit: The assayspostedonWHOwebsite( link below ) takesabout2 hoursto confirm. If it is positive, theywillrepeat2moretimesbefore confirming. So it takesabout1/ 2 day for a positivecaseto be announced( excludingthe timeit takes to send the sample to the lab) . Theassays arebeingsentto othercountriesfor diagnostics. I hopetosecuresomeforus in US. Atsomepoint, weneed to compareif there' s any differencein diagnosisin theconfirmationprocessandthreshold.https: / academic.oup. com / clinchem/advance-article/doi/10. 1093/ clinchem / /5719336trictisolation) : urgethat the quarantineof those (evacuated individualscomingback from China -- shouldbe 14 days. Since themilitarybaseis used, it is very importantthat every individualis isolated, andnotbeplaced in groups. Tests can bedonein laterperiodsformultipleintervals, since in early stagetheremaynotbeenough viral counts to render it positive. So it could be a false negative.I ran mymodels assuming 1,000 people staying in themilitary base, using a \ 3 (with mean incubation time 5 . 2 . Ifthere are 5 asymptomatic infection among them , without proper isolation , after 14 days , there could be as high as 160people infected (no symptoms)! Even if there is only 1 infected asymptomatic person the total infected is over 11people. So quarantine must be strategic and done properly with good individual separation . Or else it would result inundetected infected individuals spreading the disease at the end of the quarantine period.5. CFR: From thenews, 360peoplehavediedwith 17,205 infection, CFR remainsat 2. 1. Accountingfortestingdelay, myestimationofinfectionhoversover 110,000 ( in linewith NeilFergusonfrom ImperialCollege) CFRmaybedroppingdown( 0 . ), stillbad. I havederivedseveraltestingmodelsandwillrun thelarge-scalediseasepropagationanalysis. Willupdateyou withmyfindings.6 . Protectionofoperators: trust thathealthcareproviderswill take everyneededprecautionto protectthemselves.Screenersatportsof entry should use gloves (n addition to facemasks.7 . ED issues: There is a realneedand concern to treat these patients separately from hospitalED. Sincemostdeaths reportedhave coexisting health conditions, these 2019-nCoV infected patients should stay far from hospitalfor obviousreasonof crossinfection (or absoluteisolationhas to beensured). The fact Chinarapidly set upmassivetemporaryhospitalsmaysignalthatweneedto do thesame- setupappendix outsidehospitalsfor specialcare of these patients. This also ensuresrapid learningand sharingofknowledgeamongworkersas they take careofthesepatients.More in 2nd round.On Thursday, February6 , 2020 3 19PM , Dr. Eva K Lee @ pm .me> wrote:checkedout a few thingslastnight. Item 3 reallybothersme.1. CFR : Richard , your CFR range of 0 . 1- 1. 0 seem to cover most possible bases , as they re aligned with what amseeing in the analysis . Either we have 28, 363 reported and confirmed infection as oflast night, or it is n the order of50, 000 to 280,000 infection , counting asymptomatic cases or those not reported on purpose . Wemay never know .Mortalitycouldbeeven higherthan 1. 0 . Baseon the extremelystatic reportofdeaths(hoveringover 2 .0 everysingle day) , it seemstomethattheyareonly reportingthose infectedcasesthatresultin deaths. They aremissingallothercasesin which patients did not seekmedicalattention, or simplydie withoutany postmortem confirmation. Itcould bethatthey' re overwhelmed, or simply, deathrate is notreliablyreported. Eitherway, we could have a higherthan 1 % (countingat least50, 000 of infection) .2. Make-shift hospitals : Carter , I saw the picture of themake -shift hospital tent , itlooks very much like the sheltershelped the local health departments setup here to house the Haitievacuees and also those cameto Atlanta escapingthe hurricanes in Houston . I got some on -the -ground clinical parameters and will optimize to identify how muchresource and how to operate to get thebestoutcome. Weneed to know (hopefully CDC on -the -ground team ) howpeople die , if it is because of lack ofmedical care , insufficient care process , ineffective ad -hoc treatment regiment, orsimply the organs fail after all attempts . Everything thathappens in the clinical side is of great importance .3 . Transmission: I am very botheredby the Japanese Cruise's findings and actions: The story is that a guestsailedfrom Yokohamaon Jan. 20 beforedisembarkingon Jan. 25 . He showed no symptomsaboard the ship, but testedpositive for coronavirusin a HongKonghospitalsix days later. Since then 300 peopleon board were tested with 20positive cases. First,we can' t tellhow long thisman was infectiouswhile on board. Butclearly from allmyanalysis,us at that time If hewas, then itwasnotpossiblefor 20 people tobetested positive (notfrom the 5 dayshes on board and not from how rapid andinfectiousit is, I putin alloutrageousvalues). So this is nota single pointsource. Hecan onlybe a single point-source if he is a superspreader- and thathe' s contagiousby Jab 21and thenhe spreadsvery effectivelyacross with at leasteveryoneelse alsobecomesinfectiousafter24 hours upon infection (as in theGermanfirstcase) . I don' t know if the Japaneseintendsto testallremainingpassengersornot. Butit could be a very good caseto analyzein detail, if they can affordto do so. Regardless, I don' t think 300 contact-tracingis sufficient. think they needto samplemore. Ifhe' s not apointsource, allthemore criticalto testmorepassengers.Best, EvaMonday, February 3, 2020 8 :42 AM , Cormier, Scott @medxcelfm. com > wrote:Thank you for the information ! For our experience with the two confirmed cases in Chicago , ' m offering theseadditional comments :Incubation : This data fits perfectly with the husband ofUS patient # 2 (USP2). One of the issues we are facing ishaving to furlough employees . Along with PH and CDC we tracked unprotected exposure to USP2, and intothose that were to be home furloughed for 14 days , and those that had daily sx check . That resulted in 147 contactreviews , ofwhich 61were placed in active monitoring , 29 furloughed with monitoring (asymptomatic ), 7 PUI(homequarantine ), 1 PUI(admitted ), and 49 resolved (no contact found ) . None of the furloughs or s have converted ,and their 14 days will end this week . ForUSP6 (husband ofUSP2), he was not initially placed on any restrictions byPH and CDC , and had visited a cardiology office as well as had visits to the hospital. Fortunately , wehad decided totake extra precautions with USP6 , so we only had 17 contact reviews, but 15 are furloughed with monitoring , and 2are resolved . Of all the contact reviews,mostwere nursing with 2 registration and 1 biomed staff. The contactreview criteria is changing ( for the good , but think it should be a standardized checklist for better support andprocess standardization . None of staff have converted , however , two were found to have strep .Testing Kit: It is taking 3-5 days on average (some longer ) to get test results from the CDC . They had not prioritizedthe confirmed cases over the 's . This is delaying our process to discharge or remove from furlough . Weare toldconfirmed cases will now be a priority , but having local tests will be critical in moving people off offurlough /quarantine /PUIand keeping our health systems functioning .Protection of Operators : Greatpoint. We are using PPEmonitors, who are stationed with our two confirmed cases,and ensure airborne precautions are properly instituted on entry and exit . It seems silly , since airborne is somethingwe do every day, butunfortunately , we know that while it is done every day, it is many times done poorly . This hashelped to boost the confidence of our staff caring for the patients . We are also usingmonitors for our admitted .ED Issues : Wehave screened 20 community ' s in three of our ED' s , and we have a process of Prior notificationand scheduling , exclusive entry and exit , masking PUI, and placement in a negative pressure room . Ithas workedwell without any issues , butit has to be a formalized , trained process.Community Perception: This has been interesting. Two of our nurse have been asked by their churchesnottoattend services (these are smaller community churches while wehave confirmed cases. They do notwork with theconfirmedpatients. ManorCare, a nationallongterm care company, hasnotifiedusthattheywillnotaccepta patientfrom ourhospitalthathasthe two confirmedcasesfor 14 days. Wehave 7 patientsreadyfordischarge, so that istyingupbeds. Ourattorneysare lookinginto this, butnotsureifwecan do anything. Ithasn't affectedourpatientvolumeorprocedures, which is goodnews.Scott CormierVice President, EmergencyManagement, EC , & SafetyMedxcelOn Friday, February 7, 2020 2: 36 PM , Dr. Eva K Lee @ pm .me> wrote:HiJames, I wantto follow upmoreon lastnight' s discussion. I have answeredyour questionsbelow. After thatthoughtaboutstrategiesfor communityscreening, what' s the bestway to do so. And I did a little optimizationto casta neston whatwewantto test andhow to testacross the community. This is very crude, butyou can see thedifferentstrategies:1. Assuming the 14 -day period of incubation , we can reach out to the cohort travelers for the period Jan 24-Feb7 [ [note this lastweek is redundant, since 11airports have started testing. ] through airline operators . Basically theyonly need to send a text to those who have traveled to at-risk areas. In this case , I will cover all international travellerswhere their flight of origin is China, not justWuhan . Individuals who are willing to provide nsal swab and sputumsamples can report to the nearesthealth department. We can also give them a little form to do contact tracingthemselves . This is like population sampling, not everyone will be eager to do it. But some are willing and you will geta sample size. Samples can be shared across all state labs thathave the testing capabitiy to ensure timelyprocessed .To capure potentail cascading effect on the 2nd generation infection , we can move to Jan 17 - Jan 24 cohort and soforth . Clearly theymay nothave any viral activities if they have already shed and passed it onto someone else. Butthe contacttracing form willbeuseful.[ [You can do the samefor Cruises. ] ]This ismore of a global approach using travel and the risk factors as a means to prioritize screening.2 . For a regiona-bl asedapproach, one can approachcommunities- e . ., schools, religiousorganization,sprivatebusinesses, etc, to promotetestingamongthosewhohaverecentlytraveledoutofthe countryto China. Workforcetravelis commonin this connectedworld.Myfeelingis thatitwillbeheterogreneousacrossthe nation since someregionshavemore foreignstudentsfor exampleand othersdon t . Butoutreach via the universityhealthserviceshouldbevery feasible andeasy. In the sametoken regardingprivatebusiness. Althoughstudents/workersmayfearthatif they're tested positive, theywouldbeforcedinto self-quarantine. Myfeelingis thatwe can themessagein a positiveway( as a meansto protecttheirhealth) to promotetheir participation(orthe organizationalparticipation).This approachleveragesorganizationsinfrastructureto help systematicallyrecruit the righttypeofhigh- riskindividualsfor testing.3. On the ground, I do notknow how much testing capabilityandcapacityeach state has.Wedo wantto ensurethatsamplescanbeprocessedin a timelymanner. Certainly one can optimize.This is sort of a strategic systematic way to proritize tests . We don' t need to do it in every state, but strategicallychoose somewith high passenger volumes, or those with connecting routes.Just somethoughts. I unxderstandyou are probablybusywith the evacueestestingnow .Best, EvaFrom : "Dr. Eva K Lee" @ pm .me>Reply-To : " Dr. Eva K Lee" @ pm me>Date: Sunday, February 9, 2020 at 8:29 PMTo: "Lawler, James V " < @ unmc. eduCc: CarterMecher RichardHatchett< @ cepi.net> , "Caneva, Duane"@ hq.dhs. gov> , Hepburn ,Matthew J CIV USARMY DOD JPEO CBRND (USA)"@ mail.milSubject: Re: [Non- Source]RE: 2019- UNCLASSIFIED) - - NPI, Flu vs 2019- , ScalingoftestingthroughputNon-UNMCemailunderstandall ofyou is an expert in this area. Justmy2 cents from thecall1. Carter, I thinkwe can strategically rollout someof the social distancingrecommendations. This can bepartof the public messanging. I think different communitieshave differentwillingness to start. It doesn' t hurt them andense of comfortand awareness. Public health is already doing isolationand quarantine. This isa good timeto testhow well the digitalinfrastructure can supportteleworkbeyond the currentcapacities.Makeit intopart of thenation' s health securityresponsedrillsmayallow for dualpurpose(and secureofnecessarygovernmentfunds).2 . Flu vs 2019- . Perhaps some simple statistics may put people in the right perception :Flu In US: Roughly , 26 millions American affected, 200 ,000 hospitalization , and about 34,000 death . So it is 8. 1 %infectivity , 0 . 7 % hospitalization (of those infected ) , and 0 . 13 % mortality201-9 - in Hubei (11millions ): 16 ,902 reported confirmed cases , 3 ,400 severe / critical conditions ,699 deaths.That relates to 0 . 15 % infection (city isolated entirely within 4 -5 weeks ), 20. 1% hospitalization , and 4 % CFR . Evenwhen factoring in all uncertainties , it' s roughly 0. 15 - 0. 5 % infection , 10-20 % hospitalization , and 1. 7 % -4 % mortality .That' s over 10 -30 timesmore deadly than seasonalflu . Moreever, this is only a lowerboundbecause thefgovernmentbasically shut down and isolate the entire infectedzone. I think this givespeople a sense ofrisk . It is notto make them panic, but to prepare citizens. This is part of the readiness, mentaland physucal.3 . Scale of testing : In order to true testing capacities /surge. , wemust select a collection of assays / reagentsandmake them into standards so that you can handoff to private sectors readily for (mass )production . Heterogeneous / combination selection is a must. You want to allow alternatives and fall-back , and youalso want to scale up by boradening what can be allowed . At some point,we can do result validsation to ensureeveryone is happy with what they are using .4 . Community testingpriority: Hospitalizedpatientscertainlycan and shouldbetested. Butthat' s too late for earlyintervention( exceptcontacttracing) . Primary care wouldbegreat. Universitiesandpharmaciesare goodto include.Strategicsamplingis a mustbecauseyouwon' t be able to hostso many tests so rapidly.5 . Supply Chain : Supply chain is affected already. It is just how far and how broad itmay reach andbefelt .Thailand 's flood and Japan Fukushima delayed the sequencer s production by 2 years, affecting some of themedicalresearcn . That' s very specialized . The current impact is more general as it covers many different industrial sectors .EvaOn Sunday, February 9, 2020 10:59 PM , Lawler, James @ unmc. edu> wrote:Eva your data fit wellwith othermodelers.Weare in mitigation phase and goalis to drive down Ro.James Lawler, MD, MPH ,@ unmc. eduSunday, February 9 , 2020 11: 16 PM , Dr. Eva K Lee @ pm .me> wrote :Yes , absolutely ! And we need public engagement now . Weneed the citizens to know and practice social distancing ina way that best protect them . Every action counts . Communities can help a lot. The aging population with such highpercentage ofindividuals with multiple chronic conditions make it very hard to fight on the treatment front (alone ). It'stoo late and too costly with lower chance of success . Wehave to move the action timeline forward to the pre- emptstage. Whatever we can do to prevent and mitigate will take us a long way. Wealso need to help China to fight andcontain rapidly (so we can learn more how and what s happeneing), or else the global implact on supply - chain andthe economy will be sustantial.China also hasbird flu outbreaknow , very close to the epicenterof2019- All thesezoonoticactivitiesareworrisome. Andwecan ' t controlwhere allthebirdsare flying. .On Sunday, February 9, 2020 12 :54 PM , Lawler, James V @ unmc.edu > wrote :Thanks, Nathaniel. Great stuff . Have you taken a swag at case -ascertainment vs true cases based upon numbers ofcases outsideWuhan /Hubei and positivity rates in folks repatriated from Wuhan in last 10 days ? Those look to have aprevalence rate of 1- 2 % that would presumably reflect community prevalence in Wuhan at the time they wereextracted . This obviously suggests a much higher number of true cases and would match the data that saymostcases are mild/moderate URIand and thatwe are only mostly counting hospitalized pneumonia . Certainly affectsthe CFR prediction quite a bit and our assessment ofhealthcare surge requirement. I think everybody agrees we aredramatically undercounting the real denominator question is by how much . I think we also mostly agree thatwithoutdramatic can expect 30 -40 % infection rate by end of community epidemic - and even with dramatic NPI, thattotalmay only be slightly reduced. Any thoughts there ?James Lawler, MD, MPH, FIDSAFrom : Dr. K LeeSent: Monday , February 10, 2020 7 : 10 AMTo : LawlerCc: Carter Mecher ; Richard Hatchett; Caneva , Duane; Hepburn ,Matthew J CIV USARMY DOD JPEO CBRND(USA )Subject : Re: [Non - Source ] RE: 2019 - UNCLASSIFIED ) -- Strategic testing is a must- - testing capacity - -Stragetic testing is a must- - ifwe trulywant to get a good sense ofwhat' s happeningto the infection in thecommunity levelandhavean ability to prepare the citizens, the community, and the hospitals. [ [Thatis partofmanagingthe expectation. ] ]Diamond Princess - - as I said from the start- - offers thebiggestopportunity to study in multiple levels and I am afriadwith missingopportunitiesandmissteps. And it showswhy strategic( community) testing is amust, andwhy testing - -mustbemade effective andmustbeheterogenouswith allpossibilities.The Cruiseship is a tiny community of itself, and it showswehaveno ability to test even just that.- - 136 confirmedcasesout of 336 testedthusfar.- Japan stillmaintainsthey are goingto testthose with synptomsand the elderly. They should andmusttest all, andtruly use that opportunity to get a good sense of symptomsvs no-symptomsand patternsof allpotentialmanifestation.- The spread - - no doubt - - involves those withoutsymptoms. Who know, theymightbe just so effective to spread.JapanMUSTtest in a nonlinearmanner, it cannot prioritizein a one-side pattern as ithasdoneatthebeginningandcontinue.- Some ,850 passengers made medication requests and about 750 received thus far . A very good example for us totake note. So manypeople need medication - - notjust on the cruise , but everywhere because of prevalence ofchronic diseases.It shows they can' t even contain one cruiseship, nottomentionthe consequenceof their disembarkmen. t- Imaintain those without symptoms must be tested , even if we can' t cover all, wemust sample . That s the onlywayto fill in the gaps.- Carter- - this also re - enforces the notion thatNPIas in socialdistancinghasto beginnow, notlater -- cannotpreparethefuture by acting in the future, wemjustrollingit outnow . There' s noharm to do it, butthere can be a lotregretifnot. And the very concern regardingtesting capabilityremainscritical. Butwith limited testing ability, webetterbe smart in how to sample.- James, perhapsyou andotherscan givemethelaboratoryinformationnow oflocations, varioustestandassociated I can startoptimizing.On Monday, February 10, 2020 7: 21 AM, Carter Mecher r.net> wrote:Eva, below is our review ofthe cruise ship outbreak.The case countaboard cruise ship is now up to 136. This is unbelievable.Goback to the originaldata on this.DiamondPrincess cruise ship with 2 ,666 passengersand 1,045 crew membersDate/ Time20 17 0022 00- 21:00Jan 0700 2327 07 00 :00from Yokohama Tokyo, JapanHongKong ChinaDa Nang Hue28 10:00 18. 0031Jan 07 00 :0001Feb 13 30- :0004Naha Islandin Tokyo hotelData:Jan 20 : Departed from JapanJan 25 : 80- year- old passengerwho disembarked on Jan 25 in HongKongtested positiveon Feb 1.Feb 1: Quarantineprocedureat a port in NNaahhaa ((qquuaarraannttiinneeooffffiicciiaallshadissuedcertificatesallowingpassengersandcrew to land;nooneonboardat thattimeshowedanysymptomsand the case of themanwho disembarkedin HongKongwasnotknownatthattime. Whenresultsknown, certificateoflandingcanceledand secondquarantine. Testsfor theviruswouldbe administeredto three groups: thosewith symptoms, thosewho gotoff in HongKong, andthosewhohad close contactwith the infectedpassenger .Feb 3 Arrivesin portof YokohamaFeb 5 Japan reports 10 passengersconfirmed+Feb 6 : Japan reports10morepassengersconfirmed+ (totalof20); Japanlaterreportsa totalof41passengersnowconfirmed+ for nCoVFeb 7 Japan reportsa totalof61passengersnow confirmed+ forFeb 8 Japan reportsa totalof64 passengersnow confirmed+ forFeb 10: : Japanreportsa totalof 136 passengersnow confirmed+ forIndex case of 80 year old passenger is HongKong Case# 14Case no . Date of laboratory confirmation ; Gender; Age; Nameofhospitaladmitted ; Discharge status Hospitalised14. 01/02/2020 M 80 PrincessMargaretHospitalHospitalisedOver a span of21days (from 20-Feb 10) , this outbreakhas expandedto 136 confirmedcases. Thatis aprevalenceof 3 . 7 % over the span of 3 weeks. Thatis unbelievable.Butgo back and comparethe dynamicsof thenCovoutbreakto the springwave ofH1N1, this outbreak is evenfasterComparison of2009 and 2019-Numberof Cases & Deaths Reportedfrom Dateof 1stKnown CaseCumulativeH1N1Cases and Deaths in USThrough 118 Days from First Case Symptom Onset-Cumulative 2019- andDeaths Through 68 Days fromFirstCase Symptom OnsetedRWeare so far behind the curve.I would drop almost everythingwe are now doing and prepare for implementing TLC ( ).On Monday, February 10, 2020 9:48 PM, Caneva, Duane @ hq.dhs.gov> wrote:Just spoke with Charity.There are some challenges within the PH system to test for community spread, and the CDC are still - 2 weeksfrom operational. Movingforward through healthcare systemsis a greatoption , themore the better. IfKaiser, HCA ,DOD, VA can be leveraged, it's a caseofbeer to the first one to find the case.Whathappenedto Mike C ? ??Should webe worried ?From: "Dr. Eva K Lee" @ pm .me>Reply -To : "Dr. Eva K Lee @ pm me>Date: Monday, February 10, 2020 at 7 : 38 PMTo: "Lawler, James V @ unmc. eduCc: Richard Hatchett @ cepi.net> , Carter Mecher Caneva, Duane"a @ hq.dhs.gov > , "Hepburn , Matthew J CIV USARMY DOD JPEO CBRND (USA )"mail.mil>Subject : Re: [Non- Source] RE: 2019- (UNCLASSIFIED) -- Reachingoutto Kaiser- Strategictestingis amust- - testing capacity - -Non-UNMC emailGuysI just talkedto the KaiserEastCoast askedhim aboutKaiserlaboratory (James, Iwrotehim severalweeksagowhen wetalked aboutlab testingsin December). Hesaid thatKaiserhaslabs, mostlyon the WestCoast.askedhim if the governmentcan outsourceto them the lab tests, he said it shouldbe doableJust one piece of a solutuion , but I think it' s good to recruit them . We have to explore private business engagement.Once you get all the testkits you deem acceptable with clear instruction etc , then you willneed to make/ entice privatesectors to come in and take over the testing responsibility . I am most certain Charity is that the lady on the call fromCalifornia ) knows how to access Kaiser resources . She can ask them . I can facilitate if needed . I have done someclinical work for Kaiser with great implementation results ( improving outcome and reducing cost on their patients ).I think I can ask them to help . And in turn , they can help by reaching to other lab network . I have also extracted tonsof clinical data from their EMR system . I think their lab may have been connected already . . . not sure . I will check .On Thursday, February 13, 2020 9:21AM , Dr. Eva K Lee @ pm .me> wrote :I found it very odd that China is now rolling out the clinically diagnosed cases. All these timeas they reported over47, 000 + confirmed positive cases, they stillhave over 187 ,000 + cases that they are observing clinically . Fair enough ,they can' t confirm yet .Lastnight they reported 242 more deaths, which would have driven the CFR close to 2 . 9 % again . Butconvenientlythey are adding 13, 332 ofthe new cases from the " clinically diagnosed" pool. That keeps the CFR at 2 . 3 % . Thisseemsmore for convenience to smooth the curve rather than to truly have a good sense of what s going on .It is also odd -- why would officials in USkeep saying that they cannot confirm the extent ofhuman -to -humantransmission ? I think the public is confused by all these experts saying conflicting things . Ifhuman -to -humantransmission is still in question , how was the transmission in China ? It' s one thing that predicted based on the socialhuman interact, I got that people don ' thave to believe . But now it is very clear --based onpublished results -- that confirms over 90 % of them are not animal- to -human .I talked to a public official, he thinks this is all overblown . Hethinks flu is whatwehave to fight, not COVID - 19.Tradeoffs on Decision - Public Health and EmergencyResponse NationalED OvercrowdingStudy (NEDOCS)and theMedical/Public Health Information Sharing Enterprise.Sent: Friday, February 14, 2020 8:08 PMFrom : Dr. Eva K Lee @ pm .meTo: HARVEY , MELISSA @ hq. dhs. govCC: Cormier, Scott medxcelfm. com , Krohmer, Jon (NHTSA) @ dot.gov,Caneva, Duane @ .dhs. gov, CarterMecher, David Marcozzi @ som umaryland. edu, Chaney, Eric (NHTSA)@ dot. gov, WILKINSON, THOMAS @ hq.dhs. gov, WargoMichael@ hcahealthcare. com , @ uhc. com @ uhc.comgwu.edu edu, Firoved, Aaron @ .DHS.GOV, Quitugua, Teresa@ HQ .DHS.GOV Kshemendra gov, Eastman ,Alexander @ . gov , CHRISTOPHER ALLEN LukeStephen @ hq.dhs.gov, NathanielHupert @med. cornell.eduI wantto update some analysis - [ Sorry no graphs attached, too many and it will take too long.Protect the operators : I want to update more - maintain as my email said on Jan 31 -- must protect thehealthcare workers and the operators . The latter are not as knowledgeable and as well equipped and they canbe very exposed . Wemust train them well so that they can be protected in thebest possible manner .Infectivity andmortality : again review the models as we put in the dots onto the graphs . It remains withinour zone of prediction , since the models did include asymptomatic cases . The total infection ranges from400 ,000 to 9 million 6 months starting Nov 15 2019 , andmortality from 9 ,000 - 150,000 . The Chinese ishelping. I don ' t really care if they want to report the clinically diagnosed cases , they just have to separate theconfirmed positive vs clinically diagnosed . That is important, even though everything seems like a blackbox andthe test kits are in short supply and still not reliable .adaptability : It seems the virus is really rather adaptable to the human body , exploiting the healthconditions to assert different types of symptoms making it hard to treat and to diagnose . In that case, itcancomeback with morepower.Publichealth strategy (andpublicperception): I understandthere continuesto bedebateson weshouldputin full throttle of effort.Myfeelingis -- Publichealth alwaysfaces such a dilemma.a . Nothingbadwillhappenandweputtoomuchresourcesand effortb . Something reallyhappensand thatwemitigateandmakeit go away -- this is a goodeffortandresult,butunderstandablyit willbe underappreciatedbecausenoonewould know how itwouldplayoutwithoutinterventionandhow bad it is. So successfulmitigationis often under-valued. [ [peoplewillthink it is just (a . ] ]c. Somethingbadhappensandwe didnotdo enough -- that is a bigfallouteveryoneknowsI thinkitis very importantwetakepath (b ) and treat(a ) as a realtest ofhow goodwe canmounta full fight.Thelab tests are the firstbottleneck(besidesallthe biologicaland clinicalunderstandingofthe virus).Weshouldlayit all outallsequencesofeffort anddevelopa fullplan. Itis notgoingto belike a flu plan - becausewedon' t knowmucn abotu this virus. Butwe certainly can adaptit.incorporatethediseasemodelswithin the networkof criticalinfrastructures(Duane, I showedyou thecascadinginterdependencemulti-layergraphswith risksatvariouslayers). Thisviruscould disruptmanylayersthe supply-chainnetworks, truly affectingthewholeworld. Considerit a realugly testthatwe can blanketit andwin it it is a must.Clinicalcases: Pleasesafeguardclinicaldata andtreatmentresponse. ThatwillbeinvaluableandI would liketo performmachinelearningto uncoverpatternsand correlationsBestEvaFrom : Caneva , DuaneSent: Sunday , February 16 , 2020 9 :39 AMTo: Dodgen, Daniel( OSIASPR SPPR ) @ HHS.GOV>; DeBord Kristin (OSASPR/ SPPR )hhs.gov ; Phillips, Sally (OSASPR/SPPR) @ hhs.gov DavidMarcozzi@ som . umaryland. edu> ; Hepburn, Matthew J CIV USARMY (USA) . civ @ mail.mil> ;Lisa Koonin @ gmail.com > ; Wargo Michael @ hcahealthcare. com > ; Walters, William(STATE.GOV @ state. gov HARVEY, MELISSA @ hg. dhs. gov WOLFE, HERBERThq.dhs. gov> ; Eastman , Alexander @ .gov EVANS, MARIEFRED@ associates.hg.dhs.gov Callahan, MichaelV . . D .mgh.harvard.edu UTMB.EDU; email. unc. edu; Johnson, Robert(OS ASPR BARDA) @ hhs. gov > ; Yeskey, Kevin @ hhs. gov Disbrow, GaryOSASPR/BARDA @ . gov> ; Redd, John (OS ASPR SPPR) @ hhs. gov> Hassel,lDavid (Chris) ( @ hhs. gov Hame,l Joseph (OS/ASPR/ IO ) @ hhs. govTracey McNamara @ westernu.edu > ; Dean @ cdph .ca. gov Caneva ,Duane @ .dhs. > ; Richard Hatchett @ cepi.net> ; Lawler, James V@ unmc.edu> ; Kadlec, Robert(OSASPR @ hhs. gov Martin , Gregory J@ state. ) ' @ state . gov ; Borio , Luciana @ igt.org> ; Hanflin,gDan@ . org> ; McDonal,dEric @ sdcount.yca.gov Wade, David @ . gov ;TARANTINO, DAVID A @ cbp. dhs. gov> ; Baric, Ralph S unc.edu> ;WILKINSON.THOMAS @ .dhs.gov ; Hasse,llDavid(Chris) (OS ASPR/ @ hhs. gov> ; DavidGruber dshs. texas. gov) ; KAUSHIK , SANGEETA@ hg.dhs.govSubject : Red Dawn Breaking , COVID - 19 Collaborative , Feb 16 startPurpose : This is a new Red Dawn String to cut down the size from the previous string , opportunity to providethoughts , concerns, raise issues, share information across various colleagues responding to COVID - 19.Including all from previous string plus a few additional folks.DuaneC . Caneva,MD,MSChiefMedicalOfficerDepartmentofExecutiveAssistant : Nichole Burton(U ) Warning: This documentisUNCLASSIFIEDI FOR OFFICIALUSE ONLY(U ). Itcontainsinformationthatmaybe exemptfrom public releaseunderthe Freedom ofInformationActFrom: CarterMecherSent: Monday, February 17, 2020 8 :57 AMTo: McNamara; Dr. Eva K LeeCc: Caneva, Duane; Dodgen, Daniel(OSASPR/SPPR); DeBord, Kristin (OSASPR SPPR); Phillips, Sally(OSASPR SPPR) DavidMarcozz;iHepburn,Matthew J CIV USARMY(USA) ; LisaKoonin WargoMichae;lWalters,William (STATE.GOV ; HARVEY, MELISSA;WOLFE, HERBERT; Eastman, Alexander;EVANS,MARIEFRED; Callahan, MichaelV . , M . D .; @ UTMB.EDU; @ email unc .edu; Johnson, Robert(OS ASPR BARDA) ; Yeskey, Kevin ; Disbrow , Gary (OS ASPR /BARDA) ; Redd, John (OSASPR/SPPR ) ; Hassell,David (Chris) (OS ASPR IO ) ; Hamel, Joseph (OSASPR IO ) A @ CDPH; RichardHatchett; LawlerJames V Kadlec, Robert (OS ASPR ; Martin , Gregory J @ state .gov) Borio , Luciana; Hanfling,Dan ; McDonald , Eric; Wade, David ; TARANTINO , DAVID A ; WILKINSON , THOMAS ; David Gruber@ dshs. texas. gov); KAUSHIK SANGEETA: NathanielSubject: RE RedDawn Breaking, COVID - 19 Collaborative, Feb 16 startNPls are goingto be centralto our responseto this outbreak (assumingour estimatesof severity proveaccurate) This email group hasgrown sincewebegan (notquite epidemic-levelgrowth, butgettingthere . Lookingate wemightencounterpushback over the implementation of NPls and would expectsimilarconcerns/arguments aswere raisedback in 2006 when this strategy first emerged. It was one of the reasonsshared theupdated data on UShouseholds from American Community Survey, data on USDA programs fornutritionalsupport( includingschoolmealprograms), data on schools and enrollment, and even data on juvenilecrime. The data thatwas gatheredback in 2006 on socialdensity in various environments (homesoffices/workplaces, schools, daycare, etc . , is unchanged). Foradditionalbackgroundand context, we attached are 3papers on and TLC for thosewho are interested. Richard Hatchettdeserves full credit for birthing the idea ofTLC ( itwas actually developedin response to the threat ofH5N1and later adopted for pandemic influenzaresponse). Duane, perhapsyou can store these documents on MAX for safe keeping and access?The first paper is an historicalreview ofthe 1918 pandemic (the comparison of Philadelphiaand St. Louis isemblematicofthelessonfrom 1918 thattimingmatterswhen deploying to be early ). The second paperismodelingwork thatwas done to evaluate these strategies. Atthe time, modelerswere focusedon how best tocontain an outbreak overseas (really focusing on usingantivirals primarily for treatment and prophylaxis). Theyfocusedtheirmodels to evaluate the effectiveness of various strategiesand quantities ofantiviralmedicationsrequired to quench an emergingoutbreak. There were 3 groupswho were doing this work back then . They eachpresenttheir data in that paper. A few things to note. In all themodelruns, they did notmodelperfection or 100 %adherence (actually far from it). You will see scenarios from 30/60 (meaning 30% compliance and 60%ascertainment) on up to 90 /80 ). ( See figures 1) Even leaky implementationcan reduceoverall attack rates. Themodelers also looked at timing of implementation(see figure 3 ) At the time therewas a greatdealof skepticismwashard for people to believe this was possible. Oreven if TLC couldbeeffective, was implementationpracticalgiven the challenges trying to implementand the 2nd and 3rd orderconsequences (especially of closing schools). Butthemodeling data combinedwith the historicaldata was the tippingpoint. Marty Cetron [Dr. Martin Stuart Cetron (born 1959)] from CDC and HowardMarkelfrom U of Michigan, published a more extensivehistoricalreview of the 1918 pandemic showingmuch thesame. Since then, a group within CDC continued to work on this (collectingadditionaldata from the 2009 pandemicand elsewhere). They published an update ofCMG in MMWRin 2017. https:/ /protect2 fireeye. com /url? k = 3985fc8765d1e5fb- 3985cdb8-Occ47adc5fa2-bb4a28993b5aa9e0& u https:/ /www.cdc. gov/media/dpk/cdc- 24 -7 /preventingpandemic-influenza/community-mitigation- guidelines- for-preventing-pandemic-flu .htmlThe third paper, is a morerecentpaper(from 2017) thatRichardsharedwithme. Thepaperis a littledense, butI found this paperusefulbecauseit providesa vocabularyforstrategiesthatwehaveraised (Symptom MonitoringvsQuarantineofpotentiallyinfectedbutsymptom-free contacts duringan epidemic) . Thispaperidentifiesthoseconditionswhere SM or Q ispreferred. Figure 1 is usefulforunderstandingthechallengesgiven the picture thatseemsto beemergingwith this virus. This outbreak seemscloserto pandemicflu than SARSin termsofbobtransmissiondynamics(and hence the wewouldneedto employ) .Lastly, anotherperson, Bob GlassatLos Alamos, also did work on this separatelyfrom theMIDASgroup. Heactuallynce fair project for his daughter (using social contacts of his daughter and herclassmates at school to model disease transmission ). Heknew someone at VA who forwarded his work to us (chainof transmission ). Early on (even before the MIDAS group modeled TLC ) ,we had a Eureka moment wegraphed his data in Excel ( can share that single graph to anyone interested ). Bob Glass was also interested in tryingto determine when you could let up on the NPls during a pandemic .Here is a story aboutBob Glass and that workpublished in Fast Company will see if can find his work on when to reopen schools . Decisions in terms of lettingup on NPls could be critical down the line.From : CarterMecherSent: Monday, February 17, 2020 2:57 PMTo: TraceyMcNamara; Dr. Eva K LeeCc: Caneva, Duane Dodgen, Daniel(OS/ASPR SPPR ); DeBord, Kristin (OSASPR/ SPPR); Phillips, Sally(OSIASPR/SPPR) DavidMarcozz;iHepburn, Matthew J CIV USARMY(USA) ; Lisa Koonin WargoMichae;lWalters,William (STATE.GOV) ; HARVEY, MELISSA;WOLFE, HERBERTEastman, Alexander; EVANS,MARIEFRED; Callahan, MichaelV . . . UTMB.EDU ; @ email unc .edu; Johnson, Robert(OSIASPR BARDA ) ; Yeskey, Kevin ; Disbrow , Gary (OS ASPR /BARDA) ; Redd, John (OS ASPR ); Hassell,David (Chris) (OS ASPR IO ) Hamel Joseph (OSASPR ; CDPH ; Richard Hatchett; Lawler,James V ; Kadlec, Robert (OS ASPR IO ); Martin , Gregory @ state. gov Borio, Luciana; HanflingDan ;McDonald, Eric;Wade, David; TARANTINO, DAVID A ;WILKINSON , THOMAS David Gruber;KAUSHIK , SANGEETA ; Nathaniel @ gmail.comSubject: RE: RedDawnBreaking, COVID- 19 Collaborative, Feb 16 startTrying to estimate severity by bringing a number ofpieces together.The DiamondPrincessCruise Ship had a crew of 1,745 and 2 ,666 passengers(totalpf 3,711) Approximately 400ofthepassengersare Americans (11% ). Severaldays ago (Feb-13) we attemptedto estimate disease severity usingthe currentdata beingreportedbythemedia(numberofconfirmedcases and ICU cases) as wellas data on theoutbreak in Singapore(numberofconfirmed cases, numberhospitalized, andnumber in ICU) (see attachedWordfile )Given the additional information becoming available ( including more specific information being reported by the mediaofAmericansinfected) I wasinterestedin an updatedcrude estimate of severity ( andto see howwellthe early predictionsofseveritymatchedwith whatwasbeingreportedby themediaon illness in theAmericans. See latestre the cruise ship outbreakbelow stories) . Wecan glean from these stories that thenumberinfectedis now up to 454. And 14 positivepassengerswere includedamongthe Americanswhowereevacuated to the US. Canada, South Korea, Italy and Hong Kongannounced Sunday that they would also arrangecharter flights to evacuate their citizens . A few additional pieces of data . News reports yesterday stated that 73 of the355 confirmed cases from the cruise ship were asymptomatic 20 % ). Also , yesterday themedia quoted Dr. Faucithat the totalnumber ofAmericans who were confirmed to have COVID yesterday and who remained athospitals inJapan at44. Assuming that this number doesnot include the 14 confirmed cases that were evacuated, suggests thatthe totalnumber of Americans with confirmed COVID is 58. An earliernewsreport from Feb - 12 re a couple fromCalifornia , noted the husband was in the ICU in Japan (so at least 1American in the ICU ). [ . remained in ahospital intensive care unit andhasbeen able to communicate with his family , his wife said in a phone interview fromthe ship , where she remained in quarantine." https:// protect2 fireeve .com / url? k = -075555bf-5b017dfcOcc47adc5fa25be62cf1a816fc6d & u = https:/ /web .archive .org /web /20200212093725 /https:/ /www .ocregister .com / 2020 /02/11/ southern -california -man-on -cruise -sent-to - a -hospital-in - tokyo -with -a -high-fever-tested-for -coronavirus /So, piecing all the data together:The ~ 400 Americans account for 11% of the 3 ,711passengers and crew of the Diamond Princess .The 58 confirmed cases among Americans account for 12 % of the 454 total confirmed COVID casesAssuming that proportion of asymptomatic cases in Americans is similar to the proportion ofasymptomatic cases forthe entire ship (73/355 or 20 % ), we would estimate the number of Americans with asymptomatic infection atSymptomatics would be 46 . If 2 % of cases result in ICU admission (based on earlier estimates on Feb -12 where 4ICU cases were reported with 203 total confirmed cases ), we would expect ICU cases overall with 454 infected .Media reports from today note 19 of the passengers are " seriously ill, with some ofwhom treated in intensive careunits ." (Would be helpful to quantify " some" the earlier data , we would estimate about half that number wouldrequire ICU care at some point ). For the 54 Americans confirmed to have COVID , we would estimate 1 would requireICU care if 2 % of cases required ICU care (we are already aware of at least 1 American who was receiving ICU carein Japan ).So estimates of severity looking only at the American passengers :400 total American passengers58 confirmed to have COVID - 1912 Asymptomatic(20 % )46 Symptomatic( 80 % )totalcases mildly ill (hospitalized for isolation only ) 31cases)- 25 % of totalcases acutely ill requiring inpatient care ( 15 cases)of totalcases requiring ICU admission (1 cases)Expectedmortality for patients with pneumonia admitted to ICU ( 15 -50 % ) ; assuming 2 % of thosewhobecomeinfectedwith COVID- 19 require ICU care, these mortality rates equate to a CFR of 0. 3 % - 1. 0 %Those estimates fit pretty well with the estimates from Feb - 13. To firm up these numbers it would be useful to haveactualnumbers from Japan on ICU admissions , number requiring mechanical ventilation , nbecause they are acutely ill and number in the hospitalbecause of isolation only (mildly ill or asymptomatic ). Alsowould be helpful to havemore granular information on the Americans (hospital data in Japan including numberacutely ill number needing ICU admission , and number only in the hospital for isolation ). Would also be critical togather / compile the same information from Canada , South Korea , Italy , Hong Kong, and other nations as they alsoevacuate their citizens . The cruise ship is a circumscribed population where it is possible to get a handle on severityfairly early in an epidemic . The limitation though , is the population on board that ship is elderly ( so need to be carefulabout generalizing to the entire population ). But it is thebest data wehave.The reasonwhythis is so importantis decisionsre theimplementationofNPls dependupon severity (themoreseverethemoreintensethe . The soonerwehave a moreaccurateassessmentof severity, the better formakingplans forNPls.From : Carter MecherSent: Monday , February 17, 2020 10 : 39 PMTo: Caneva , Duane ; Tracey McNamara ; Dr. Eva K Lee; ail. com￿￿ .com om > ; Dodgen, Daniel(OSASPR SPPR) ; DeBord Kristin(OSIASPRSPPR); Phillips, Sally (OSASPR ) ; DavidMarcozz; iHepburn, Matthew J CIV USARMY(USA) ; LisaKoonin; WargoMichae; lWalters, William (STATE.GOV) ; HARVEY, MELISSA; WOLFE, HERBERT; Eastman,Alexander EVANS, MARIEFRED Callahan. MichaelV . UTMB.EDU unc.edu; Johnson, Robert(OSASPR/BARDA) ; Yeskey,Kevin; Disbrow, Gary (OSASPR/BARDA) ; Redd John (OS ASPR SPPR); Hassell, David (Chris)(OSIASPR Hamel, Joseph (OSASPR IO ) ; A @ CDPH; RichardHatchett; Lawler, James V ; Kadlec,Robert(OS/ASPR/ ; Martin, Gregory J ) ; Borio , Luciana; Hanfling Dan McDonald ,Eric ;Wade, David; TARANTINO , DAVID A ; WILKINSON , THOMAS ; David Gruberis. texas. gov); KAUSHIK , SANGEETA ; Nathaniel HupertSubject :RE: Red Dawn Breaking COVID - 19 Collaborative , Feb 16 startreallyneedhelp thinkingthru the testingpiece(screeningfor COVID- 19) . How doweprotectthe staffin outpatientclinics (whereallthe ILI is typicallyseen and conservePPEby shiftingall themildillness away from clinics andtoward patients' homesusingtelephonecare/ telehealthandhomehealthcareand employinghomeisolationfor thosewho are infectedand voluntaryhomequarantinefor otherwisewell (butexposedandpotentiallyinfectedhouseholdcontacts? Havingallthesuspectedpatientscomingin to clinics to be screenedreally defeatsthepurpose. So howId very large numbers of outpatients get screened ? Home screening ? Drive thru screening ? Or creating a freestanding screening facility for rapid screening ? Has anyone thought this thru (how you screen for disease pluspromote adherence /compliance to home isolation and home quarantine and shift outpatient care of patients with milddisease to telephone /home care to protect outpatient clinic staff ? Looking for practical solutions .Just to remind you, here are the estimates of demand (assuming we would need to screen all ILI — about 88K perday in primary care clinics across the US.US Datapopulation 325,700,000HospitalBeds , 107ICU Beds 81,790Hospital Admissions 36 ,353,946.00ER Visits 145,600, 000Family Practice/PC Visits 481, 963, 000TotalDeaths ,813,503A Day in the USHospitalAdmissions 99,600InpatientCensus 85 % occupancy) 785 491Census (85% occupancy) 69,522ER Visits 398, 904Family Practice/PC Visits 1 ,447DeathsCurrentBackground of Similar to COVID -192019-20 Flu Season MMWR Week 5 ILIRate 6 .7 %1.4M hospitalizations annually forpneumoniaMedicare AverageLOSPneumonia 6 days55 672 pneumonia & influenza deaths annuallyDaily Hospital Admissions PneumoniaHospital Census Pneumonia 23,014Daily cases seen in 26,727Daily cases seen in FP/PC clinics 88,470Daily pneumonia & influenza deaths 1533, 836Tuesday, February 18, 2020 11:01AM , CarterMecher rote:More puzzle pieces re the cruise ship outbreak .About 2 / 3rds ofthe passengers have been tested so far (2 ,404 out of 3 ,711).61Americans opted to remain onboard and not be evacuated .Japanhas completed tests for all passengersand crew aboard the ship as ofMonday, butthe results for thelastbatch of tests aren' t expecteduntilWednesday, the day that the quarantineis slated to end. So far, resultsare back for 2 ,404 passengersand crew , outof the 3,711whowere on board the ship when the quarantinebeganonFeb. 5 .Japanese Health Minister Katsunobu Kato said Tuesday that people who have tested negative for the virus wouldstart leaving on Wednesday , but that the process ofreleasing passengers and crew won 't be finished until Friday,according to theWashington Post.The remaining61American passengers on the DP who opted not to join the evacuation will notbe allowed to returnto the US March 4 , accordingto the American embassy in Tokyo . The governments of Australia , HongKongandCanada have also said they would evacuate passengers.Elsewhere, Japan confirmed threemore cases of the virus. This time, they were confirmed in Wakayama, aprefecturein eastern Japan .February 18, 2020 11:39 AM , Dr. Eva K wrote:WepredictedtheDiamondPrincessinfection totalitybeforethey announcedit. Whatit shows-- is that intervention(NPI)mustbedonetimely. A delayedinterventioncannotreversethe course and canbecatastrophic. Theyhavefarmorepositive infectedcasesthan they shouldhave, havethey interveneddifferentlyand swiftly. The health systemburden cannotbe overemphasized. Justthink about1 % infectionin Georgia, outofthat 20 % requiresmedicalattention. Thatis over 18,000 people. Canwehandle theseextrapeoplein the hospitalsin a timelyand prolongedmanner? That is assumingnooneis goingto infect anyoneanymore. So this is themessagethe localMUSTundersatandand takeactionnow .So assumethose61Americanswillatleastget offthecruiseand stay inland in Japan. AndI hope Japanwillnotmakethe crew stay on boardthe ship forlongerperiod ofquarantine. Everyonehasto get off the shipnow. The shipnow becomesthe bestclinicalforsenic evidenceto study the sufface contact, how longinfectionremainsactiveandof course, large-scaledisinfectionat the very end. ButI hope atleasttheywill collectsomeevidential samplesfirstbeforeeverythingis destroy.From : CarterMecher <Sent: Tuesday, February 18, 2020 1:32 PMSubject: RE: RedDawnBreaking, COVID- 19 Collaborative, Feb 16 startCAUTION : This email originated from outside of DHS. DO NOT click links oropen attachments unless you recognizeand / or trust the sender . Contact your component SOC with questions or concerns.Mythinkingis evolvingin termsofhealthcaresystem response. Initially I described how Iwould refocus theoutpatientclinics away from COVID care and leveragetheNPls ofisolationandquarantineto help keep theworkplacesafe for the clinic staffand otherpatients ratherthan a strategy thatemploysPPE. Iwould onlyuse theoutpatientclinic staff to help with telephone/homecare supportof those patients underhomeisolation or homequarantine help with complianceladherenceto isolationand quarantine, monitoringtheir health, andoptimizingthecare of their other chronicmedicalconditions( to keep them outofthe ER and the hospita)l. Butas I thoughtmoreutthis, itoccurs tomethat this can be generalizedbeyond outpatientclinics.I would think about dividing our healthcare system into two big pieces : (1) acute care (EDs, acute inpatient care ,critical care ); and (2) non acute care including outpatient clinics (PC/Family Practice, pediatrics, OB/GYN ,medicalspecialty , surgical specialty , dental,mentalhealth rehab , . ), as well as other inpatient areas (inpatient mentalhealth, substance abuse , nursing homes, hospice care , memory care , assisted living, etc .). Inpatient surgery ( and Isuppose labor and delivery ) is part of acute care , but for this outbreak , it probably bestbelongs bundled with the othernon -acute inpatient areas. I would anticipate that the tripwire for implementing NPls (community transmission ), willalsobe the triggerforhealthcaresystemsto dialdownor turn off electiveadmissions(primarilysurgica)l to freeupacute care and ICU/monitoredmeds. Themosteffectivewayto protectthesenon-acuteareas is by shuntingpotentialCOVID patientsawayfrom these areasand eitherprovidingthis typeofcarewhile the patientsis hospitalizedinacute care or thru telephonecare/homecare forpatientswithmild illnessreceivingcare athome. And themosteffectivewayto shuntthese patientsawayfrom non-acute care areasis thru theimplementationofearly andaggressiveNPls ofisolationofthe illandhomequarantineofhouseholdcontacts (andnotfit testingtheworld andpassingoutPPE thatwe don' t have).On Tuesday, February 18, 2020 1:51PM, Caneva, Duane wrote :Seems to mea big challenge willbe asymptomatic or mild symptoms in kids, spread through the schools , shed toparents who both categories acute and non -acute care clinics . If there are several days of asymptomaticshedding , how do you prevent spread to the vulnerable , high risk patients in each category ?Willmild symptoms drive complacent compliance ?On Tuesday, February 18 , 2020 2: 20 PM , Dr. Eva K Lee > wrote:Duane, Yes. (asymptomaticormild symptoms) this is theworry at thevery start, anditremainsthemostcritical .Henceeven 1 % ofinfection for us -- canballoonout ofproportionandwecan' t handle. Sheddingnotonly duringinfectionperiod, butalso post-recovery. It' s a very long timelinethatwehave to dealwith . Then youhaveall theuniversity siudents. Students travelledto China and cameback to school, they askedhealth service if they neededtoquarantineor takeany action, theadvice - - noneed. Those aremissedopportunities. Again , seasonalinfluenzaaffects8 - 10 % Americans .7 % of those innffeecctteeddrreeqquuiirreeddhhoossppiittaalliizzaattiioonn andmorality is roughly 0 . 1% . So it is easyto " calculate" all these numbers backwards... So 20 % ofCOVID 19 infectedmayneedhospitalization,mortality is 1030 timeshigher than seasonalflu . How much canwe toleratebefore anyonewould spring into action? Keep in mind,somebegin to infectrapidly upon contractingthe virus, the incubation is so short (and so long) and infectious tooduringthatperiod (with much beingunknown).Carter, I think you will expectheterogeneousapproachesfrom differentcommunitiesin the overallresponsestrategy,since it dependson the socialsettingand the demographicsandmore importantlythe localresources. Wehave tooptimize for sure.On Tuesday, February 18, 2020 7 :56 PM , CarterMecher t> wrote:Japan inching toward mitigationAbeurgespeople with cold- like symptomsto avoid work , schoolToday 06 :30 am JST 24 CommentsTOKYOPrime Minister Shinzo Abe on Tuesday advised people across the country not to go to work or schoolif they developcold -like symptoms, as the country grapples with the spread of a new coronavirus originating in China.Workplacesin the country, knownfortheir longhours need to encouragepeopleto takedaysoffwithouthesitationifthey do notfeelwell, Abesaid." Thefirst thing that I wantthe people of Japan to keep in mindis to take timeoff schoolorwork and refrain fromleavingthe house ifthey develop cold -like symptomssuch as fever, " Abe told a meetingofa governmenttask forceon the viraloutbreak.Teleworking is an "effective alternative" to help preventthe virus from spreading further, Abe said .Hemade the remarks as the government is scrambling to contain the virus that originated in Wuhan , with morepeople with no obvious link to China getting infected in Japan .The global outbreak of the disease called COVID - 19has prompted some event organizers in Japan to rethink theirplans for hosting mass gatherings .Thenumber of confirmed cases in Japan has topped 600, includingover 500 passengers and crew on the DiamondPrincess, a quarantined cruise ship docked atYokohamanear Tokyo with more than 3 , 000 confined .The steadyrisein infectionsin variouspartsof Japanhasraisedpublic concern, promptingthehealthministryto askpeoplewho developsymptomssuch as a temperatureof 37. 5 C orhigherfor at leastfourdaysto consultlocalhealthcare centersand go to designatedhospitals. Theperiodis set shorterfor the elderly, thosewith underlyingconditionsand pregnantwomen.As Tokyo and othermajorcities in the country are notorious for packed rush hourtrains, commutershave beenencouragedby a governmentpanelofmedicalexperts to go to work earlieror later than usualas the risk of infectionis increasedin crowds.On Tuesday , Fujitsu Ltd and Hitachi Ltd said they are expanding teleworking, though Japanese companies overallhave been slow to introduce it.From : CarterMecherSent: Wednesday, February19, 2020 4 :45 PMSubject: RE: Red Dawn Breaking, COVID- 19Collaborative, Feb 16 startWas listeningto the discussiontoday. There wasa discussionabout the shortagesofPPE. There wasalsodiscussionre , but m notsure thatmostfolks appreciatethat the thathavebeenarrayedas partoftheTLC strategyto reducediseasetransmissionin the communitycan beleveragedto create safercompartmentsorspacesby shuntingdiseasetoward thehome. By implementingthese interventions, one could reducethe likelihoodofdiseasein workplaces( homeisolationandhomequarantine keepingsick employeesathomeandkeeping employeeswhoarewellbutpotentially infectedbecausesomeoneis sick in theirhousehold, atneasuresincludingsocialdistancingatwork, helpsto reducecommunitytransmission(addsadditional protectionto the workplace). Theconsequenceis shuntingdiseaseto thehome- 120M differentcompartmentsin theUS, andmakingtheworkplacethe safe place. Thatis potentially veryimportantforcriticalinfrastructure. The answeris notPPE for these employees. Andwhywouldwe expectthat employeesinthese sectorswould haveanybetterIPCwith theuse ofPPE thanwesaw with staff on theDiamondPrincess?Healthcareis a keycriticalinfrastructure. It is differentfrom the othersectorsin thatitwillbeattractingpatientswithCOVID likea magnet. It is hardto imaginehow one couldmakeshealthcare a safeworkplace. Butit is onlyhardtoimaginehow onecould do thatunless youbegin to look a little closeratthedifferentcomponents thehealthcaresystem and the roleseach component mightplayduringthis pandemic.To illustrate this, I took a stab atdevelopinga conopsorroadmapto look atthe variouspiecesofthehealthcaresystem. The shuntingofdiseaseis really fractal . Justaswecan look atshuntingdiseaseacross a communityintoone compartment (thehome) tomakeothercompartmentssafer, wecan do thesamewithin ourhealthcaresystemshuntdiseaseto the acute care area whereCOVID patientswillbeconcentrated. Whatare the strategiesto do that?This conops is notiona. l It is purposelydesignedfor a severeoutbreakwith severe diseaseand assumesthatthehealthcaresystem mustsomehow continueto limp alongand continueto care for thebackgrounddiseasewe seeduringnormaltimes(strokes, fracturesandtrauma, appendicitis, otherseriousinfections, CHF, diabeticemergencies, psychoticepisodes, preeclampsia, complicateddeliveries, end stagerenaldiseaseanddialysis, etc. )aswell as sustain outpatientswith chronic conditionsthatrequiremonitoringand careto keepthem wellandoutofthe ER andoutofthehospita.lFrom : CarterMecherSent: Thursday, February 20 , 2020 6 : 39 AMTo: RichardHatchett; Dr. Eva K LeeCc: Tracey McNamara; Caneva, Duane; @ gmail.com ; Dodgen, Daniel(OSASPR/SPPR); DeBord, Kristin(OSASPRSPPR); Phillips, Sally (OSIASPRSPPR) ; DavidMarcozz;iHepburn, Matthew CIV USARMY(USA) ; LisaKoonin;WargoMichae; lWalters, William (STATE.GOV) ; HARVEY, MELISSA;WOLFE, HERBERT; Eastman,Alexander; EVANS, MARIEFRED; Callahan,MichaelV . , . D . ; @ UTMB.EDU; @ email.unc.edu; Johnson, Robert(OSASPR/BARDA) ; YeskeyKevin; Disbrow, Gary (OSASPR/BARDA) ; Redd, Johnt(OS ASPR ) ; Hassell , David(Chris)(OSASPR IO ) ; Hamel Joseph (OSASPRI Lawler, James V Kadlec, Robert(OSASPR ); Martin Gregory te .gov) ; Borio Luciana; Hanfling, Dan McDonald, Eric; WadeDavid; TARANTINO DAVID A WILKINSON THOMAS: David Gruber ; KAUSHIKSANGEETA ; Nathaniel HupertSubject: RE: Red Dawn Breaking , COVID - 19 Collaborative , Feb 16 startKeeping track ofthe outbreak aboard the cruise ship . The latest update is the announcement of 2 deaths (bothpatients in their 80s). An 87 -year -old man and an 84 -year-old woman , died on the 20th . Both were Japanese (the87-year-old man was hospitalized on Feb - 11and the 84 - year-old women on Feb - 12 ). So time to death fromrecognition of infection was 8 -9 days. On Feb - 12, the total number of confirmed cases was 203. So estimated CFRback dating the denominator to Feb - 12 is 1 % . Assuming a denominator of621, the CFR is 0 . 3 % . deaths arelagging by 8 - 10 days (and confirmed cases plateau ), we should have a pretty good estimate of CFR for he entiregroup in another week or so . Willneed to peel off the number of cases involving the crewestimate of CFR in the elderly. These numbers are within the range we have been estimatingThe 2,666 passengers are similar in age ( and likely in co -morbidities ) to the population we see in a nursing home orresidential care facility . The 1,045 crew are a proxy for a young healthy population . Itwill be important to look at theoutcomes separately . One of the concerns is how a ' remake of this movie' could play out in similarly confinedpopulations of elderly frailAmericans . Here are the numbers of long term care facilities /programs in the US that carefor the frail elderly . A large number of locations and a large number of residents /participants . I know thathealthcareleaders were engaged yesterday , is anyone engaging this sector (long term care )? The healthcare leaders seemedmore concerned about critical supply shortages (akin to the IV fluid shortage ). Listening to them , it felt like theirconcerns seemed almost divorced from the threat of COVID .Number ofFacilities /CommunitiesNumberofAgencies/CentersNumber of Number ofBeds ResidentsNumberofParticipants15 ,60028, 9001,700,0001001 300 ,000811, 500NursingHomesResidentialCareHospice Care|AdultDayCare4 ,300 1 ,400,0004 600 286, 300Source: https: //www.cdc.gov/nchs/ fastats/nursing-home-care. htmThe outbreakon the cruise ship shouldbethe wake up call forleadersin longterm care ( and I would think healthcareoverall)Here is a summary ofthe cruise ship data (as of Feb 20)Date EventCumulativeNumberofConfirmedCasesCumulativeNumberof NotesDeaths20- Jan25 - JanCruise ship departs from Yokohama Japanyear old passenger disembarks in HongKongyear old passenger confirmed to haveCOVID - 191 -FebWhen results known, certificate oflandingcanceled and ship under quarantine . Tests forthe virus would be administered to threeIgroups: those with symptoms, those who gotin Hong Kong, and those who had closecontact with the infected passenger.-Feb Ship arrivesin portofYokohamaJapan415-Feb6 -Feb8 -Feb10 -Feb11-passengers and crew confirmed +more passengersand crew confirmed +more passengerand crew confirmed +morepassengerand crew confirmed +morepassengerandcrew confirmed+170136203218285more passengerand crew confirmed +| more passenger and crew confirmed +passenger and crew confirmed +67 more passenger and crew confirmed +439 tested492 tested4 in ICU713 tested12-Feb13- Feb14 -Feb 927 tested15 -Feb passenger and crew confirmed + 355 73 asymptomatic;1,219 tested16 -FebAmerican evacuated from cruiseship (14 of the evacuees found to be+ ) 61Americansremained onboard 44Americans remained hospitalized in Japan17-Feb more passenger and crew confirmed + 454 191,723tested;seriously ill18-Feb ,011tested19-Febmorepassengerandcrew confirmed+22 ddeeaatthhss 621Data by country is a bit sketchyCountry PassengersTotalConfirmedCases AdmissionsDeathsus 434HongKongCanada330256 32Australia 241 46UKItalySouth KoreaJapanSubtotal 142New virus cruise ship disembarksand kills two Japanesepassengersin hospitalFebruary 20, 2020 11:38Two Japanesemenandwomenin their 80swhowerehospitalizedand treated for the viruswere killed on the 20th ina cruiseship passengerwhowasconfirmedto beinfectedwith the new coronavirus. This is the firsttime a cruiseship passengerhasdied and threepeoplehavebeen killed in the country.As of the 19th ,621 cruise ships outof approximately 3 , 700 crew members and passengers on the cruise ship whereoutbreaks of the new coronavirus were confirmed were confirmed .According to government officials , two of them , a 87- year- old man and an 84-year - old woman, died on the 20th .Both were Japanese and had a basic illness and were confirmed to have been infected with the virus, so itwas saidthatmen were hospitalized on the 11th of this month and women on the 12th to be treated .This is the first time a cruise ship passenger has died.In addition, three people have been killed in Japan , following the death of a woman in her 80sliving in KanagawaPrefecture on the 13th of this month.From : CarterMecherSent: Thursday, February20, 2020 7: 15 AMTo: RichardHatchett; Dr. Eva K LeeCc: TraceyMcNamara; Caneva, Duane; gmail.com ; Dodgen, Daniel(OSASPR SPPR) ; DeBord Kristin(OSASPR/SPPR) ; Phillips, Sally (OSASPR SPPR) ; DavidMarcozzi;Hepburn, Matthew J CIV USARMY(USA) ; LisaKoonin; WargoMichael ; Walters, William (STATE.GOV) ; HARVEY, MELISSA; WOLFE, HERBERTEastman,Alexander; EVANSJohnson , Robert (OS ASPR /BARDA ); Yeskey ,Kevin ; Disbrow , Gary (OS ASPR /BARDA ) ;Redd, Johnt(OS ASPR ); Hassell David (Chris )(OS ASPR IO ); Hamel, Joseph (OS ASPR IO ); Dean , ; Lawler, James V Kadlec, Robert(OS ASPR IO ) ; Martin , Gregory J @ state . gov) ' ; Borio , Luciana; Hanfling, Dan McDonald , Eric ; Wade,David ; TARANTINO , DAVID A ; WILKINSON , THOMAS ; David Gruber @ dshs.texas. gov) ;KAUSHIK,SANGEETA; NathanielHupertSubject : RE: RedDawnBreaking, COVID- 19Collaborative, Feb 16 startWhat hasmeworried is whathappened on the cruise ship is a preview ofwhatwill happen when this virus makes itsway to the US healthcare system (not to mention institutionalized high -risk populations in the US, like nursinghomes ). I 'm not sure that folks understand what is just over the horizon .Remember the story about Mann Gulch ? Weare at the equivalent of about 5 :44. I anticipate that when we reach5 : 45 , there is going to be chaos and panic to get anything in place . I doubt that what we would then hurriedly put inplace will be any better than what they did on that cruise ship . As a consequence , would expectmuch the sameresults .I listened to the discussion yesterday . After listening to James and Michael describe the conditions on and aroundthe cruise ship , Iwondered whether anyone in healthcare leadership (outside the expertise at our biocontainmentfacilities ) is thinking about infection control practices for any staff entering areas of a hospital caring for COVIDpatients ( like changing clothes before entering and perhaps wearing scrubs, notbringing personal items into the arealike iphones , ipads , stethoscopes , white coats , purses , briefcases , etc . ) ? And instituting policies that require allpatients to phone for clearance to enter prior to presenting at safe acute and non -acute areas including communitybased clinics we confident of the infection control practices of acute care staff (that they know the basics of howto don and doff PPE and behavior while in PPE ? ) Would HCWs in outpatient clinics or long term care facilities beany better prepared than the crew on board the cruise ship or the responders in Japan ? 'm no expert in infectioncontrol and would defer to the expertise in this group . I was just a little surprised how little this seemed to be aconcern for the healthcare leaders gathered yesterday .I thinkweare getting close to the point where we need to drop those things that are not criticaland focuson themostimportantthings.We are going to have a devil of timewith lab confirmation — it is just too slow (they had a 2 day turnaround on thecruise ship and we just don ' t have the capacity for the volume of tests we would anticipate . Charity has stressed thispointagain and again . That means we are going to have to fly blind early on . Perhaps the best we are going to bebegin to accelerateis screenallsuspectcases (prettymuchanyonewithsymptomswith a quick flu testandassumeanyonewho testsnegativeis suspectedCOVID untilprovenotherwiseandtreat everyonewho tests positivewith Tamiflu. It will proveproblematicearly on, butastheepidemicbarrelsalong, COVID will displaceeverything( atthatpointwe willjustassumethatanyonewith a feveror ILIhasCOVID). Theproblem is in thebeginning. It is goingto beso hardto sort things out. Matt, Jamesandothersarepushingformorerapid screening but just aren't there yet. The consequenceis thatwewillbeplacingpatientswith resp illness (thatis not flu andpresumedto beCOVID) in areaswith actualCOVID patients. I hate to do that,butnotsurehow it couldbe avoidedearlyon. Butwewould only do thatfor those whoare illenough to behospitalized. Thelargenumberofasymptomaticandmildlyillpatientswouldbeunderhomeisolation (so no worriesaboutmixing confirmedand suspectedpatients) . The downsideis thatwewould havelargernumberofpeopleisisolation andhomequarantinethan is really necessary(and the consequenceofincreasedworkplaceabsenteeism) .And it is becausehomeisolation andhomequarantineare so important , healthcaresystems( andnotjust publichealth) haveto grab a hold ofoperationalizingthose NPlswith bothhands. A while back, I created someprescriptions tonguein cheek) , just to underscorethatphysiciansdo have a role in isolationand quarantine(it is notlimitedto public health). Wemightnothavepharmaceuticalsavailable to treatCOVID, butwhy can' twewriteprescriptionsfornon-pharmaceuticals? don' t thinkhealthcareleadersappreciatethis point. Every COVID patientweadmit or see in the ER willrequireus to follow upwith householdmembersto makesure they know to homequarantine(need to do the sameanywherein our system wefind a patientwho is infected) . You could notimaginethe pushback have receivedwhen proposedthatwemusthavean activerole seem to think that state andlocalpublic health is aloneresponsiblefor this. I would think publichealth willbe overwhelmedand takingchargeofthis is ourbest strategy to keep our safe areas safe.I would be interested to hear how other healthcare systems andpublic health leaders are thinking about this.From : CarterMecherSent: Sunday, February 23 , 2020 7 :28 AMTo: RichardHatchett; Dr. Eva K LeeCc: Tracey McNamara Caneva, Duane com ; Dodgen , Daniel (OSASPR / SPPR ); DeBord , Kristin(OS ASPR SPPR ); Phillips, Sally (OS ASPR /SPPR ); David Marcozzi ; Hepburn , Matthew J CIV USARMY (USA); LisaKoonin ; Wargo Michael;Walters , William (STATE .GOV);edu;Johnson, Robert OS ASPR/ BARDA) ; Yeskey, Kevin Disbrow, Gary OS ASPR/ BARDA) ; Redd,Johnt(OS ASPR ) ; Hassell, David (Chris) ( IO ); Hamel, Joseph (OS ASPR IO )@ CDPH;Lawler, James V ; Kadlec, Robert(OSASPR/IO ); 'Martin, Gregory J @ state.gov) ; Borio,Luciana; Hanfling, Dan; McDonald, Eric;Wade, David; TARANTINO, DAVID A ; WILKINSON, THOMAS; DavidGruber shs.texas.gov) ; KAUSHIK, SANGEETA; NathanielHupertSubject : RE: RedDawnBreaking, COVID- 19 Collaborative, Feb 16 startCruise Ship Update: Japan announced 3rd death. With 634 confirmed cases, lowestlimit of CFR is now at 0 . 5 % .Couldn' t sleep.Woke up with an idea that I wanted to try and articulate.First, I wentthru someofmyold emails and tried to thin thru the conops for envisioninghow to organize and realignthe healthcare system to respondto this loomingthreat.Somefollow up thoughts. Protectingoutpatientcare ( and therole and function ofoutpatientcarewith amassiveshifttoward care deliveredthru a phone) and leveragingTLC ( especiallyhomeisolationandhomequarantine) is relativelystraightforward. Doingthe sameforacute care areasdedicatedfor caringfornon-COVID patientsandlongterm careis muchmorecomplex.A thoughtcameto meas I reread something shared with the group earlier.The conceptof shuntingof disease is really fractal. Justas we can apply and look at shuntingdisease across acommunity into one compartment( the home) to make other compartments safer, we can do the samewithin ourhealthcare system disease to the acute care area where COVID patients willbe concentrated as well asshuntdisease into the home (homeisolation and homequarantine).We talk aboutmedicalhomesfor patients, so think ofthe equivalentof a medicalhomemodelfor inpatientcare. Justas we think aboutshuntingdiseaseto the home(as a meansofprotectingthe entire community) , canwe think of aninpatientarea thesameway. The entire inpatientarea (the entiresafe area ofthehospital) is the communityandwithin the communityare a numberof inpatientmedicalhomes. And those medicalhomeshavethe equivalentofhouseholds(the patient( s ) within thathomeand theHCWscaring for them ). For TLC the smallest unit is thehousehold. Whatis thatequivalentsmallestunit in hospitalsettingThe risk of introducingCOVID into this very dynamiccommunitycan bethru patientsor staff. Thenumberofinpatientstaff is probablyon the orderof 5 FTE perbed(roughly 5M staff for nearly 1 M beds), andnursesaccountforabout 30 % ofhospitalstaff, so about 1. 5 perbed. Thetotalhospitalstaffingincludesnumbers ofemployeeswhonevercomein contactwith patients (oreasily could bepreventedfrom cominginto contactwith patients) .So over the span of a day, thenumberoftotalhospitalpersonnelis about5 times higherthan the numberofinpatients, however, the staff of greatestconcern arenurses. So let' s focuson the primary care giverwho willhavethemostcontactwith the patient nursing. Overthe span ofa day, the numberofnursesthatwillhave contactwithpatients is aboutthe sameasthe numberofinpatients. Nearterm turnoverofnursesis negligible Turnoverofpatients ismuch, much higher(inpatient turningover on averageevery 3 - 4 days). So the risk is much, muchgreaterthatCOVID willbeinadvertentlyintroducedthru a patientwhowasincorrectlytriaged or slips through withasymptomaticdisease.So now let's getback to the idea of an inpatientmedicalhome. Patients are transients . They will enterand stay inthe inpatienthomefor their hospitalization ( 3 - 4 days ). The idea of a homeis to also dedicate inpatient staff to thatofnosocomial transmission/outbreakwithin this acute care area, we can shuntthe diseaseoutbreakto individuailnpatienht omesand protectthe restofthe community(entirehospita).l Ideally, one would wantdedicatedstaff (primarilynursing, butonecouldalso thinkofother inpatientteam memberssuch asNAs, healthtechs, housekeepin,ghospitalis,tetc.). It is unrealisticto have singlepatienthomes (just notenoughstaff to do that).Sowhatcouldbe the smallestunitwithin a hospita?l This doesn' t needto beperfectjustbetterthan randomdistributionofpatientsthroughoutthe hospitalandassignment ofstaffto care forthem . Inpatientwardsdo thisalreadybyspecialty( surgica,ml edica,lpsychiatric, etc. ). Nursingandotherstaff tend to havea homein eithermedicineor surgeryorpsychiatry, butit isn' t ironcladand nursesdo getreassigsimple solution wouldbeto have a ward = inpatient medicalhomebutbemuch stricterin termsofdedicatedstaffing.Soif a staffmemberworkingthere is foundto haveCOVID, we isolatethe staffmemberand quarantinethe ward( effectivelytakingit outof service), butsparingtherestofthehospital . Thesameifwefinda patientwho is foundtohaveCOVID, weisolatethe patientand quarantinethe restof thepatientsand staff. Again, effectivelytakingitoutofservicebutsparingtherestofthehospita. l Itis relatively straightforwardandwardsarephysicallyisolated (so staffandpatientscanbepreventedfrom mixing). This wouldrequiretreatingeachwardas a separateentity (nopatientmovementsto otherwards, exceptfor theneed for ICU care which createsmorethings to think thru). Thatmaywork for largehospitalswith largenumberofwards. Itmaynotwork in smallerhospitalswith few wardsormixedmedica/sl urgicapl atients.Anotherthoughtis to define thepatienthomeby the day of admission. Wedid thatin the old dayswhen I was aresidentandweadmittedpatientsto a team (thatincludedtwo internsand twomedicalstudents) every 3rd day. Butwehousedpatientsalloverthe hospital(prettymuchwherevertherewasan openbed). Think ofdoingexactly thesamebutonly admittingthem to a dedicatedareaorinpatienthomewith dedicatedinpatient24/ 7 staff. Thatwouldssion andkeep them togetherwith single team caringfor them (fromdedicatednursingacrossthe shift, tech, hospitalist , etc. ). Wouldneedto think aboutwhatmakes sense theinpatienthomeopeningits doors for admissionsevery 3 - 4 days or so) . If a patentis foundto haveCOVID, the responsewould focuson thatinpatienthomeisolate the illpatientand quarantinethe restof thehome patientsand staff) . If astaff is found to haveCOVID, the responseagain would focuson the inpatienthome, isolate the staffmemberandquarantinetherestof thehome(patientsandstaff) . Bydefininginpatienthomeby dayofadmission, it alsohelpsusquickly doingthe equivalentofa contacttracing sincewewould know the day the suspectpatiententeredthe systemandwhohadcontactwith the patient .can't underscoreenoughhow importantthe early implementationof TLC is in a communityto tamp downcommunitytransmissionandreducethe probabilitythateithera staffmemberof a patientpresentingto thehospital willbeinfected. It is the singlemostimportantthingwecan do. Thesestrategieshelp to minimizethe disruption shouldinfectiousindividuals(staff or patients) slip thru our defenses.In addition to an inpatient medicalhome, how elsemightwe leverage social distancing and infection control tominimize transmission among staff and patients within an inpatienthome ?The next thing we need to think more about is the nursing home. Should we think of compartmentalizing the nursinghome? The risk to the nursing home is primarily from staff since turnover ofnursing home residents is so low . Arethere ways to create a LTC home where we break the nursing home into smaller subunits or LTC homes with a smallnumber of dedicated /assigned staffing to minimize the introduction of infection from staff into the nursing home or atleast shunt it into a subunit of the nursing home? It is easier to minimize the introduction ofCOVID thru a patient(would need to quarantine all new admissions in an another area for 14 days before allowing them to be introducedinto the nursing home community ). Would also need to make sure that the staff caring for the quarantined nursinghome admission do not care for any nursing home patients or mix ormingle with other nursing home staff . I cantunderscore enough the importance of early TLC in a community to tamp down community transmission and reducethe probability that a staffmember working in a nursing home will become infected . These strategies help to minimizethe disruption should infectious individuals (primarily staff ) slip thru our defenses .Just trying to think thru waysto apply TLCmoreeffectivelyto healthcareto reducetransmissionand shuntdisease tosmallercompartmentsto safeguardthe entire system .On Feb 23, 2020 , at 7: AM , Dr. Eva K Lee > wrote:A few things I want to highlight - -1. Meansofspread A study from AMA confirmedmanyoftheparametersassumed in ourmodels:andwenton infecting 5 relatives. When they testedpositivewas finally isolated, buttestednegativestill, and latertestedpositive, andremain normalon chestCTwith no fever,stomachorrespiratorysymptoms(cough or sore throatas late as Fen 11( timeofthepapertstudy duration) .So spreading and its wide scope is unavoidable because there exists these very healthy individuals who can spreadeffectively - - even during incubation period -- while they remain perfectly healthy . It also showcases difficulty in testing-- negative test -- may notbe the end of it.2 . Iranian cases, though mysterious since the origin was not traced to China, may very well show that COVID - 19virus is very adaptable and mutating rapidly .3. LongrecoveryThe longrecoveryperiod is troubesomeandmustbe taken seriouslyby healthprovidersas theypreparefor hospitalization. Thereis notmuchsurgecapacity in hospitals. So they mustbe innoativein the staggeringprocessandisolationis ofparamountimportance. Governmen/Lt ocalshouldbereadiedfor supplementingmedicaltents outsidehospitalswhenneeded(clearly extra staff too) .4 . Citizes' view I was traveling so I did a real- time on -the-road analysis ofhuman behavior and anxiety level. Ioverheard many people-- (a ) asked when CDC would tell us more on what to do .-- (b ) wish they could pull their kids outof school but there is no such option as part of the preventive measure (notannounced by CDC).-- ( ) wish CDCwouldrecommendtele-work optionsso they don't haveto traveland exposethemselvesand theirfamily to unneccessaryrisk.-- (d) haveno cluewhat thegovernmentis doingto keepthe risk low asitis now. Whatexactlyis beingimplementedto keep it low.5 . Resource- limited countries praythat itwould notreachthe resource-limitedcountrieslikemanyin Africa(though it seemsunavoidable). I cannotimagine the consequence.6 . Whatwemustdo:Wemustleveragethe knowledgefrom other countriesto betterprepareourselves. Japan' sCrusis showsthe importanceof TIMELYproperisolationandSTRATEGICoperationslogisticsin testingandinquarantine. South Korea (contrastingwith HongKong, Singapore) demonstratescriticalimportanceof EARLYsocialdistancingandhigh compliancecommunity intervention. China' s latestlockdownof 1/ billionpeopletrulysignifiesthatgravity anduncharteredterrorityof this virus. No countrywouldtake to such extrememeasure.7 . CFR Sinceover 90 % of influenzaisneverrecorded/known, this COVID- 19 seemsto fall into similar spiritnow ,with somany cases ofasymptomticand transmissionwhile incubating. While the true CFR remainsunknown, theCFR oftested positivecases shouldoffer a good comparisonto theCFR of tested positive flu cases. That gives us aclearer estimate of health-resourceburden .On Sunday, February 23, 2020 11: 35 PM , Kadlec, Robert (OS ASPR > wrote:Eva this true ? ! If so we have a hugewhole on our screening and quarantine effort.(DrLee is a atGaTech.Means of spread A study from AMA confirmedmanyof the parameters assumed in ourmodels :- A 20 -year old infected with COVID -19 leftWuhan and went on infecting 5 relatives. When they tested positive, shewas finally isolated, buttested negative still, and later tested positive, andremain normal on chest CT with no fever,stomach or respiratory symptoms (cough or sore throatas late as Fen 11(time of the papert study duration ).So spreading and its wide scope is unavoidable because there exists these very healthy individuals who can spreadeffectively -- even during incubation period -- while they remain perfectly healthy . It also showcases difficulty in testing-- negative test -- may notbe the end of it.Sent: Monday, February24, 2020 12:07 AM From: Dr. Eva K .meTo: Kadlec, Robert(OS ASPR IO ) ov CC: Giroir , Brett (HHS/OASH gov, Fauci, Anthony( NIH/NIAID ) [ E gov, Redfield, RobertR . (CDC/OD) , Redd, John (OSASPR/SPPR ), Bryan (OSASPR/ IO ) B .gov, Lee, Scott (OSASPR/EMMO), Yeskey, Kevin (OS ASPR / hhs.gov, CarterMecherRichardHatchett pi.net, TraceyMcNamara @ westernu . edu, Caneva Duane(DHS.GOV) @ dhs. gov, mail. com gmail. com , Dodgen, Daniel(OSIASPR/ SPPR ) @HHS.GOV, DeBord, Kristin ( OS/ ASPR /SPPR ) @ hhs. gov , Phillips,Sally (OS ASPR SPPR) @ hhs.gov, DavidMarcozzi @ som .umaryland. edu, Hepburn , MatthewJ CIV USARMY (USA) .civ @ mail.mil @ gmail. com , Walters, William(STATE.GOV) @ state. gov, HARVEY, MELISSA . dhs. gov, Wolfe, Herbert(DHS.GOV)@ hq. dhs. gov, a@ . . gova @hq.dhs. gov, EVANS, MARIEFRED@ associates.hqdhs. gov, Callahan, Michael V . @ mgh.harvard.edu,@ UTMB.EDU edu, email.unc. edu @ email.unc. edu, Johnson, Robert( OSIASPRBARDA) @ hhs. gov , Disbrow, Gary (OS ASPR BARDA @ hhs. gov, Hassel,lDavid (Chris) (OS ASPR @ . gov, Hamel, Joseph (OS ASPR/ @ hhs. gov, Dean,CDPH @ cdph. ca. gov, Lawler, James r @ unmc.edu, Martin ,Gregory J) @ state.gov, Borio , @ iqt.org , Hanfling , iqt.org,@ sdcounty.ca. gov@ sdcounty. ca.gov, WadeDavid . dhs. gov ,@ cbp. dhs. gov @ cbp. dhs. gov, WILKINSON, THOMAShqdhs. gov, @ dshs. texas. gov @ dshs.texas. gov, KAUSHIK ,SANGEETAS hq.dhs. gov ,NathanielOnMonday, February 24 , 2020 12: 07 AM , Dr. Eva K Lee > wrote:HiBobYes, it is reported in JAMA:https: // jamanetwork . com / journals / fullarticle /2762028Clearly, there're stilllots ofuncertainty. However, there is no reason forthem to lie . Furthermore, in thevery firstmodel sentaroundthe resultson Jan 30 , assumeinfectiousfor patients evenduringincubation, during infection,1 / 3 asymptomatic, 2 / 3 symptomatic. I wasmotivatedto do that after talkingto theheadoflaboratoryin HongKongon Jan 29. Hesaidmanycases from his findings supportthatthe viralcounts are simply too low to surfaceatthebeginningandhencecannotbedetected.With that assumption , themodel can explain how and why the spread is so furious in China and why China resorts tocomplete lock down ofHubei, and now 1/ 2 billion people Simply , people are carrying the virus everywhere . And thisyoungwoman is doing exactly that. Shewasn't even tested positive after she infected her 5 relatives . Onlyafterwards . That's why Imodeled the test and told James of the days to test and thatwe either must test all,or wemust sample . The Diamond cruise partially supports that priority screening on only " suspected symptomaticindividuals " are not sufficient. Please note also thatbefore the Jan 23 lock down ofHubei, approx . 5 million peoplehave left the city , traveling everywhere in China . This woman left on Jan 10.Bob , if Europe fails , there is very little chance we can contain . So wemust rolloutthe NPI systematically .Best, EvaOnMonday, February 24 , 2020 5 55 AM , Dr. Eva K Lee < > wrote:HiBob,In addition to the JAMApaper, there ismore -1. Infectiousduring incubation:Attached is anotherpaperthatwillappearin LancetID this week . The viralload atearly diseaseonsetin high. In thisstudy, therewere two individualssheddinghigh level of viralRNAbefore symptoms. The resultin this LancetIDpaperwasthe basis formymodelassumption. [ [ received the initialdraftabout4 weeksago .]]2. DiamondPrincess:If the 80 yearold who boardedthe ship on Jan 20 and disembarkedon Jan 25 and showedsymptomslater andtested positiveon Jan 31, then that s yetanotherasymptomatictransmission. Theway the infectionspreadon theship, even assumingnoquarantineatall, reflects asymptomaticsecondaryinfection too in orderto reach such highnumber. Orthatthismanis a superspreader.3 . Early a must:Even if there is only 1 % COVID- 19 infection, andwithin which 20 % requireshospitalization, this will alreadyoverwhelm ourhealth systems. Singaporeand HongKonghavedemonstratedthat early NPIcanhelp contain andpreventdiseasespread. In HongKong, governmentandprivate sectorsarepracticinghome- office tele-work) ,schools are closed, community service even churchesare doingdistanceworship, and public places are disinfectedregularly, so is personal hygiene. Regardlessifthere is anyasymptomatictransmission, wemusttakethese stepsearly.Weneedto allow parentsmake thatchoice, workersmakethatchoice, withoutbeingpenalizedby theirteachersand employers.4 . Screening: Wemustbe strategic in community screening. Cartermademanypoints. Patientswho have flu - likesymptomswill go to their primary care, pediatrician, urgentcare, or even ED . So there is a big contaminationrisk.Settingup a POD (likemass dispensing) for screeningmightbe good. Sowecan ensure screening is doneproperlyandwith properprotectionto the providers. Since so little is knownaboutthis COVID - 19, a concentratedeffortassuch allowsfor knowledge sharing anddisseminationrapidly across. Itis invaluablefor the whole process.5 . Care for COVID -19patients : advocate separating the COVID -19 patients from hospital ED/ICU patients sinceCOVID - 19 seems to attack patients with co -existing health issues . Hence exiting hospital patients are at high risk .On Tuesday , February 25 , 2020 11:34 AM , Carter Mecher wrote:South Korea now has 977 cases and 10 deaths . are about where Wuhan was on January 25th (so about 1month behind). Wuhan was overwhelmed less than 2 weeks later . I would expect the same for South Korea with theepicenter being in Seoul.I think Iran is about at the same point(maybe even a little ahead ) of South Korea. Tehran is another very large citythat will likely becomes its epicenter .I see a few hopeful signs. Singapore and Hong Kong have done a great job thus far and have implementedvery early . Both have great surveillance . They are holding the line. They are also small and islands. Japan on theother hand is struggling and hasn't been as aggressive as Singapore and HongKong.Theother thing thatgivesmehopeiswhatI see in HubeiandWuhan. realize the data is a little sketchybecauseChinahasgoneback andforth with the definitionofcases, butI tried to smooth thatoverby lookingat cumulativehospitalizationratesper 100,000 (likewedo for flu ) . Hubei(andWuhan is a city withinHubei ) reportseach day thecurrentnumberofpeople in thehospital( # currently in severe condition, in criticalcondition) , cumulativenumberofhospitaldischarges, cumulativedeaths, andcumulativecases. From thiswecan estimate cumulativehospitalizationsand then rates. 92 % ofthe caseshavebeenhospitalized(up thru Feb 2nd 100% of the casesthey reportedwerehospitalized) Knowingthe numberof cases in Wuhan, wehavebeen estimatingthe numberhospitalizedassumingasimilar % ofthe casesrequiringhospitalizationrate forWuhan (that92 % ofthe cases arebeinghospitalized thatnumberis adjustedeach day basedon currentdata ). So wereally can' t back outtheWuhannumbersfrom theHubeinumbers. Thebestwecan do is compareHubeitotals (includingWuhan) with an estimateofWuhan. Thisdata isgoodenough to show thatthe Chineseappearto be slowing transmissionoutsideofWuhan (Theywere late toimplementNPlsin Wuhanbutwere able to implement earlier in the epidemicoutsideofWuhanbecausetheoutbreakhadabouta 2 week head-start in Wuhan) .< EOB38B2300CE43F09DC37BFDDDB81F.p3nCg>Weneedto emulatethebluecurve. If could subtractWuhan, this curvewouldbesignificantlylower.Remember the goals ofNPls.From : Caneva, DuaneSent: Monday, February 24, 2020 12 : 28 PMTo: Subject: RedDawnBreakingBad, StartFeb 24Importance: HighAllThis is a new RedDawn Email String. Pleaseuse this one going forward .BestDuaneDuane C. Caneva, MD MSChiefMedicalOfficerDepartment of Homeland Security(U) Warning: This documentis UNCLASSIFIED//FOR OFFICIALUSE ONLY (U //FOUO). It contains information thatmaybe exemptfrom publicreleaseunderthe Freedom of InformationActFrom : Carter MecherSent: Monday, February 24 , 2020 4 :58 :53 PMTo .dhs .gov @ hq.dhs. gov ; Richard Hatchett@ cepi.net> ; Caneva Duane.dhs. > gmail.com . com > ; Dodgen, Daniel( )@ HHS.GOV>; DeBord Kristin (OSASPR ) @ hhs. gov Phillips, Sally(OSIASPR SPPR ) @ hhs. gov> David Marcozzi @ som.umaryland. edu> ; Hepburn, MatthewCIV USARMY(USA) n . civ @mai.lmil ; LisaKoonin @ gmai.lcom > ;Walters,William@ state .gov ; HARVEY, MELISSA . dhs.gov WOLFE, HERBERT@ hg.dhs.gov> ; Eastman, Alexander @ . . gov> ; EVANS, MARIEFRED@ associates. .gov> ; Callahan MichaelV .. . .@ mgh.harvard.edu> ; UTMB.EDU mb.edu ; @ email.unc. edumail.unc. edu > ; Johnson, Robert(OS ASPR/BARDA) <Robert. Johnson@ hhs. gov ; , Kevinhhs.gov>; Disbrow, Gary ( ASPR/ BARDA) @hhs. > ; Redd, John(OSASPR SPPR) @ hhs. ; HassellDavid(Chris) (OSASPR ) @ hhs.gov> ; Hame,lJoseph (OS ASPR hhs. gov ; Dean, Charity A CDPH @ cdph. ca . gov ; Lawler,James V @ unmc. edu> ; Martin, Gregory @ state .gov Borio, Luciana< org> ;Hanfling, Dan @ iqtorg> ; @ sdcounty. ca .gov @ sdcounty. ca. gov > ; Wade,David @ hg. dhs.gov ; TARANTINO, DAVID A @ cbp . dhs. gov ; WILKINSON ,THOMAS @ . dhs. gov@ dshs. texas . gov @ dshs.texas .gov > ;KAUSHIK SANGEETA kaushik @ .dhs. gov Nathaniel Hupert @ med.cornell. edu> ;McNamara ra @ westernu.edu > Eva K Lee Lee, Scott@Subject: RE: RedDawn Breaking Bad, Start Feb 24Several new countries announced first confirmed casesAfghanistanBahrainIraqKuwaitOmanFrom : Walters , William @ state . govSent: Tuesday , February 25 , 2020 6 : 56 PMTo: @ . dhs. gov; Richard Hatchett @ cepi.net> ; Caneva, Duane@ hg.dhs gmail.com ; Dodgen, Daniel (OSIASPR SPPR )@HHS.GOV > ; DeBord Kristin (OSASPR SPPR ) @ hhs. gov> ; Phillips, Sally(OS/ ASPR/ SPPR) @ hhs.gov> DavidMarcozzi i @ som . umaryland.edu > ; Hepburn , MatthewCIV USARMY (USA iv @ mail.mil> ; Lisa Koonin @ gmail.com > ; HARVEY, MELISSA@ .dhs. gov> WOLFE, HERBERT @ . gov Eastman, Alexander@ .dhs.gov EVANS, MARIEFRED @email.unc.edu; Johnson,Robert (OS/ASPR/BARDA) < @ hhs. gov Yeskey, Kevin @ hhs.gov Disbrow, Gary(OSASPR/ BARDA) @ hhs. gov> ; Redd, John(OSASPRSPPR) hhs. gov> ; Hassell,David (Chris) (OS ASPR l @ . gov > ; Hamel, Joseph (OS/ASPR/ IO ) el @ hhs . gov ;Dean, Charity A @ CDPH < Charity . Dean @ cdph .ca. gov ; Lawler, James V <james. lawler @ unmc. edu ; MartinGregory tate .gov Borio, Luciana org >@ hq.dhs. gov ; TARANTINO,DAVID .dhs.gov > ; WILKINSON, THOMAS@ .dhs.gov r @ dshs.texas. gov; KAUSHIK, SANGEETA@ hq.dhs. gov> ; NathanielHupert 005 @ med. cornell.edu> ; TraceyMcNamarasternu.edu> ; . K Lee Lee, Scott .gov> ; CarterMecherSubject: Re: Red Dawn Breaking Bad, Start Feb 24Colleagues,Does anyonehave a case fatality rate projection broken down by age?William A . Walters , M . D . ,MBAExecutive Director andManaging Director for OperationalMedicineBureau of Medical ServicesU . S . Departmentof StateFrom : CarterMecherSent: Thursday, February 27 , 2020 5 :00 AMTo : TraceyMcNamara; RichardHatchett; Tom BossertCc: Caneva Duane; Dr. Eva K Lee Martin Gregory J; Walters, William ; HAMILTONCAMERON .com ; Dodgen, Daniel(OS ASPR/SPPR) ; DeBord Kristin (OS ASPR SPPR) ; Phillips,Sally (OSASPR/SPPR) DavidMarcozziHepburn Matthew J CIV USARMY(USA) : LisaKoonin HARVEYMELISSA;WOLFE, HERBERTEastman, Alexander; EVANS,MARIEFRED; Callahan MichaelV . M . D . ; @ UTMB.EDU; email.unc.edu; Johnson, Robert(OSASPR BARDA) ; YeskeyKevin Disbrow Gary (OSASPR/BARDA) Redd John (OSASPR ) HassellDavid (Chris)(OSASPR/ IO ; Hame,l Joseph (OS ASPR ; A @ CDPH; Lawler James V ; Borio Luciana; HanflingDan; @ sdcounty . ca . gov; Wade, David ; TARANTINO DAVID A ; WILKINSONTHOMAS dshs . texas. gov ; KAUSHIK , SANGEETA ; Nathaniel Hupert; Lee, Scott; Padget, LarryG ; Ryan Morhard ; Stack Steven J (CHFS DPHSubject: RE: Red Dawn Breaking Bad , Start Feb 24Details below on case in California . From the cruise ship data we would estimate there are 20 -50 cases for each ICYadmission (assuming ICU admissions in 2 % -5 % of cases ). That ratio was for an aged population . Suspect that ratiomight be higher for a general population . And given the time from disease onset to being on a ventilator for at least aweek (since at least Feb 19 when the patient arrived atUC Davis ), the outbreak has had a good head start. Thatwould suggest we already have a significant outbreak and are wellbehind the curve . We are now well past theequivalent 5:45 moment atMann Gulch . You can ' t outrun it. They need to be thinking locally (full TLC includingschool closure ).[ I will send something I was looking at re the cruise ship data and kids. ]https: //www .sacbee. com /news/ loca/larticle24068231.h1tmlLatest: CoronaviruspatientatUCDavisMedicalCentersinceFeb. 19wasn' t testedfor daysThe SolanoCounty residentwho is the nation' s first confirmedcaseof coronavirusfrom " exposurein the communityhasbeen underthe care ofUC DavisMedical Centerfor a week, accordingto an internal memoobtainedWednesdaynightby TheSacramentoBee.Justbefore 10 p. m ., thehospital published thememothatwassentto employeesby UC DavisHealthleadersearlierin the dayandoutlinesthe timelineofthepatien'ts admissionand disclosedthatseveralemployeeswhowereexposedto the patientself-isolateathome"outofabundanceof caution."Thepatientwhom the U . S . CentersforDiseaseControlandPreventionconfirmedhas testedpositivethe COVID- 19strain, wasmovedto the Sacramentoteachinghospitalon Feb. 19, accordingto thememosentto staffersby DavidLubarsky, theheadof the hospitalandUCDavisHealth' s vice chancellorofhumanhealth services, and BradSimmons, thehealth system' s interim CEO .The patient was transferred to the facility from another hospital, where a medical team had already put the patient ona ventilator ." The individual is a resident of Solano County and is receiving medical care in Sacramento County . The individualhad no known exposure to the virus through travel or close contact with a known infected individual, CaliforniaDepartment of Public Health officials said in a news release .Because physicians at the first hospital suspected the patient had a virus, they issued an order that health careworkers should wear personal protective gear when with the patient to guard against exposure to droplets , said thememo , which was first reported by the Davis Enterprise newspaper .The UCD medical team used the proper infection protocols out of concern that the individual might have coronavirus ,according to the memo, and upon the patient' s admission , UCD physicians requested that public health officialsperform a test to determine whether the person had 19 ."We requested COVID - 19 testing by the CDC , since neither Sacramento County nor CDPH is doing testing forcoronavirus at this time," the memo says . " Since the patient did not fit the existing CDC criteria for COVID - 19, a testwas notimmediately administered . UC Davis Health does not control the testing process . "On Sunday , the CDC ordered a coronavirus test on the patient, and UC Davis Health officials discovered Wednesdaythat the patient tested positive for the deadly respiratory illness that causes coughing, fever and shortness of breath .That prompted hospital officials to tell number hospital workers to stay home and monitor themselves forpossible infection .Just as when a health care worker has a small chance of exposure to other illnesses , such as TB or pertussis , weare following standard CDC protocols for determination of exposure and surveillance , the memo said . “So , out ofanabundance of caution , in order to assure the health and safety of our employees ,we are asking a small number ofemployees to stay home and monitor their temperature ."We are handling this in the same way wemanage other diseases that require airborne precautions and monitoring ,thememo said , adding hospital officials are in constant communication with the state health department and theCDC and Sacramento County Public Health about the optimal management of this patient and possible employeeexposures ."UCD officials did not respond to The Bee' s request for comment.Thememo ended : “We are dedicated to providing the best care possible for this patient and continuing to protect thehealth ofour employees who care for them . "From : CarterMecherSent: Friday, February 28, 2020 5 : 20 AMTo : TraceyMcNamara; Baric, Ralph S Caneva,Duane; Richard Hatchett; Dr. Eva K LeeCc: Tom Bossert; Martin , Gregory ; Walters, William ; HAMILTON, ; Dodgen, Daniel(OSIASPR SPPR) ; DeBord Kristin (OSASPR SPPR ); Phillips, Sally (OSASPR ); DavidMarcozzi; Hepburn,Matthew J CIV USARMY (USA); Lisa Koonin HARVEY,MELISSA WOLFE, HERBERT; Eastman,Alexander; EVANS,MARIEFRED; Callahan,MichaelV . , M . D . ; MB.EDU ; Johnson, Robert(OS ASPR BARDA) ; Yeskey, Kevin; Disbrow, Gary (OSASPR/BARDA) ; Redd, John (OSASPR/SPPR) ; Hassell,David (Chris) (OS ASPR IO ) Hamel, Joseph (OS ASPR IO ) Dean, ; Lawler James V ; BorioLuciana; Hanfling, Dan sdcounty. ca. gov; Wade, David; TARANTINO, DAVID A ; WILKINSON,KAUSHIK, SANGEETA; Nathaniel Hupert; Lee, Scott; PadgetLarryG ; RyanMorhard; Stack, Steven J (CHFSDPH); Adams, Jerome(HHS/OASH); Fantinato, Jessica - OHS,Washington, DC; Colby,Michelle - OHS,Washington, DCSubjec:tRE: RedDawnBreakingBad, StartFeb 24Japan announced fifth death of Diamond Princess passenger (70 year old woman ). CFR for infected passengers isnow 0 .67 % ( this represents the lower limit ofCFR ). Below are the latest numbers I have (had to make a correctionwhen Ilearned that the 705 total cases reported by Japan also included the 14 confirmed cases in Americans whowere evacuated butnot the cases that have appeared in the remaining citizens from the US (28 ), Australia (8 ), HongKong (4 ), UK ( 4 ), and Israel (2 ) after they were evacuated .Date EventCumulative Number ofConfirmedCasesCumulative Number ofDeathsNotes20-Jan Cruise ship departs from Yokohama Japan25-Jan 80 year old passenger disembarks in Hong Kong80 year old passengerconfirmedto haveCOVID- 191 -FebWhen results known, certificate oflanding canceled and ship under quarantine. Tests forthevirus would be administered to three groups: those with symptoms, those who gotoffHongKong, and those who had close contactwith the infectedpassenger.3 -Feb arrives in port of Yokohama Japan5 -Feb 10 passengers and crew confirmed +6 - Feb more passengers and crew confirmed +7 -Feb morepassengerand crew confirmed+8 -Feb morepassenger and crew confirmed +10-Feb more passenger and crew confirmed + 136 439 tested11-Feb more andcrew confirmed+ 175 492 tested12-Feb morepassengerand crew confirmed+ 203 4 in ICU13-Feb 15 more passenger and crew confirmed + 218 713 tested14- Feb morepassengerand crew confirmed+ 285 927 tested15 - Feb more passenger and crew confirmed + 3551,219tested; 73asymptomatic16 - Feb329 American evacuated from cruise ship (14 ofthe evacueesfoundtobe61Americans remained onboard 44 Americans remained hospitalized in Japan36917-Feb morepassengerandcrew confirmed+ 4541, 723ested ;seriously ill18 -Feb more passenger and crew confirmed + 621 3 ,011tested19-Feb 2 deaths 62120-Feb 13morepassengerand crew confirmed + 6343 , 066ested; 28seriouslyill; 322asymptomatic23-Feb Death reported in Japan24-Feb Japanupdatestotalto 691; USreports 36 in US 69125-Feb Death reportedin Japan ; USreports 40 in US UK 4 Australia 7 HongKong 4 ; Israel2 ;Total 744 ; plus 4 not on ship3 ,894tested; 35seriouslyill; 380asymptomaticJUS reports total of 42 cases in US Japan announces that45 of813 former passengers26 -Feb symptomsand will need to be tested new cases confirmed in the DiamondPrincess cruise ship , raising the total to 705 cases inside the ship75027-Feb Australia + 1) 8 cases(repatriated)27 -Feb Death reported in JapanCou Passengers/CrewCasesHospitalizedinJapanCasesConfirmeduponRepatriationTotal ConfirmedCasesICU Admissions DeathsInfected20 %HongKong160CanadaAustraliaUKItalySouthKoreaIsrael 2JapanSubtotal 1,433 262Total 3 ,711 691 751From : CarterMecherSent: Friday, February 28, 2020 5 : 37 AMTo : TraceyMcNamara; Baric Ralph S Caneva,Duane RichardHatchett; Dr. Eva K LeeCc: Tom Bossert; Martin Gregory ; Walters William ; HAMILTON CAMERON; gmail.com Dodgen Daniel(OSASPR SPPR) ; DeBord Kristin (OSASPR/SPPR ); Phillips, Sally (OSASPR SPPR Marcozzi; Hepburn,Matthew J CIV USARMY (USA); Lisa Koonin HARVEY, MELISSA , HERBERT Eastman,Alexander; EVANS, MARIEFRED Callahan, MichaelV . . nson Robert(OSASPR /BARDA ); Yeskey, Kevin Disbrow , Gary (OS ASPR /BARDA) ; Redd , John (OS/ASPR/SPPR ) Hassell,David (Chris ) (OS ASPR ; Hamel, Joseph (OS ASPR Lawler, James V Borio,Luciana: Hanfling Wade David; TARANTINO DAVID A ; WILKINSONTHOMAS; KAUSHIK , SANGEETA ; NathanielHupert; Lee Scott Padget, LarryG : Ryan Morhard : Stack Steven J (CHFS DPH) Adams (HHS/OASH ) Fantinato Jessica - OHSWashington DC; Colby Michelle - OHS Washington DCSubject : RE: Red Dawn Breaking Bad, Start Feb 24New areas impacted of spread from Italy), which tells us that the outbreak in Italy is substantial . Mostconcerning development is case in Nigeria .Belarus traveler from Iran)LithuaniaNetherlands traveler from Italy)New ZealandNigeria (travelerfrom Italy)Northern Ireland (traveler from Italy)Wales (traveler from Italy )FIRST CASE OF CORONA VIRUS DISEASE CONFIRMED IN NIGERIAFriday, February 28, 2020The FederalMinistry of Health has confirmed a coronavirus disease (COVID - 19) case in Lagos State Nigeria .Thecase, which was confirmed on the 27th ofFebruary 2020 , is the first case to be reported in Nigeria sincethe beginning ofthe outbreak in China in January 2020 .The case is an Italian citizen who works in Nigeria and returned from Milan, Italy to Lagos , Nigeria on the 25thof February 2020 . Hewas confirmed by the Virology Laboratory of theLagos University Teaching Hospital,part of the Laboratory Network of theNigeria Centre for Disease Control. The patient is clinically stable, withno serious symptoms, and is beingmanaged at the Infectious Disease Hospitalin Yaba, Lagos .The GovernmentofNigeria , through the FederalMinistry of Health has been strengthening measures toensure an outbreak in Nigeria is controlled and contained quickly . Themulti-sectoralCoronavirusPreparedness Group led by the Nigeria Centre for Disease Control (NCDC) has immediately activated itsnationalEmergency Operations Centre and willwork closely with Lagos State Health authorities to respondto this case and implement firm controlmeasures.wish to assure allNigerians thathave we have been beefing up our preparedness capabilities since the firstconfirmation of cases in China, andwewill use all the resources made available by the government torespond to this case .Wehave already started working to identify all the contacts of the patient, sinceheentered Nigeria . Pleasebe reminded thatmostpeople who become infected may experience only mild illness and recover easily , butit can bemore severe in others , particularly the elderly and persons with other underlying chronic illnesses.All Nigerians should take care of their health andmaintain hand and respiratory hygiene to protectthemselves and others, including their own families , following the precautions below :1. Regularly and thoroughly wash your hands with soap andwater , and use alcohol-based hand sanitiser.2. Maintain at least 1 & halfmetres (5 feet) distance between yourself and anyone who is coughing orsneezing.3 . Persons with persistentcough or sneezing should stay homeorkeep a social distance, butnotmix incrowd4 . Make sure you andpeople around you, follow good respiratory hygiene,meaning cover yourmouth andnosewith a tissue or into your sleeve at the bent elbow or tissue when you cough or sneeze. Then dispose ofthe used tissue immediately.5 . Stay homeif you feel unwell with symptoms like fever , cough and difficulty in breathing. Please callNCDCtoll free number which is available day and night, for guidance 970000 -10. Do notengage in selfmedication6 . Stay informed on the latest developments aboutCOVID - 19 through official channels on TV andRadio ,including the Lagos State Ministry of Health , NCDC and FederalMinistry of Health .Citizensmustnot abuse socialmedia and indulge in spreading misinformation that causes fear and panic .The FederalMinistry of Health , through Nigeria Centre for Disease Control, will continue to provide updatesandwill initiate allmeasures required to preventthe spread of any outbreak in Nigeria .DrOsagie EhanireHon. MinisterofHealthhttps: / /ncdc.gov.ng/news/ 227 /first- . .med in -nigeriaFrom : CarterMecherSent: Friday, February 28 , 2020 7 : 31 AMTo: Tracey McNamara; Baric ,Ralph S ; Caneva, Duane; RichardHatchett; Dr. Eva K LeeCc: Tom Bossert; Martin, Gregory J;Walters, William ; HAMILTON, CAMERON Dodgen Daniel(OSIASPR/SPPR ) DeBord, Kristin (OS ASPR /SPPR) ; Phillips, Sally (OS ASPR / SPPR ) ; David Marcozzi;Hepburn,Matthew J CIV USARMY (USA); Lisa Koonin HARVEY, MELISSA; WOLFE, HERBERT; Eastman,Alexander; EVANS, MARIEFRED Callahan,Michael V . Johnson, Robert(OSASPR BARDA) ; Yeskey, Kevin; Disbrow,Gary (OSASPR BARDA) ; Redd, John (OSASPR ) ; Hassell ,David (Chris (OSASPR IO ) ; Hamel, Joseph(OSASPRI Lawler, James V ; Borio ,Luciana; Hanfling, Dan; David; TARANTINO, DAVID A ; WILKINSON,THOMAS; SANGEETA; NathanielHupert; Lee, Scott; Padget, LarryG ; RyanMorhard; Stack, Steven J (CHFSDPH); Adams, Jerome(HHS/OASH) ; Fantinato, Jessica- OHS,Washington, DC; Colby, Michelle- OHS Washington, DCSubject: RE: Dawn BreakingBad, StartFeb 24Italy has emerged as a major exporter of COVID . Above the surface , nothingmuch was happening in Italy until Feb21 before that just a few cases reported, on Feb 20 Italy reported a cumulative total of 3 cases/ deaths ). Over theexplodedand Italy hasexported casesaroundthe world . Things exploded in matterofdays (or atleastwere recognized to have exploded in a matterof days). That is what will likely happenhere. Itwillbethat fastand soon theUS (becauseweare a major travelhub/destination could becomean exporterofdisease likeItaly. Think of thatwrt thewindow for implementingcommunity mitigationmeasures.Timeline for ItalyFeb 22:Over 50,000 people have been asked to stay at home in the areas concerned , while all publicactivities such as carnival celebrations , church masses and sporting events havebeenbanned for up to a week .Coronavirus , ordinance on compulsory quarantine and isolation for those returning fromChinaVENETIAN UNIVERSITIES CLOSED. The universities of Veneto will remain closed due to theCoronavirus emergency . This was announced by the president of Veneto , Luca Zaiaspecifying thathehad consulted with the rectors of the various universities in the region :"we have decided to keep them closed from next week " he said . Responding to journalistson possible measures for events such as the Venice Carnival, Zaia said he awaits theguidelines that will be issued by the minister ofhealth , Roberto Speranza ,because theinitiatives must be uniform across the country .Cases of the new coronavirus in Italy , themost affected country in Europe, rose onSaturday to nearly 80 , killing two people and prompting the government to close off theworsthit areas in the northern regions of Lombardy and Veneto . Authorities in the tworegions, where the outbreak is concentrated , have cancelled sports events and closedschools and universities , while companies from Ray -Ban owner Luxottica to the country ' stop bank UniCredit have told workers living in the affected areas to stay home.Feb 23" Prohibitionofallindividualsstillpresentin themunicipalityorareafrom leavingthemunicipalityor theaffectedarea" ; " banon accessto themunicipalityor area concerned" ; " suspensionof eventsorinitiativesofany nature, ofevents andof any form ofmeetingin a publicorprivateplace, includingthoseofa cultural,recreationa, lsportingand religiousnature, even if carried out in closedplacesopen to thepublic" . Thesearesomeofthemeasurescontainedin the law decreeapprovedthis eveningby the CouncilofMinistersto dealwith thespreadof the crown virus in the outbreakareas.Othermeasuresalso include" the suspensionofearly childhoodeducation servicesand schools ofall levels,as wellas theattendance ofschooland higher educationactivities, exceptfor distance learning activities" ,the " suspension of openingservicesto themuseum public " that" every educationaltrip , both on thenationaland foreign territory " , and" the applicationofthe quarantinemeasurewith active surveillanceamongindividualswho havehad closecontacts with confirmed cases ofwidespreadinfectious disease " .Municipalities affected: Elevenmunicipalitiesiinnthe Lodiarea and in the Veneto region are affected by thecoronavirus emergency andby the relevantmeasures taken by the authorities to prevent the spread ofthevirus. Here is the complete list:Vo ' EuganeoCodognoCastiglioned' AddaCasalpusterlengoFombioMaleoSomagliaBertonicoTerranova deiPasseriniCastelgerundoSan Fiorano.Carnivale in Venice suspendedFeb 25Veneto , what is suspended and what is not. Open markets , closed cinemas . And ' private weddingCoronavirus , what can be done and what cannotbe done, after the state of emergency proclaimed inVeneto ?What are the prohibited and allowed venues and events ? A circular from the Region explains itindetail1. All events that cause ' significant concentrations of people in public and private places' ARE SUSPENDED .IN DEPTH2. ' fairs and festivals , attractions and fairgrounds , concerts , sporting events with presence of the public ,such as championships , tournaments and competitions of all categories and disciplines ' ARE SUSPENDED .3 . 'theatrical, cinematographic , musicalperformances , including discos and dance halls ' ARE SUSPENDED .4 . Ordinary amateur activities are NOT SUSPENDED as ' courses of various kinds and sports training ,language centers , after -school activities, music centers, driving schools , sports facilities , gyms and publicand private swimming pools, playgrounds '.5 . ' public businesses , canteens, weekly markets ' remain open .6 . Support activities for the disabled and elderly are NOT SUSPENDED , even in semi-residential services andday centers .7 . Marriages and funerals , civil religious , are NOT SUSPENDED , provided that participation is limited tofamily members only .Italian oil and gas contractor Saipem has confirmed thatmore than 2 , 000 staff are working from homedue tothe coronavirus.Around 2,196 employees , many whom are based in the firm ' s headquarters in Milan , are under what Saipemcalled " working ”.Feb 26AnItalian cruise ship, theMSCMeraviglia, was rejectedby two ports in theCaribbean, Jamaicaand theCayman Islands, forfear of the coronavirus. A crew memberwould notbein goodhealth. TheNew Yorkthe ship over 4 ,500 passengersand 1,600 crew members. Ithad arrived Tuesdaymorningatthe portofOcho Rios, Jamaica, comingfrom Miam. i The landingbanwas triggeredwhen the captaincommunicatedthe flu status ofoneofthe people on board. Samesituation atthe portofGeorgetownin theCayman Islands.Feb 27Coronavirus in Veneto , hospitals under pressure: more infections among doctorsAnother cluster grows in Treviso . Zaia orders another 200 permanent hires for the emergencyFrom : CarterMecherSent: Friday, February28, 2020 8: 39 AMTo: TraceyMcNamara; Baric, Ralph S Caneva, Duane; RichardHatchett; Dr. Eva K LeeCc: Tom Bossert; Martin, Gregory J; Walters, William ; HAMILTON, CAMERON; Dodgen, Daniel(OSIASPRSPPR); DeBord, Kristin(OSASPR SPPR); Phillips, Sally (OSIASPRSPPR); DavidMarcozz;iHepburn, Matthew J CIV USARMY(USA); LisaKoonin; HARVEY, MELISSA; WOLFE, HERBERT;Eastman, Alexander; EVANS,MARIEFRED; Callahan, MichaelV . , M Johnson, Robert( OS/ASPR/ BARDA); Yeskey, Kevin; Disbrow, Gary(OS ASPR BARDA); Redd, John (OSASPR SPPR); Hassell , David (Chris) (OSASPR/ IO) ; Hamel, Joseph(OSIASPR/ IO ) ; , James V ;Borio , Luciana; Hanfling, Dan ; Wade, David; TARANTINO DAVID A; WILKINSON ,THOMASScott; Padget, Larry G ; Ryan Morhard ; Stack, Steven J (CHFS DPH );Adams, Jerome (HHS/OASH ); Fantinato , Jessica -OHS,Washington , DC; Colby , Michelle - OHS , Washington , DCSubject : RE: Red Dawn Breaking Bad, Start Feb 24Updated tablesDateCumulativeNumberofDeathsNotes20 -Jan25 -Jan1- FebCumulativeEvent Number ofConfirmed CasesCruise ship departs from Yokohama Japan80 year old passenger disembarks in HongKongyear old passenger confirmed to haveCOVID -19When results known, certificate of landingcanceled and ship under quarantine . Tests forthe virus would be administered to three groups:those with symptoms, those who got off in HongKong, and those who had close contact with theinfected passenger.Ship arrives in port of Yokohama Japan10 passengers and crew confirmed +31 morepassengers and crew confirmed + 4130 more passenger and crew confirmed +9 more passenger and crew confirmed + 7066 more passenger and crew confirmed + 136more passenger and crew confirmed + 175more passengerand crew confirmed+ 20315 more passengerand crew confirmed+ 21867morepassengerandcrew confirmed+ 28510613 - Feb5 -Feb6 -Feb7 - Feb8 - Feb10 -Feb11- Feb12 - Feb13 -Feb14 -Feb439 tested492 tested4 in ICU713tested927 tested1,219 tested;73 asymptomatic15 -Feb morepassengerand crew confirmed+ 35516- Feb329Americanevacuatedfrom cruiseship ( 14 oftheevacueesfoundto be61Americansremained onboardAmericansremainedhospitalizedin Japan3694417-Feb 85 morepassengerand crew confirmed+ 454 1,723tested19 seriouslyill18 -Feb 3 ,011tested19-Febpassenger andcrew confirmed +2 deaths621621 220 -Feb morepassengerand crew confirmed+ 634 23 , 066 tested28 seriously ill;322 asymptomatic23-Feb24-Feb 69125 - Feb 7343 , 894 tested35 seriously ill;380 asymptomaticDeathreportedin JapanJapanupdatestotalto 691USreports36 inUSDeathreportedin Japan reports40 in USUK 4 Australia7 Kong4 Israel2744; plus 4 notonshipUSreportstotal of 42 cases in US Japanannouncesthat45of813 formerpassengershavesymptomsandwillneedto betested 14new casesconfirmedin theDiamondPrincesscruiseship raisingthe totalto 705 casesinsidetheshipAustralia( 1) 8 cases(repatriated)2 deathsreportedin Japan26 - Feb27-Feb 75128- Feb 751TotalCountry Passengers /CrewCasesHospitalizedin JapanICUConfirmedAdmissionsCasesDeathsCasesConfirmeduponRepatriation42Infected434 863642562414455475920 %16 %18 %23 %13%8USHongKongCanadaAustraliaUKItalySouth KoreaIsraelJapanSubtotalTotal78351411 45%1,4333 ,711202691 20 %From : CarterMecherSent: Friday, February 28, 2020 9 : 14 AMTo: TraceyMcNamara; Baric, Ralph S ; Caneva, Duane; RichardHatchett; Dr. Eva K LeeCc: Tom Bossert; Martin, Gregory ; Walters, William ; HAMILTON, CAMERON; Dodgen , Daniel(OSIASPR SPPR ); DeBord , Kristin(OS ASPR ) ; Phillips, Sally (OS ASPR ); David Marcozzi; Hepburn , Matthew J CIV USARMY (USA); LisaKoonin ; HARVEY, MELISSA; WOLFE, HERBERT;Eastman , Alexander; EVANS , MARIEFRED ; Callahan, Michael V ., M . D . ; UTMB. EDU ; Johnson , Robert( OS ASPR/ BARDA ; Yeskey, Kevin Disbrow , Gary(OS ASPR /BARDA ) Hassell, David ( Chris) (OS ASPR /IO ) ; Hamel, Joseph(OS ASPR IO ); Ir James V ;Borio, Luciana; Hanfling, Dan; v ;Wade, David ; TARANTINO DAVID A ; WILKINSON ,THOMAS ;KAUSHIK , SANGEETA; Nathaniel Hupert; Lee, Scott; Padget, Larry G ; Ryan Morhard ; Stack , Steven J (CHFS DPH );Adams, Jerome (HHS/OASH ) ; Fantinato , Jessica -OHS, Washington , DC; Colby , Michelle - OHS, Washington , DCSubject: RE: Red Dawn Breaking Bad, Start Feb 24This might be ofinterest. A comparison I ran of the distribution of the US population by age group compared to thepassengers and crew aboard theDiamond Princess ( surprised nobody ever did this ). Except for kids, the cruise ship data tells a lot about adults (reallyshifted toward the 60 -80 yearold group )AGEUSPopulation2017% Distribution % Distribution0 %1%9 %0-9 years10- 19 years20-29 years30-39 years40-49 years50-59 years60-69 years70-79 yearsCruise ShipPassengers &Crew2334742833439812 %13%14%13%12 %13%12 %40,243,09841,910 ,11445 ,489, 09543,204,20940 ,617,23143, 409,05036 , 824,08321, 588 , 32612, 433, 972325 719, 1789 %11%11% 9237 %25 %27 %> years 4 %Total population1,015227,7116 %100% 100 %Here is how the distributions compare when I only look at age essentiallyAGEUSPopulation2017% Distribution % Distribution19%18%9 %12 %20-29 years30-39 years40-49 years50-59 years60-69 years70-79 years> yearsTotal population9 %45 ,489,09543,204, 20940,617,23143,409,05036 ,824, 08321588, 32612, 433, 972243,565, 966Cruise ShipPassengers &Crew3474283349231,01522767217%18 %15 %9 %5 %%11%25 %27 %6100 %Friday, February 28 , 2020 12:21PM , Dr. Eva K LeeThree things:1. biosurvellianceCarter, yes, a month ago you talked aboutwanting to screen everyonewho comes into ED and ICU. And I wanted tosample tests even those who don 't comeinto ED ICU , and wewanted to include primary care also .Atthemoment, weindeed havenotyet gone forward with any of these. The" unknownorigin" casein Californiashowsttatwemissed a wholeweekbeforeshewas tested. And shemayvery wellnotbepatientzero becauseshecould have gotten it from someonewith no symptomsatall. Andyes, wenow havemultiplesources(clearly) and it isunclearhow faritwill / can go.Weare like Europe, each state is connectedto each otherthrough air and groundtransit.It is notunexpected about the widespread from Italy. I know it sounds a bit silly , when I lived in Lausanne Switzerlandwewould drive to Annecy France to have dinner (students do go everywhere ). So spread in Europe is unavoidable .Theunusalcaseis thatthis Californiacase sheis youngbutshe is very sick.This site has details on mortality vs age groups.https: / /multimediascmpcom / infographics/news/china/article/ 3047038/wuhan-virus/index.html2. Drive Through ScreeningI just gotback from discussion with the head nurse in Mississippi. I went through the drive -through setup andscreening and she is very pleased. She told mealthough they have been planning for pandemic since 2006 ,manypeople still do notknow what their roles are and what they are supposed to do during pandemic flu crisis . NowCOVID - 19 causes more confusion . I wll finish the final layout and the information and send it around for comments.Some states already havemy earlier version . I want to give more detail so they can prepare .3 . HomelesspopulationAny big or urban cities are going to face the challenges in containment and homeless popiulation needs to be takencare of. there is any infection there , it will spread like fire . I am very worried about California . Even Atlanta , Seattle ,DC, New York City , andmany more cities have these additionalworries . I am going to Good Samaritan now to checkouthow the homeless population is preparing for these and what we are providing on the medical fronts .EvaOn Friday, February28, 2020 8: 16 AM , CarterMecher wrote :Myconcernis that a possiblescenario is thatwe becomeItalypart 2 (the sequel ) .Italy had to have had ongoing community transmission well before Feb 21st when things appeared to take off for thereak to take off this quickly including 17 deaths) and to have the amountof spread across the globe in such ashortperiod of time. I suspect thatprevalence ismuchhigher than anyonerealized. Watchinghow aggressively theyimplementedNPls includingcordon sanitaire (within just a couple of days ofthe first deaths and the acceleration inthenumber of confirmed/suspected cases) and the continuedexplosivegrowth suggests to methatdiseasemusthavebeenmuchmore prevalent.The lesson is that although things mighthave looked under control on Feb 20 (3 cases / deaths), things obviouslyweren 't fine . They couldn 't see how large the iceberg was below the water line. They were blind to the extent ofdisease and the extent ofongoing transmission .Wehavealsobeenflying blind.Weseethatpartof icebergabove the surface ( 60 cases in theUS) . Butbecauseof little to no surveillance(otherthan ourfocuson travelersfrom China), wehavelittle awarenessofwhatisbelow the surface. Thecase in CA confirmsthatwhatis below the surfaceislargerthan whatis above (given whatwelearned from the cruise ship wrt the % ofcases that endup in the ICU andthe delay in recognizingthis case) . TheCA patientwas in an ICU andon a ventilator formore than 1week beforewe even hadconfirmation.So the scenario am concerned about is the Italy scenario. Wehave unrecognized smoldering communitytransmission . We don't recognize the large numbers of asymptomatics (maybe half of the cases) , we miss the mildlyill (maybe another 38 % or so ), and the remaining 12 % get lost in the busy flu season .Italy actually acted pretty quickly once they realizedwhatwas happening (things explode on Feb 21and theyimplementNPls pretty aggressively on Feb 22) . ' m notsure wewillbe able to act thatquickly.A few weeks ago we talked about our priorities surveillance and early implementation of NPls. We still don ' t havesurveillance , and because of thatwe will likely be late to implement like Italy.From : CarterMecherSent: Friday, February 28, 2020 9:26 AMTo: TraceyMcNamara; Baric, Ralph S; Caneva, Duane; RichardHatchett; Dr. Eva K LeeCc: Tom Bossert; Martin, Gregory J; Walters, William ; HAMILTON, CAMERON ; Dodgen, Daniel(OSASPR ); DeBord, Kristin(OS/ASPR/SPPR); Phillip,sSally (OSASPR/ SPPR); DavidMarcozz;iHepburn, Matthew J CIV USARMY(USA); LisaKoonin; HARVEY, MELISSAWOLFE, HERBERT;Eastman, Alexander; EVANS,MARIEFRED; Callahan, MichaelV. , M . D . ; UTMB.EDU; Johnson, Robert( OSASPR/ BARDA); , Kevin; ,(OSASPRBARDA) ; Redd, John (OSASPR/SPPR); Hasse,llDavid(Chris) (OSASPR/ ; Hame,l Joseph(OS ASPR IO ); Lawler, James V ;Borio, Luciana; Hanfling, Dan;davidKAUSHIK, SANGEETA; NathanielHupert; Lee, Scott; Padget, Larry G ; RyanMorhard; Stack, Steven J (CHFS DPH) ;Adams, Jerome(HHS OASH) ; Fantinato, Jessica -OHS, Washington, DC; Colby, Michelle- OHS Washington, DCSubject: RE: RedDawnBreakingBad, StartFeb 24I think this data is close enough to convince people that this is going to bebad and wewillneedto pull the full arrayofNis (TLC) . Allthat is leftis when timing .I went back to our comparison of Philadelphia and St. Louis in 1918 . The difference between Philadelphia and St.Louis in terms when they pulled the trigger on was about two weeks during the course of their individualoutbreaks .In St. Louis , were put in place 1 week after the first cases at Jefferson Barracks, 5 days after the first death , and3 days after the first civilian cases in St. Louis . In Philadelphia , were put in place 3 weeks after the first cases atthe Navy Yard , 16 days after the first civilian cases inPhiladelphia, 2 weeks after the first death . In the cases of , timing matters.We would estimate that the outbreak in Wuhan had about a 2 week head start on the rest of Hubei. So the measuresChina implemented to slow transmission happened about two later in the course of the outbreak in Wuhan comparedto the restofHubei Province . That comparison looks a lot like Philadelphia and St. Louis.So we have a relatively narrow window and we areflying blind.Looks like Italy missed it.From : Tom BossertSent: Friday, February 28 , 2020 8 : 06 : 19 PMTo : Carter MecherCc: Tracey McNamara @ westernu.edu>; Baric, Ralph email.unc.edu> ; Caneva, Duane@ . gov> ; RichardHatchett @ cep. inet> ; Dr. Eva LeeMartin, GregoryJ @ state. gov ; Walters, tate.HAMILTO,NCAMERON @ hg.dhs. . com @ gmai.lcom >; Dodgen,Daniel(OS ASPR SPPR) @ hhs. gov ; DeBord Kristin (OSASPR ). gov> ; Phillips, Sally (OS/ASPR SPPR @ hhs.gov> DavidMarcozzisom .umaryland.edu> ; Hepburn,Matthew J CIV USARMY(USA) @ mail.mil> ;LisaKoonin @ gmail.com > ; HARVEY, @ . gov ; WOLFE, HERBERT@ hg.dhs. gov > ; Eastman, Alexander @ hg. dhs. gov > ; EVANS, MARIEFREDorg >@ associates. . . gov ; Callahan, MichaelV . , M . D .@mgh.harvard.edu> ; @ UTMB.EDU @ utmb. edu> ; Johnson, RobertOSASPR/ BARDA) hhs. gov ; Yeskey, Kevin < k @ hhs.gov> ; Disbrow, Gary(OS @ hhs. gov ; Redd, John (OSASPRSPPR) @ hhs. gov> ; Hasse,llDavid ( Chris) (OS/ ASPR/ ) @hhs. gov> Hamel, Joseph(OS/ASPRO hhs. gov> ;Dean, Charity A @ CDPH< @ cdph. ca . gov> ; Lawler, James mc.edu> ; Borio, Lucianaarg> ; Hanfling, Dan@ sdcounty.ca.gov d @ sdcounty. ca . gov ; Wade, David@ . dhs.gov ; TARANTINO, DAVID A @ cbp. dhs. gov> ; WILKINSO,NTHOMAS@hq . gov> ; r @ dshs.texas. gov @ dshs. texas. gov > ; KAUSHIK ,SANGEETA < hq . Nathaniel Hupert 5 @ med. cornell. edu > ; Lee, Scotthhs. gov > ; Padget, Larry G state . gov> ; RyanMorhard rd @ weforum .org > ;Stack , Steven (CHFSDPH) k @ky. gov ; Adams, Jerome(HHS/OASH) < s @ hhs.gov ;Fantinato, Jessica - OHS,Washington, DC @ usda.gov> ; Colby, Michelle - OHS, Washington , DCy @ usda.govSubject: Re: Red Dawn Breaking Bad, Start Feb 24On Friday, February 28, 2020 8 :28 PM , Caneva, Duane . dhs. gov> wrote :Criticalsectors likeHealthcareneedto be empoweredby Governmentto establish ReliabilityOrganizationsunencumberedby Federalbureaucracy. The sector shouldbeexpected to identify risk, prepareandrespondtopredictablehazards. Lessthan a yearafterCrimsonContagion, andhow much ofthe Sectorwas informedandimprovedby the "lessonslearned ' s even heard ofit ?On Friday, February28, 2020 10 : 39 PM , Dr. EvaK Lee @ pm .me> wrote:I don' t know much aboutthe CrimsonContagion. Butclearly planningitselfdoesnot includeenough uncertaintiesforpeople to really think aboutwhatcould go wrong. Forexample, itassumesevery place is goingto acceptthepatientbeing sentto them is thattrue, I donotknow) . The Alabamacase where they refusedto house someAmericanpassengerswith coronavirusin Anniston, Ala . after these individualswere evacuatedfrom the Diamond Princesscruiseshipwas a good example- - canwe plan that a judge or the presiden,t or senatorswould intervenein suchsituation ?James accepts the 14 patients readily in Nebraska. Theunknowniswhatwehave been planningfor allthese years.So if not doing itnow , when ? Everyonehas to step up now.I do believe ifwe can summon all the capabilities around the country (private and government sectors ), we can put upa very good and successful fight. And being decisive in making the calls of action is of paramount importance .From: CarterMecherSent: Friday, February 28, 2020 9:26 AMTo: TraceyMcNamara; Baric, Ralph S Caneva, Duane; RichardHatchett; Dr. Eva K LeeCc: Tom Bossert; Martin, Gregory J ;Walters, William ;HAMILTON, . com ; Dodgen, Daniel(OSIASPR/SPPR) DeBord, Kristin (OSASPR/SPPR) ; Phillips, Sally (OS ASPR/ SPPR) ; DavidMarcozzi;Hepburn,Matthew J CIV USARMY(USA); Lisa Koonin HARVEY, MELISSA; WOLFE, HERBERT; Eastman,Alexander; EVANS, MARIEFRED Callahan,MichaelV . @UTMB.EDU; Johnson, Robert(OS ASPR /BARDA) ; Yeskey, Kevin; Disbrow , Gary (OS ASPR /BARDA) ; Redd, John (OS ASPR/SPPR ); Hassell,David (Chris ) ( IO ) ; Hamel, Joseph (OS ASPR /IO ) ; CDPH ; Lawler, James V ; Borio ,Luciana; Hanfling, Dan ; sdcounty.ca . gov ; Wade, David; TARANTINO, DAVID A WILKINSONTHOMAS; . texas. gov; KAUSHIK, SANGEETANathanielHupert; Lee, Scott; Padget, LarryG ; RyanMorhard; Stack, Steven J (CHFSDPH) ; Adams, Jerome(HHSOASH) ; Fantinato, Jessica - OHS,Washington, DC Colby Michelle - OHS, Washington, DCSubject: RE: RedDawnBreakingBad, StartFeb 24I think this data is close enough to convince people that this is going to bebad and we will need to pull the full arrayof Nis (TLC ). All that is left is when (timing ).I wentback to our comparisonofPhiladelphiaand St. Louis in 1918. The differencebetweenPhiladelphiaand St.Louis in termswhen they pulledthe trigger on NPlswasabouttwo weeksduring the courseof their individualoutbreaks.In St. Louis , NPls were put in place 1week after the first cases at Jefferson Barracks, 5 days after the first death , and3 days after the first civilian cases in St.Louis. In Philadelphia , put in place 3 weeks after the first cases atthe Navy Yard , 16 days after the first civilian cases in Philadelphia , 2 weeks after the first death . In the cases of, timingmatters .Wewould estimate thattheoutbreakinWuhanhad about a 2week headstarton therest of Hubei. So themeasuresChina implemented to slow transmissionhappened abouttwolater in the course of the outbreak in Wuhto the restofHubeiProvince. That comparisonlooks a lotlike Philadelphia and St. Louis.we have a relatively narrow window andwe are flying blind.From CarterMecherSent: Friday, February 28, 2020 11:52 AMTo: TraceyMcNamara; Baric , Ralph S ; Caneva, DuaneRichardHatchett; Dr. Eva K LeeCc: Tom Bossert Martin Gregory ; Walters, William HAMILTON, CAMERON; Dodgen, Daniel(OS ASPR/SPPR ); DeBord, Kristin (OSASPR SPPR ) Phillips, Sally (OS/ASPR/SPPR ); DavidMarcozz;iHepburn,Matthew J CIV USARMY(USA) LisaKoonin HARVEY,MELISSA: WOLFE HERBERT: EastmanAlexander EVANS, MARIEFRED; Callahan MichaelV . Johnson, Robert(OS/ASPR/BARDA) Yeskey, Kevin Disbrow Gary (OS/ASPR/BARDA) ; Redd John (OSASPR/SPPR) HassellDavid (Chris) (OS ASPR IO ); Hamel Joseph (OSASPR IO ) ; Dean, Charity A @ CDPH Lawler, James V Borio,Luciana; Hanfling, Dan; Wade, David ; TARANTINO , DAVID A ; WILKINSONTHOMAS; @ dshs.texas. gov KAUSHIK, SANGEETA Nathaniel Hupert Scott PadgetLarryG : RyanMorhard: Stack Steven J (CHFSDPH) Adams Jerome(HHS/OASH) Fantinato Jessica- OHSWashington, DC Colby, Michelle - OHS,Washington, DCSubject: RE: RedDawnBreakingBad, StartFeb 24Estimatesofthe impactofCOVID on VAIn FY2019, VA cared for 6,271,019 unique veteransandhad 9,237 ,638 veteran enrolleesThe DiamondPrincesscruise ship outbreakcanprovideinvaluableinsightsinto the potentialimpactto VA.Below is a comparisonoftheUSpopulation, the adultpopulationaboardthe cruise ship , and the Veteranpopulation.347428 12 %33420- years30 -39 years40 - years50 -59 years-69 years70-79 years> 80 yearsTotal population45,489,095, ,209 18 %,231 17 %,050 18 %36 ,824,083 15 %,326 19%12,433,972 5 %, 565 , 966 1009231,0152273,6729 %11%25 %27 %100 %932,473,0452 194,5053, 169,7873,735, 3994, ,551,94319,209,7045 %10 %17 %19 %14%100 %TheVeteranpopulationis similar to the cruisepopulation. If anything, theveteran populationis evenolder( ateven higherrisk) . There were 3 ,711passengersand crew aboardthe crew ship ( 1, 045 crew and 2 ,666passengers) . AsofFebruary 28, 2020, therehavebeen 751confirmedcases of COVID (attack rate of20 % ) . Therehavebeen6 deathsthusfar (lowerlimitof a casefatality rate of 0.80 % ) A timelineofthe outbreakisprovidedatthebottom ofthismessage. 380 of the confirmedcaseswere asymptomatic(50.6 % ). Itis estimatedthatapproximately12 - 15% of the 751passengersand crew with confirmeddiseaserequiredacute care with 36 hospitalizedpatientsreportedto be in seriouscondition (5 % ) .Given the similaritiesof the demographics ofthe cruise ship and veterans, we could projectthe potentialimpactonveteransAll VeteransVeteran EnrolleesVeteran Uniques19,209,704,237,638,271,0193,841,941 1, 944,022,528 ,8491254, 204 1634 627461,033703150,504192,097, 37671030 ,73614,78010 034Need to place these numbers into perspective .Acute Inpatient Care VHA TotalOperatingBedsHospital 15,744OperatingBedsMedicine/Surgery 9,817Operating Beds ICU 1,692ADC Hospital ,805ADCMedicine/Surgery 6,225ADC ICU 1,101ADC On a Ventilator 40DailyHospital Admissions 1641Daily Admissions Medicine/ Surgery 1,226Daily Admissions/Transfers in ICU 389EmergencyDepartmentCareDailyER Visits 6 . 874OutpatienCtare(non- ER)Clinic Visits 209 336Annually, VA has:450,000 acute (medica/ lsurgica)l admissions140.000ICU admissions2 .5M ￿R/UrgentCare visitsIfweassumethatthis outbreak will lastapproximately3months, we can then overlay the projecteddemandupon theusualbackgroundutilizationover3 months.Even if wesimply focuson the veteran uniques (veteranswho use VA services), we can assume that theremightbe3 ER visits for each admission-- so roughly 450,000 ER visits, 150,000hospitalizations, and63,000 ICU admissions.Over an average 3month period, VA wouldhave ,000 ER/Urgentcare visits, 112,000 acute care admissions,and 35,000 ICU admissions.Now youunderstandthe challenge.On Friday, February 28, 2020 10: 39 PM, Dr. Eva K Lee wrote:I don' t know much about the Crimson Contagion . But clearly planning itself does not include enough uncertainties forpeople to really think aboutwhat could go wrong . For example , it assumes every place is going to accept the patientbeing sent to them is that true, I donotknow ). TheAlabama case where they refused to house some Americanpassengerswith coronavirus in Anniston, Ala ., after these individualswere evacuated from the Diamond Princesscruise ship was a good example - - can weplan that a judge or the president, or senators would intervene in suchsituation ?James accepts tthe 14 patients readily in Nebraska . The unknown is what wehave been planning for all these years .So if notdoing itnow , when ? Everyone has to step up now .I do believe ifwe can summon all the capabilities around the country (private and government sectors ),we can put upa very good and successful fight. And being decisive in making the calls of action is of paramount importance .< FFrom : CarterMecher ernetSent: Saturday, February29 2020 2:09 PMTo: Dr. Eva K Lee me>Cc: Lawler, James V .edu ; Tracey McNamara @ westernu. edu > ; Baric, Ralph Sc. edu ; Caneva, Duane .dhs. gov> ; RichardHatchett @ cepi.net Tom Bossert me.com Martin . Gregory J@ state . gov ; Walters, William @ state .gov> ; HAMILTON, CAMERON@ hq.dhs. gov gmail.com ; Dodgen, Daniel (OS/ASPR/ SPPR ). gov> Kristin (OS ASPR/SPPR) @ hhs. gov> ; Phillips, Sally(OSASPR SPPR) hhs. gov> ; DavidMarcozzi @ som .umaryland.edu> ; Hepburn, MatthewCIV USARMY(USA) mail.mil> ; Lisa@ gmail.com >; HARVEY, MELISSA< @ hq.dhs. gov> ;WOLFE, HERBERT@ hq.dhs.gov>; Eastman, Alexander @hq.dhs. gov> ; EVANSMARIEFRED associates.hqdhs.gov> Callahan, MichaelV ., M .D .@mgh.harvard.edu> ; LeDuc, James W . TMB.EDU>; Johnson, Robert(OSASPR/BARDA)@ hhs. ; Yeskey, Kevin @ hhs. gov > ; Disbrow , Gary (OS ASPR BARDA)@ . gov> ; Redd, John (OS/ASPR SPPR ) @ hhs. gov ; Hassel, lDavid( Chris) (OSASPRIO) hhs. gov> ; Hame, lJoseph(OSASPR/ @ hhs. gov ; Dean,Cha . ca.gov> ; Borio, Luciana iqt. org > ;Hanfling, Dan @ iqt org > ; @ sdcounty. ca .gov; Wade, David @ hq.dhs.govTARANTINO, DAVID .dhs. gov> ;WILKINSON, THOMAS@hq.dhs. gov> ; dshs.texas. gov; KAUSHIK , SANGEETAhq.dhs.gov> ; Lee , Scott . gov> ; Padge, tLarryG <PadgetLG@ state. gov> ;RyanMorhard< @weforum.org> ; Stack, Steven J (CHFSDPH) ; Adams,Jerome (HHS OASH ) s @ hhs. gov> ; Fantinato, Jessica - OHS Washington, DCgov > ; Colby, Michelle - OHS,Washington, DC @ usda. govSubjec:tRE: RedDawnBreakingBad StartFeb 24WARNING: This emailoriginatedfrom outsideofUTMB' s emailsystem . Donotclicklinksor open attachmentsunlessyou recognizethe senderandknow the contentis safe.I am also concerned about Seattle (Kings County). Charity , do you have contacts there ?Orcould someone reach outto Jeff Duchin from CDC or HHS?https://www .kingcounty .gov /depts/health /communicable -diseases/diseasecontrol/ /media / depts/health /communicable diseases/documents / influenza/ 2020 /week -08 .ashxThis is week 8 data (so recentdata ). Compare the 3 graphs. Seeing a mismatch between pathogensdown) and syndromic surveillance (flat). Also looking at ED visits and seeing anupward trend in school age kids (ages 5- 17) and 45 -64 year olds. Something doesn't sit rightwith me.PublicHealth- Seattle & CountySummary ofInfluenza SyndromicandLaboratory SurveillanceInfluenzaandother respiratorypathogens,PCR testingonly (NREVSS)2 /20599/3/23/20194/6///5/25/61///7/7//27/8//9/34/ / 11 /9/11 /23//21 /2019 /1/25/20202/2/22 /2020King County syndromic surveillanceED Weekly ED Visits forGroup2014Percent 209206 -Legend30 - 64 -76534 38 40 42 44 46 1 3 9 11 23 31AllagesNote - 9 .Last , 22Base MA wook period 2 for 2the ' of for-201902201904 /13201905060806-07 /80/1708/09142019092812 /2019-2019-01042020-022020Week EndingALLHOSPITALS 2020OKC.GOV>From: James W .Sent: Saturday, February29, 2020 3:08 PMTo: CarterMecherCc: JeffDuchin(Jeff.Duchin@ METROKC.GOV) <Subjec:tRE: RedDawnBreakingBad, StartFeb 24ContactingJeff Duchin.JimJamesW . LeDuc, Ph. D.DirectorGalvestonNationaLlaboratoryUniversityofTexasMedicalBranchGalveston, TX 77555-0610From : CarterMecherSent: Saturday, February29 2020 2 :58 PMTo: Dr Eva K LeeCc: Lawler, James V ; TraceyMcNamara; Baric, Ralph S ; Caneva, Duane; RichardHatchett; Tom Bossert; Martin,Gregory J; Walters, William ; HAMILTON, CAMERON ; Dodgen, Daniel(OSASPR SPPR) ; DeBord Kristin (OS ASPR SPPR); Phillips, Sally (OSASPR SPPR) ; DavidMarcozz; iHepburn,Matthew J CIV USARMY(USA) ; Lisa Koonin HARVEY,MELISSA WOLFE, HERBERT; Eastman,Alexander; EVANS,MARIEFRED; Callahan,MichaelV . M . D . .EDU; Johnson, Robert(OSASPR BARDA) ; Yeskey, Kevin Disbrow, Gary ( BARDA) ; Redd, John (OS ASPR/SPPR) ;Hassel,lDavid (Chris) (OSASPR/ IO) ; Hame,l Joseph(OSASPR/ ; , Luciana;Hanfling, Dan; . ca .gov; Wade, David; TARANTINO, DAVID A ;WILKINSON, THOMAS @ dshs. texas .gov; KAUSHIK , SANGEETA ; Lee, Scott; Padget, Larry G ; RyanMorhard ; Stack , Steven J (CHFS DPH ); Adams, Jerome (HHS/OASH ); Fantinato , Jessica - OHS,Washington , DC ; Colby, Michelle - OHS,Washington , DCSubject: RE: Red Dawn Breaking Bad, Start Feb 24Charity, do you have any contacts in Hawaii? Would really be interestedin Week 8 data .remembera story of a couple from Japan who were symptomatic while visitingHawaiiandwere confirmedto haveCOVID upon their returnto Japan.https: //bigislandnow. com / 2020/02/17/53-self-monitor- for- coronavirus- in -hawaii-after- visiting-japanese-couple-testspositivelMyunderstandingis thatHawaiidid notperform testingon anyone ( monitored somecontacts from symptoms).Iwent to Hawaii's flu surveillance (their latestdata is from week 7).My concern is the continuedrise in despite adrop offin influenzain the lab.https: / /health.hawaii.gov/docd/files/ 2018/03/FLU_ Influenza_ Surveillance.pd-From : Dr. Eva K LeeSent : Saturday, February 29, 2020 1: 15 PMTo CarterMecherCc: Lawler, James V TraceyMcNamara; Baric, Ralph S Caneva, ; Richard Hatchett; Tom Bossert; Martin,Gregory J; Walters, William ; HAMILTON, CAMERON; @ gmail. com ; Dodgen, Daniel(OSASPR SPPR) ; DeBord Kristin (OSIASPRSPPR); Phillips, Sally (OSASPR SPPR) ; DavidMarcozz;iHepburn,Matthew J CIV USARMY (USA); Lisa Koonin HARVEY,MELISSA WOLFE,HERBERT; Eastman,Alexander; EVANS, MARIEFRED; Callahan, MichaelV ., M . D . ; UTMB.EDU; Johnson, Robert(OS ASPR BARDA) ; Yeskey, Kevin; Disbrow, Gary (OSASPR/BARDA) ; Redd, John (OSASPR SPPR) ;Hassell , David (Chris) (OSASPR/ IO ) ;Hamel, Joseph (OSASPR A @ CDPH; Borio, Luciana;Hanfling, Dan; sdcounty. ca. gov;Wade, David; TARANTINO, DAVID A ;WILKINSON, THOMAS; dshs. texas. gov ; KAUSHIK , SANGEETA ; Lee , Scott ; Padget, Larry G ; RyanMorhard ; Stack , Steven J (CHFS DPH ) Adams, Jerome (HHS/OASH ); Fantinato , Jessica - OHS,Washington , DC; Colby , Michelle - OHS , Washington , DCSubject : Re: RedDawnBreakingBad, StartFeb 24Oops. I mixedup the order. It shouldbe -From travelers: Washington, Illinois, California, Arizona,MAWisconsin, OregonUnknownorigin: California, Oregon,WashingtonI did a quick analysis on strategic screening, ifwehave enoughtesting power, I would suggestcommunitytestingstrategicallyin California, Chicago/ Illinois, Oregon,Washington, Boston, Atlanta, NewYork. Itwould be great ifwecan covermore. Wehaveto go beyondcontacttracing. Itis also good to coversomeuniversities.From : Duchin , Jeff @ kingcounty . gov >Sent: Sunday, March 1, 2020 10: 16 AMTo: Bell, MichaelMD (CDC /DDID /NCEZID /DHQP) cdc . gov> ; Jernigan, Daniel B.(CDC/ DDID/NCIRD/ ID ) . gov > ; Armstrong, Gregory DC/ DDID /NCEZID /OD )@ cdc.gov> ; Pillai , Satish K . (CDC/DDID /NCEZID /DPEI) @ cdc. gov >Cc: Kay,Meagan K . ( CDC kingcounty. gov) y @ kingcounty gov>Subject: Fwd: exposuresin hospitalsWearehavinga very serious challengerelated to hospitalexposuresandimpacton thehealthcaresystem .Would be greatto have a call to discuss.Willbemeetingwith your teamherethismorningand then maybewecan chat after that._ Jeffrey S . Duchin,MDHealth Officer and Chief, CommunicableDiseaseEpidemiology& Immunization SectionPublic Health - Seattle and KingCountyProfessorin Medicine, Division ofInfectiousDiseases, UniversityofWashingtonAdjunct Professor, Schoolof PublicHealth4015th Ave , Suite 1250, Seattle, WA 98104From : Armstrong, Gregory (CDC/DDID/NCEZID/OD)To: Duchin, JeffSubject: RE: exposuresin hospitalsDate: Sunday,March 1, 2020 7 :45:23 AM[EXTERNALEmailNotice! ] Externalcommunicationis importantto us. Becautious of phishingattempts. Donotclick or open suspicious links or attachments.Tom Clark is the lead.John is lead of the Infection Control /Prevention team (which is definitely the biggestpart so far).Here in Atlanta, ErmiasBelay is thePOCOn Sunday,March 1, 2020 11:42 AM , CarterMecher wrote:Shouldhavepulled all the triggers for NPlsbynow they are alreadylater than they realize. I fear weare about to see a replay of Italy. Other citiesneedto learn from Seattle.Eva , I did someback ofthe envelope estimates of hat a 1 % threshold means and when I would pullthe trigger.Imadesomeestimatesusingthe cruise ship data butthenmadesomeadjustments assumingthat ifwe could do serology, the extentof the outbreak is likely twice as large as whatwe are estimatingfromswabsandpc (JamesLawler' s argument). So here ismysecondtry with themath adjusting for trueprevalencebeing doublewhatwe think it is on the cruise ship .So assumptionsare 80% asymptomatic, 6 % hospitalized, 1% critical , 0 .4 % CFR. Partofthisassumptionis thattrueprevalenceusing serologywillproveto be significantly greater than prevalencebased on currentdiagnostics (swabs)andasymptomatic/mild diseasein the age groupsunderrepresented on the cruise ship (kids andyoung adults) will dilute thenumberswe are estimatingfromthe cruise ship. [So this is a bitof SWAG. ]Weusually think of the window for implementing NPls as before 1% prevalence . But this diseasewould be predicted to have more than 80 % asymptomatics , so the threshold is really 0 . 2 % prevalenceof any symptoms (including very mild symptoms ). ButCDC criteria for testing is severe disease. Let' ssay that 1 % of those who are infected have severe disease , thatmeans our threshold is 1 % * 1 % =0 .01% . But it takes 2 weeks or so before a patient who is infected becomes seriously ill. Over thespan of 2 weeks plus the lag time for testing, the outbreak could have had at least 3 doublings (so an8 - fold increase ). Thatmay be conservative . So we are really talking about a threshold of close to0 .01% 8 = 0.00125 % . For a city of M that is 12 serious cases, 250 symptomatic , 1,250 infected . In2 weeks , these numbers could be 100 serious, 2 , 000 symptomatic , 10,000 infected (the 1 %threshold ). Once you are there , the window is closed . Ifwe assume a 3 week lag from infection onsetto death , the number of deaths would be based on a denominator of 3 weeks ago , so divide 1,250infected by roughly 3 (assume cases triple in a week ), to get 400 . Assume a CFR of 0 . 4 % , so about 1death . More than 1 death permillion population is probably too late .Wecan work backwards from the first critically illcase involving local transmission and no linkage to aknown case . Ifour threshold is 15 cases of seriously ill individuals (really ICU cases ), and casesincrease by a factor of 8 over a period of about 2 weeks , the far end of the window is about 2 weeksfrom when you identify 2 critically ill cases . To give you a cushion , I would be ready to pull the triggerno later than 2 weeks of the first critically ill patient. If we look at the in CA , that patient had beencritically ill for at least a week . Thatmeans they had about a week from recognition until the windowsstarts to close . Iwould be pulling the trigger in Fairfield / Sacramento .So think oftime to act.1 Bythe timeyou identifythefirstdeath per millionpopulation in someonewith localtransmission (no linkage to a known case) , youneedto pullthetriggeron . LookingatSeattle(populationofcity ofSeattleof740K and populationofmetroSeattle of3. 5M ) , Iwouldpullthe trigger very soon thewindow is very close to closing.2 . No later than 2 weeksfrom the confirmation of the first critically illpatientpermillionpopulation. The window is very closeto closingforFairfield/SacramentoCA.From : Dr. Eva Lee lee64 @ gmail. com >Sent: Monday, March 2 , 2020 7 :45 :51AMTo : THOMAS < @ hq. dhs. gov > ; M . D . @mgh.harvard.edu> ; TraceyMcNamara@ westernu.edu> James V @ unmc.edu> ; Duane @ hq.dhs. gov> ; David@ som .umaryland.edu>; Tom Bossert @ . com > ; Charity A @ CDPH@ cdph.ca. gov> ; Ralph 9 email.unc. edu> ; RichardHatchetti @ cepi.net ;Gregory @ state .gov > ; William @ state. gov > ; CAMERON@ . dhs @ gmail. com @ gmail.com ; Daniel(OS/ ASPR )@ hhs. ; Kristin (OSIASPRSPPR) @ hhs.gov ; Sally (OS ASPR SPPR )@ hhs. gov > ; Matthew CIV USARMY (USA) iv @mail.mil> ; LisaKoonin@ gmail.com > ; MELISSA @ . dhs. HERBERT @ hq . gov ;Alexander < @ .gov > ; MARIEFRED@ associates.hg.dhs. gov > ; @ utmb.edu @ utmb. edu> ; Robert(OSASPR/BARDA)@ hhs. gov> ; Kevin @ . gov> ; Gary (OSASPR BARDA) < G @ hhs.gov ;John (OS/ ASPR/ SPPR . gov > ; David (Chris) ( OS ASPR/ IO ) hhs. gov Joseph(OSASPR / el @ hhs .gov > ; Luciana @ igt.org Dan @ igt. org> Eric ( San DiegoCounty) @ sdcounty.ca .gov ; David < e @ . gov > DAVID A@ .dhs.gov @ dshs. texas er dshs.texas. gov> SANGEETAushik @ hg.dhs.gov> ; Lee hhs.gov ; Larry G < @ state . gov > ; RyanMorhardd @ weforum . > ; Steven Jt( ) @ky.gov ; tJerome (HHS/OASH )ms @ hhs. gov >; DC . gov >usda .gov ; @ usuhs. edu usuhs. edu > ; Danny Shiaucghe org> @ hhs.gov @ hhs.gov > ; Eva LeeCarterMecherSubject: RE: RedDawn Rising Start Feb 29Weneed actions, actions, actions andmore actions .We are going to have pockets of epicenters across this country ,West coast, East coast and the South . Our policy leaders must act now . Please make ithappen !On Mon. Mar 2 . 2020 at 11:29 AM TraceyMcNamara westernu. edu > wrote :S . Korea drive through COVID19 testing.Weneed this nowTraceyGet Outlook for AndroidOnMon,Mar 2 , 2020 at 11:58 AM Dr. Eva Lee wrote:Yes, they are processing10,000 screeningper day. I believewehave to putin NPIactionsnow across the affectedcommunities- - - those sensiblesteps ofschoolclosure, tele-work , call- in advisoryhot-lines forself-reportingoradvice) , avoidcrowds, businesscontinuityplans, exercisecautionson travel , practicepersonalhygiene, etc . Thesewon' t requiretoomuch governmentresources( . . funds) . Thebiggestpartis screening. Screeningrequiresfinancialsupportand requirestimeandactualhumanand lab resources. Sowemustengage private laboratoriesto providethe screeningsurge capacitiesthatweneed. I willwork tomakesure Kaiserlabswillbe on board.From: CarterMecherSent: Monday,March 02, 2020 11:45 AMTo: Dr. Eva Lee 1; TraceyMcNamaraCc: THOMAS @ .gov> ; M . D .@ unmc.edu> ; Duane @ . > David@ mgh. harvard.edu > ; James Vm .umaryland. edu> ; TomBossert @me. com > ; CharityA @ CDPH @ cdph . ca . gov > ; Ralph@ email. unc. edu> ; Richard Hatchett t @ cepi.net> ; Gregory @ state . gov ; William@ state. gov @ . gov ; gmail . com; Daniel(OS/ASPR/SPPR) < D @ hhs. gov> ; Kristin(OSASPR SPPR) @ hhs. gov Sally(OS ASPR /SPPR ) hhs. gov > ; Matthew J CIV USARMY (USA) @ mail.mil > ;Lisa Koonin com > MELISSA y @ .gov ; HERBERT@ hg.dhs .gov Alexander . dhs.gov ;MARIEFREDates.hg.dhs.gov Robert (OSIASPR/BARDA)son @ hhs.gov> ; Kevin < key @ hhs. gov > ; Gary (OS ASPR BARDA)@ hhs. gov Joseph(OSIASPR IO l @ hhs. Luciana < @ igt. org> Dan D @ iqt. org > ; Eric (San DiegoCounty ) d @ sdcounty . ca . gov > David d de @ . dhs. gov > ; DAVID A@ hhs. gov Larry G LG @ state. > ; RyanMorhard d @ weforum .org > ;Steven Jt( ) k @ ky. gov > ; tJerome (HHS/OASH) ms gov > ; DCusda. gov ; DC < m by @ usda. gov @ usuhs.edu; DannyShiau@ cghe.org > . Eva K Lee <Subject: RE: RedDawnRisingStart Feb 29<6 deaths in SeattleSeattlemissed thewindow . . It is too late for NPlsFrom : Dr. EvaLeeSent: Monday, March 2 2020 12: 12 PMTo: TraceyMcNamaraCc: THOMAS; M . D . James V; Duane; David; Tom Bossert CDPH; Ralph S ; RichardHatchett; GregoryJ; William ; CAMERON; Daniel (OS ASPR /SPPR ) Kristin (OS ASPR / SPPR ); Sally(OS ASPR /SPPR ) CIV USARMY (USA ) LisaKoonin : MELISSA HERBERT Alexander :MARIEFRED : @ utmb. edu ; Robert(OS ASPR /BARDA ); Kevin ; Gary (OS ASPR /BARDA ); John (OS ASPR /SPPR ); David (Chris ) (OS ASPR / IO ); Joseph(OS ASPR IO ); Luciana; Dan; Eric (San Diego County ); David ; DAVIDA david .gruber @ dshs. texas. gov ; SANGEETA ; Scott ; Larry G Ryan Morhard ; Steven Jt ; tJerome(HHS ) ; DC; DC; @ usuhs.edu; Danny Shiau ; rid t @ hhs. gov; Carter Mecher; Dr. Eva K LeeSubject : Re: Red Dawn Rising Start Feb 29Lastnightitwas 62 countries as I was writing an email. Now it's 74 countries . And we' re in the 30 's a week ago. Wehave a ton to catch up. I understand it is always difficult decisions for policy makers . But hopefully the contrasts ofHong Kong/ Singapore vs Italy / Korea/Japan provide a good concept ofwhatneeds to be putin placeimmediately. We need multiple measures in place to slow down the spread that clearly is happening around thecountry .From : TraceyMcNamaraSent: Monday, March 2 , 2020 9:57 PMTo: CarterMecher; Dr. Eva LeeCc: THOMAS M . D . James V ; Duane; David; Tom Bossert; CDPH; Ralph S; Richard Hatchett; GregoryJ ; William ; CAMERON gmail.com DanielOS ASPR /SPPR ) Kristin (OS/ASPR/ SPPR ) Sally(OSASPR SPPR) J CIV USARMY(USA) LisaKoonin MELISSA; HERBERT; Alexander MARIEFRED edu; Robert(OSASPR BARDA) Kevin; Gary (OSASPR BARDA) John (OSASPR/SPPR) ; David (Chris ) (OS ASPR IO ) ; Joseph(OSASPR IO ) ; Luciana; Dan; Eric (SanDiego County) ; David; DAVIDA s. texas. gov; SANGEETA; Scott; LarryG ; RyanMorhard Steven Jt ) ; tJerome(HHSOASH); DC; DC; @ usuhs. edu; DannyShiau gov Dr. Eva K LeeSubject: RE: Red Dawn Rising Start Feb 29Courtesyof unsw .edu. auI think one of the problems is the poor sensitivity ofthe throat swab. Several studies have shown that serial throatswabs can be falsely negative. A nasalswab is more sensitive . There should be guidelines stipulating that a sputumis the gold standard , and if that is notpossible for a "recovered" patient, serialnasal swabs should be done. I thinkthis is also telling us the duration viral shedding is quite long. 5 - 9 days from symptom onset to seeking medicalcare; + 2- 3 weeks in hospital+ shedding in the convalescentphaseaddsup, Mostofthemodellingstudiesassume7 days of viralshedding, which is clearlywrong. See:importantpapershowing:1 viralload in asymptomaticsameas symptomatic2. Viralloadhighestearlyin the illness, when symptomsmild or absent3. Nasal /NP swab more sensitive than throatswabAndin termsof the slow progresstowardsserology, it seemsSingaporehas developeda serologicaltest.Sensitive diagnostic tests are the highest priority for containment , but we seem to be slow off themark , with everyonefocused on vaccinesRegardsRainaProfessorRainaMacIntyreHead Biosecurity Research Program Kirby Institute MedicineProfessorofGlobalBiosecurity & NHMRCPrincipalResearchFellow-From : CarterSent: Tuesday, March 03, 2020 2 : 27 AMTo: Richard Hatchett < i .net > ; Tracey McNamara < du >; Dr. EvaLeeomCc: THOMAS .dhs. gov ; M . D . gh .harvard. edu> ; James V@ unmc. edu> ; Duane < hq.dhs. gov>; David @ som .umaryland. edu> ; TomBossert @me. com > ; CharityA @ CDPH cdph .ca . gov > ; Ralph Sc @ email.unc. edu> ;Gregory @ state. gov ; William state. gov> ; CAMERONn @ .dhs. gov ; @ gmail. com ; Daniel(OSIASPRSPPR) < D @ hhs. gov ;Kristin (OS/ASPR/ SPPR) . gov Sally SPPRE @ hhs.gov> ;Matthew JCIV USARMY(USA) civ @ mail.mil> ; Lisa Koonin @ gmail. com > ; MELISSA@ dhs.gov > ; HERBERT @ . . gov Alexander@ . dhs. gov > ;MARIEFRED @ associates.hq.dhs. gov> @ utmb.edu;Robert(OSASPR/ BARDA nson@ hhs. gov> ; Kevin @ hhs. gov ; Gary(OSASPR BARDA)hs. gov ; John (OS ASPR SPPR) dd @ hhs. gov > ; David ( Chris) ( IO ). gov> ; Joseph (OSASPR/IO ) mel@ hhs. Luciana @ iqtorg> ; Danorg>; Eric (San Diego County) < @ sdcounty . ca. gov> ; Davidde @ hq.dhs. gov ; DAVID A < no @ cbp. dhs. gov er @ dshs.texas.gov; SANGEETAshik @ hq.dhs. gov> ; Scotti @ hhs.gov ; Larry G @ state.gov> ; RyanMorhardorhard @ weforum. org> ; Steven Jt ky. gov tJerome(HHS/OASH)< ams @ hhs. gov> DC @ usda. gov ; DC@ usda. gov > ; uhs. edu; DannyShiau @ cghe.org @ hhs. gov; Dr.Eva K Lee < h @ pm .me>Subject: RE Red DawnRising Start Feb 29The documents Richard sentare excellent. Iwent thru and pulled out excerpts that really struck me. To get to thebottom line, I pasted the recommendation for us.For countries with imported cases and/or outbreaks of COVID - 191 Immediately activate the highest level of nationalResponse Managementprotocols to ensure the all-ofgovernmentand all -of-society approach needed to contain COVID -19with non -pharmaceuticalpublic healthmeasures;2 . Prioritize active , exhaustive case finding and immediate testing and isolation, painstaking contact tracing andrigorous quarantineofclose contacts ;3. Fully educate the generalpublic on the seriousnessof COVID - 19 and their role in preventing its spread;4 . Immediately expand surveillance to detect COVID - 19 transmission chains, by testing all patients with atypicalpneumonias, conducting screening in somepatients with upper respiratory illnesses and/or recentCOVID - 19exposure, and addingtesting for the COVID - 19 virus to existing surveillance systems( e g. systems for influenza -likeillness and SARI);Conductmulti-sector scenario planningand simulationsfor the deploymentofeven more stringentmeasurestointerrupttransmission chainsas needed( e. g. thesuspensionoflarge-scale gatheringsand the closure ofschoolsandworkplaces)On Tuesday, March 3, 2020 1: 56 PM , Marcozzi, David < DMarcozzi@ som umaryland.edu> wrote:Act. Now.Respectfully,David Marcozzi, MD,MHS- CL, FACEPAssociate ProfessorDirector of Population HealthDepartment of Emergency MedicineUniversity ofMaryland School ofMedicineDr. Eva K Lee pm .me>Sent: Tuesday , March 3, 2020 3 :53 PMTo: Marcozzi, David umaryland. eduCc: CarterMecher rter.net> ; TraceyMcNamara a @ westernu. edu > ; Richard Hatchett@ cepi.net> ; . Eva Lee 64 gmail. com > ; WILKINSON, THOMASInson @hq.dhs.gov> ; M . D . <MVCALLAHAN@ mgh. harvard.edu> : James V er @ unmc.edu > ;Caneva, Duane < va @ . gov> ; Tom Bossert t @ me. com > ; Charity A @ CDPH< g n @ cdph .ca .gov > ; Ralph @ email unc.edu> ; Gregory J J state . ; William<WaltersWA2 @ state . gov> HAMILTON , CAMERON n @ hg.dhs. gov ir @ gmail.com Daniel(OS ASPR SPPR ) @ .gov > ; Kristin (OSIASPR hhs. gov Sally(OS ASPR SPPR) @ hhs. gov Matthew J CIV USARMY(USA) iv @ mail.mil> ;Lisa Koonin < 1 @ gmail.com > ; HARVEY, MELISSA < m harvey @hg. dhs. gov > ; WOLFE, HERBERTdhs. gov Eastman, Alexander < n @ .gov > ; EVANS,MARIEFRED@ associates. .dhs.gov @ .edu ; Robert (OSIASPR /BARDA)nson @ hhs.gov Yeskey, Kevin < hhs.gov > ; Gary (OS/ASPR/BARDA). gov> ; John (OS ASPRSPPR) < @ hhs. gov> ; David ( Chris) (OS ASPR.gov> ; Joseph (OSASPR/IO ) @ hhs.gov ; Luciana rg>; Dan@ igt. org >; Eric (San DiegoCounty) < @ sdcounty. ca. gov> ; Wade, David@ hq.dhs. gov> ; TARANTINO, DAVID A@ cbp.dhs. gov> ; er @ dshs.texas. gov; KAUSHIK, SANGEETAaushik @ hq.dhs.gov ; Scott ScottLee .gov Larry G @ state.gov> ; Ryan Morhard@ weforum . org> ; Steven ) ky. gov ; (HHS/OASH )< Jerome @ hhs. gov> ; DC to usda. gov>;usda. gov ; @ usuhs. edu; DannyShiau . > ; @ hhs.govSubject: Re: RedDawn RisingStartFeb 29Yes, weoughtto actnow . Ok, I know have been urgingthis for a longtime. I wantto cover a few itemsdiscussedhere1. Socialdistancing, NPIcan deterthespreadSingaporeandHongKongprovethatwithoutanydefinitivetreatmen, tand absenceof anyprophylacticMCMprotection, closingschools, home-officebusinesscanmakea hugedifference. I ran a fewmodelsfor schoolclosureandbusinesstele-work for Santa Clara, KingCountyand I wantto sharesomegraphshere.Santa Clara: Onepositivecaseon Jan 31. I lookat closingschoolas oftoday, andtele-work by 0. 5 millionworkers.Wecan seethe rapid decrease ofspreading. I also contrastthe results ifwe close a week from now, or twoweeksfrom now.Please note , the parameters need notbe perfect. The idea is to contrast how NPIcan work very effectively and weMUST actnow and make it a success .Santa Clara: Strategies for ContainmentTotal Inectionsvs Intervention, 90 days Totalinfectedcaseswith intervention2500012000 Confirmedpositive closeon 3 /3intervention 20000 Schoolsclose on 3 /1010000close on 3 / 3 Schoolsclose on 3/ 17Schoolsclose on 3 / 10 15000 School+business 3 /3- Schools close on 3 / 17 Schoo+lbusiness 3 / 10Number of infectedSchool business3 3 10000 -school+ business 3 / 17.. . .. School+ business 3/ 104000- + business 3 / 17 500020002/7/20201/31 / 3/6/20202/21/20202/28 /20205/1/20203 / 31/2020 4 / 30 /2020 5 / 31/ 2020640 9 ,724 139,774Total infection without intervention6 / 29/2020911,2042/14 /20203/13/20203/2/20020EK Lee, Copyrightmaterials20203/27/20204/3/20204/10 /20204/17/20204/24 /20202 . Quarantinea city ?I believethere's a contingencyplan (I did recallworkingwith National Guardon it) wherewewillquarantineeveryoneinsidea city if there' s a severe diseasespread. It is like whatChinadid forWuhan. WithMCM, we can give citizensMCMbeforethey leave. There is noMCMnow .While one can a federalquarantineandtotal lock downof a city ismoreeffective, I think Lu's commentisonpoint.Wecannotexpectperfectparticipation. Everyoneis goingtomakea decision. Ifwecan contain 80 % of thepeople' s movement(as in HongKongand Singapore, orin the Santa Claramodelabove), you can see thatwearestoppingthe spread. Clearly, thosewho getout ofthe city mightvery wellbe infected and sow a seedto otherplaces.Yes, we probablyneed to think harderwhatto do. The closing schools and tele-work in a sense is volunteeringquarantine. It can work beautifully andvery effectively. Note thatHongKonghasonly limited transportationban. Thecitizensand thehealthcareworkers protestto close theborder, buttheborderwasn't closed. So the effortisvolunteeringquarantineof their own residentsand then quarantinefor everyonewho enters thecity. Together, itputs a brakeon the spread. It is rightto do it now .3 . KingCountySeattleTrueto the form oftheCOVID-19and themortalityof elderly, whichis 1. 3 % , 3. 6 % , and 14. 8 % from 50 yearsowards, for every 10 yearagebracke.tSowesee the veryhighmortalityof thenursinghome. AlthoughI know nextto nothingaboutwhat' s goingon in China, thesefiguresseem to bea good guidingpointfor us.Whattroublesmeaboutthe spreadis that it is almost likeby- the-book .Wegotschoolteacher get infected, nursinghome, a very sick patientin ICU (healthcareworkers got quarantine) you see wherewe are heading, everyvulnerablepopulation is hit.4 . Limited TransportationBanSo lastweek, wrote thatweneedto includeNew York andAtlanta in the screening. Badenough thisweekwehavecasesin these cities. I do thinkweneedto step up in reducingthe South Korean flights into theUS. HongKongusesbrand-new public estates to quarantinethe incomingtravelersfrom high-risk regions. It is a luxury thatwe do nothave. Here, wemustfigure outan effectivequarantinefor these enteringvisitors orreturningcitizens. Maybeit is timeto stop visitors Korea and Italy. Itis just temporary . So we can focus on handling citizens coming back. Weneed to let them in . Cannotleave them outside their own country .On Tuesday, March 3, 2020 4 :22 PM , Caneva, Duane @ hq dhs. gov> wrote :Lookingat a projectto develop triggers for communitymitigationbasedon proxy data such as ICU cases, deaths,surveillancediagnostics, and gap betweenILIpresentationswith ILI+ panels. Wehave gooddata from other citiesaroundtheworld on whattheir data showedandwhen they implementedmitigation efforts. Wecan measurethatdata in near-realtimeanduseitas objectivemeasure to pull the trigger.Thoughts?From : CarterMecherSent: Tuesday,March 3, 2020 5 :59PMTo: Dr. Eva K Lee: Eastman. AlexanderCc: Caneva, Duane;Marcozz,iDavid; TraceyMcNamara; RichardHatchet;tDr. EvaLee;WILKINSON, THOMAS;M . D . James V ; Tom Bossert; Ralph S ; Gregory ; William ;HAMILTON, CAMERON;ail.com ; Daniel(OS/ASPR ); Kristin (OS ); Sally (OSASPR/SPPR); Matthew J CIVUSARMY(USA) ; Lisa Koonin; HARVEY,MELISSA; WOLFE, HERBERT; EVANS, MARIEFRED utmb.edu;Robert(OSASPR BARDA) ; Yeskey, Kevin;Gary (OS ASPR BARDA) ; John (OS ASPR ) ; David(Chris)(OSASPR IO ) ; Joseph (OS ASPR/ IO ) ; Luciana; Dan; Eric (San Diego County) ; Wade, David; TARANTINO, DAVIDA ; .gov; KAUSHIK , SANGEETA ; Scott; Larry G ; Ryan Morhard ; Steven Jt(tCHFStDPH );tJerome (HHS/OASH ); DC DC ; u @ usuhs. edu; .gov; Jolly , Brantley (OS ASPR EMMO )(CTR ) ; Cordts , Jerome (CTR ); Mansoura , Monique K .Subject: RE: Red Dawn Rising Start Feb 29I don' t getthe sensethat Seattle will considerclosing schools ( exceptperhapsreactiveschoolclosuredue to highabsenteeism) .HasSeattlemodeledthe potentialimpactto their healthcaredelivery system ofan unmitigatedoutbreak? The high %ofasymptomatic/mild diseaseis a bitmisleading. Itmightbe eyeopeningfor Seattle to simply overlaythe cruise shipdata atop their populationage >60 andassumeeveryoneunder60 hasmild diseaseandeven use an attack rateof20 % . Easy enough to do forthem .King County health officials : No reason yet to close schools for COVID - 19Localhealth departments recommended Monday schools stay open asmore announcements of cases of the novelcoronavirus were made,butseveral districts closed schools on Monday anyway , mostly as students were testedThere were no blanket closures, or a scene of district-wide shutdowns , but different schools had different reasons forclosingMonday . As ofMonday , no schools in Washington state had confirmed cases of COVID - 19The schools that have closed so far have done so for deep cleanings after students were either being tested forCOVID - 19 orhad come into close contact with someone who had the virusAnother school district is closing Tuesday for staff training on how teachers can continue their lesson plans remotelyshould the schools need to shut down as the virus spreadsDr. Jeff Duchin , health officer for King County Public Health , said during a press conference Monday if there areconfirmed cases , the agency will work with schools directly to provide guidance"Schools don ' t need to take any specialprecautions beyond what we've recommended for good hygienerecommendations ," he said ,mentioning that ill students and staff should stay home from schoolThe Centers for Disease Control and Prevention recommends school districts take steps that prioritize thecommunity ' s health while causing the least amount ofdisturbance to students" Schools should continue to collaborate , share information , and review plans with localhealth officials to help protectthe whole school community , including those with special health needs, the CDC said on its website . School plansshould be designed to minimize disruption to teaching and learning and protect students and staff from social stigmaand discrimination . "From : CarterMecherDate: Tue, Mar 3 2020 at8 :55 PMSubject : RE: RedDawnRising StartFeb 29To: Dr. Eva K me> , Eastman, AlexanderM .Cc: Caneva . dhs. gov> , Marcoz,zDi avid < d . edu> , TraceyMcNamara nu.edu> , RichardHatchett rich @ cepi.net> , Dr. EvaLeem > , WILKINSON, THOMASharvard.edu> , James c . edu , Tom Bossert @me. com > ,Charity A @ CDPH . ca .gov Ralph .unc.edu> , Gregory J@ state.gov William state .gov HAMILTON , CAMERONn @ .dhs.gov , @ gmail.com <r com > , Daniel (OS ASPR SPPR )en @ hhs. gov Kristin (OS ASPR SPPR ) @ hhs.gov> , Sally (OS ASPR/SPPR )hhs. gov Matthew J CIV USARMY (USA) @ mailmil Lisa Kooningmail.coWOLFE @ .gov MARIEFRED vans @ associates.hq.dhs.gov ,@ . edu @ utmb edu> , Robert(OS/ASPR/BARDA) gov , Yeskey , Kevin. gov , Gary (OS/ASPR/BARDA) < G w @ hhs.gov> , John (OSIASPR SPPR )@ hhs.gov > , David (Chris ) (OSASPR / ) @ hhs.gov> , Joseph (OS ASPR.gov Luciana org > Dan fling @ igt. org > ( San Diego County )@ sdcounty .ca.gov > , Wade, David de@ hq.dhs. gov> , TARANTINO, DAVID A@ cbp.dhs. gov> , as.gov < da er @ dshs. texas. KAUSHIK ,SANGEETA hik @ . gov Scott hs. gov Larry G state. gov> , RyanMorhard weforum. org> , Steven Jt(tCHFSDPH) . gov> , tJerome(HHS/OASH). gov> , DC @ . gov> , DC y usda.gov@ usuhs. edu < @ hhs.gov @ .gov> , Jolly, BrantleyOSASPR/EMMO) (CTR) < Cordts, Jerome( CTR).hq. dhs.gov Mansoura, Monique K . @ mitre.org >Iwas curious what is meant by mild disease . Somebody can double check mymath .Attachedis a back-of-the-envelopeestimateofthe impactof COVID on a notionalcity of 3. 3M [The currentUSpopulationis ~ 330M, a notionalcity of3. 3M isassumedto be 1 % of theUSpopulation, with 1 % ofhealthcareassets (hospitalbeds/ICU beds) , 1% ofhealthcareutilization(hospitaladmissions /hospitalBDOCs/ BDOCs/ ERvisits/outpatientvisits) , and 1 % ofannualall- causedeaths— a notionalaverageUS city representing1% oftheUSpopulation. I 3 . 3. M becausethis makesthemath simpMethodologyto estimatethe impactof COVID on this notionalcity:Forthe population age > 60weassumedan attack rateof 30 % and appliedthe cruise ship outbreak data ( 50%asymptomatic; 12% acutelyill; 2 - 5 % ICU admission; 0. 92 CFR)For the under age 60 group, we assumed there willbe a similar degree of disease transmission (AR 30 % ) androughly 50 % asymptomatic and 50 % mild /moderate disease and occasional serious disease requiring them to touchour healthcare system (100 % requiring outpatient care / 10 % ER care) . [very conservative estimates]Really interesting what havocmild disease might cause on this notional city . In this scenario , roughly 89 % of thosewho are infected are asymptomatic or mild disease . I assumed the event would stretch over 90 days — theacceleration in acute care demand in Wuhan was concentrated over a period of 5 -6 weeks . So the estimates ofdemand relative to capacity superimposed over a shorter time period and adjusting for peak demand are much worsethan what the numbers convey .This is why Eva is so concerned about not delaying the implementation ofmitigation measures. She understandswhat is going to happen .Metro Seattlehasa populationof .5M (close enough to this notionalcity) .From : CarterMecher: Wednesday , March 4 , 2020 6 :09 AMSubject: RE: Red Dawn Rising Start Feb 29It is how high the prevalence must be in Italy to have the amount of spread we are seeing associated withtravelers from Italy . What is equally amazing is how it was hidden until it exploded . I suspect what happened in Italyis really the movie' for the rest ofthe world , including the US. Itwould be really usefulto have better intel on what ishappening to the healthcare delivery system in Italy ( Italy also has the 2nd oldest population with 23% age 65 + whileJapan is at 27 % and the US at 15 % )The only report noticed was a brief report on Twitter that Italy - Converting military barracks to makeshift hospitalsin anticipation of the development of Coronavirus spread"Does anyone have better data ?OnWednesday, March 4 , 2020 7 : 44 AM , CarterMecher harter.net> wroteHongKong( 101case/ 2 deaths) and Singapore(110 cases/ deaths) continueto hold the line. Singaporehaslineargrowth (keepingRo close to 1) ; HongKongalsohas linear growth. This is reallybestpracticefor a city. Mightbeworthwhile forUS citiesto take a close look at how SingaporeandHongKonghaverespondedthroughoutthis crisis.When this allbegan, HongKongandSingaporewere seeded early andvery early on theyhad the largestnumberofcases followingmainlandChina. Since then havewatchedother countriescome outofnowhere andracefar aheadofHongKongandSingapore(linear growthvs. exponentialgrowth). SouthKorea ( 5 ,621/ 28 deaths) ; Italy ( 2 ,502/79) ;(293/6 ) France (212 4 ) (203/ 0 ) Spain ( 165 / 1) 127/ 9 ). Seattle alone willovertake HongKong and Singaporeby the endoftheweek . Organizations and governments and scientistslike to talk about learning from best practices. Wellhere they are.When show the slide ofPhiladelphia-St.Louis in 1918 often ask audiences which city they would have preferred tobe living in during the 1918pandemic. When we look back atthis pandemic, wewill have new contrasting city pairs and contrastingcountry pairs and can pose a similar question .From : Dr. Eva K LeeSent: Wednesday, March 4 , 2020 1: 54 PMTo: CarterMecherCc: TraceyMcNamara; RichardHatchett; Dr. Eva Lee; THOMAS; M . D .; James V; Duane; David; TomBossert; Ralph S ; Gregory J; William ; CAMERON om ; Daniel(OS ASPR SPPR ): Kristin (OSASPR/SPPR ) : Sally (OS ) : Matthew J CIV USARMY (USA) :Koonin ; MELISSA; HERBERT; Alexander;MARIEFRED @ utmb.edu; Robert(OS/ASPR/BARDA; Kevin Gary (OSASPR/BARDA) ; John (OSASPR/SPPR) ; David (Chris) (OS/ ASPR/ IO ) ; Joseph(OSASPR/ IO ) ; Luciana; Dan; Eric (San DiegoCounty); David; DAVIDA ; xas.gov; SANGEETA ; Scott; Larry G Ryan Morhard; Steven Jt( ); tJerome(HHSOASH ); DC DC Shiau t @ hhs.govSubject: RE: Red Dawn Rising Start Feb 29Carter, please review the information I sent regarding the NPIintervention model I sent for Santa Clara yesterday . Iran it for Hong Kong. It is another perfect result to confirm what we should do .I am not sure how we can use increase of ILIand other disease activities to predict COVID -19 They should be used,but they are secondary because by the timewe are seeing the citizens ' symptoms and complaints , we are a fewweeks late already . The " unknown " cases are out there already . Those with no/mild symptoms , or doesn 't reallymatter if there 's any symptoms or not, the 1 case in Santa Clara on Jan 31 is real. It's one -- and as we see in themodel -- one case is one case too many already , because it's already growing . Because itmeans there' re others wedon 't know .For example for the Seattle nursing home -- they get infected and they have respiratory distressed . But they don't getregistered onto public / hospital records. And then university students , they get sick all the time, not that they willseethe doctor or anyone . So we won 't register them either. Then ICU/ED patients . Ok, thatwe can screen and shouldscreen . Also , the flu may be masked by COVID -19 , as in Japan where COVID - 19 basically halted the flu season . Sothere may be no spike at all in the surveillance data , since it is the usualpattern , butinstead of the usual flu / cold etc ,it is replaced by COVID - 19 . It is really quite difficult to use disease surveillance as a guide , becalate atleastby 2 weeks . ifnot more weeks . Themoment the first case appears , we're late already by 2 weeks .From : CarterMecherSent: Wednesday, March 4 , 2020 2 : 19PMTo: Dr. Eva K LeeCc: TraceyMcNamara; RichardHatchett; Dr. Eva Lee; THOMAS; M . D . James V ; Duane; David; TomBossert; S ; Gregory J William ; Daniel(OS ASPR SPPR) ; Kristin(OSASPR SPPR) Sally (OSASPR SPPR) ; Matthew J CIV USARMY(USA); LisaKoonin; MELISSA;HERBERTAlexander; Robert(OSASPR/BARDA) Kevin Gary (OSIASPR/BARDA) ; John (OSIASPR/SPPR) ; David (Chris) (OS ASPR/ IO ) ; Joseph(OSASPR/IO ) ; Luciana; Dan; Eric (San DiegoCounty) ; David; DAVIDA ; s.texas.gov; SANGEETA; ; Larry G ; RyanMorhard; Steven Jt( ) ; tJerome(HHS/OASH) ; DC hs.edu; Danny Shiau; rSubject: RE: Red Dawn Rising Start Feb 29Eva, I agreewith you. Politicalleadersandpublichealth leadersneedto be convincedof theutility oftheseinterventionsandthe courageto act. Iftheymissthewindow to act, theydon' t get a do-over. Can' t take a Mulliganwith . There is noresetbuttonto playthe gameagain. You only getoneshot. I fear that Seattlemayhavemissedtheir opportunity. OutofdesperationI predicttheymayeventuallyimplementand endureallthe downsidesofwithmarginalto little upside. This is exactlywhathappenedin 1918. A whileback shared someslides on thelessonslearnedfrom 1918. Unfortunately,wehaveto learn somelessonsagain andagain.From : CarterMecherSent:Wednesday,March 4 , 2020 2 : 36 PMTo: Dr. Eva K LeeCc: TraceyMcNamara; Richard Hatchett; Dr. Eva Lee; THOMAS; M . D .; James V ; Duane; David; TomBossert; Charit Ralph S Gregory ; William ; CAMERON; .com ; Daniel( /ASPR / SPPR ); Kristin (OS/ASPR / SPPR ); Sally (OS/ ASPR / SPPR );Matthew J CIV USARMY (USA ); LisaKoonin ;MELISSA; HERBERT; Alexander ;MARIEFRED ; utmb.edu; Robert (OS/ ASPR /BARDA);Kevin ; Gary ( /ASPR / BARDA John (OS/ ASPR / SPPR ); David (Chris) ( / ASPR / ); Joseph (OS/ ASPR / 10 );Luciana; Dan ; Eric (San Diego County ); David ; DAVID A ; dshs. texas.gov; SANGEETA ; Scott;Larry G ; Ryan Morhard ; Steven ( ); (HHS/OASH );DC; DC; @ usuhs.edu;Danny Shiau; @ hhs.govThe US is now up to 11deaths ( 10 in Washington and 1in California).I think there is disconnect among very smart people. They hear the high % of patients who are asymptomatic or havemild illness and equate this to a mild outbreak . Hard forme to understand how they come to this conclusion .2019NovelCoronavirus(COVID-19) in WashingtonPositive(confirmed)DeathsSnohomish County - 8 including 1 death- 31 including 9 deathscontact the local health department for informationNumber of People UnderPublic Health SupervisionNumberofpeopleunderpublichealthsupervisionnumberof people under public health supervision includes thoseatrisk ofhaving been exposed to novel coronaviruswho aremonitoring their health under the supervision of public health officialsThis number includes peoplewho have returned from China in the past14 days and are included in federal quarantine guidanceOn 4 Mar2020, at 20 :31, CarterMecher @ charter.net> wrote:Rhetoricalquestion, what ishe evaluating daily ?SEATTLE -- Washington state on Wednesdayreported a 10th death from coronavirusGov. Jay Insleesaid hewasevaluatingdaily whetherto orderwidespreadclosures and cancellationsdue to theoutbreak.Thestate Department of Health released updated figures showing that nine people had died in KingCounty, the state ' smost populous, and onein Snohomish County. Thestate hasnow reported 39COVID -19 cases, allin the greater Seattle areOnWednesday, March 4 , 2020 3: 37 PM , Richard Hatchett < @ cepi.net> wrote:Itis remarkable that leaders are reluctant to implementinterventions that they willhave to implement anyway when they lose control. Do they think the virus ismagically going to behave differently when it gets to their community ? Why can' tthey look atthe successfulexamples and emulate these ?On Mar 4 , 2020 , at 10 : 24 PM , Caneva , Duane a @ . gov > wrote:Please use this thread as of evening of 04 MarchDuane C . Caneva , MD,MSChief MedicalOfficerDepartment ofHomeland SecurityExecutive Assistant: Nichole< DBrian Benson @ icloud . com >Sent: Thursday , March 5 , 2020 12:08 AMTo: Caneva , Duane < @ hq . govCc: CarterMecher < t > ; Mecher, Carter outlook . comer @ va.gov ; TraceyMcNamara < t westernu.edu> ; Hunt , Richard(OS ASPREMMO@ hhs.gov ; RichardHatchett< ett @ cepi.net> ; Dr. Eva Lee> ; WILKINSON, THOMAS N @ hq.dhs. gov> ; M . D .mgh harvard.edu> ; James V er @ unmc.edu > ; David@ som .umaryland.edu ; Tom Bossert rt@me. com >; Charity A @ CDPH@ cdph. ca .gov Baric, Ralph unc. edu > ; Gregory J GJ@ state . gov ; Walters ,William (STATE .GOV [ . safelinks .protection outlook . com ]) a2 @ state . gov ; HAMILTON , CAMERON@ hg. dhs.gov gmail. com ; Dodgen, Daniel(OS ASPR )@ HHS.GOV> ; DeBord Kristin (OSIASPR/SPPR ) @ hhs.gov ; Phillips, Sally(OSIASPRSPPR) < s @ hhs. gov> ; Matthew J CIV USARMY(USA) < m @ mail.mil> ;Lisa Koonin @ gmail. com > ; HARVEY, MELISSA < hq.dhs.gov ; WOLFE, HERBERT@ .dhs.gov Eastman, Alexander< a an @ .gov> ; EVANS,MARIEFREDs @ associates .dhs. gov> ; @ utmb.edu; Johnson, Robert (OSIASPR BARDA)< on @ hhs. gov Yeskey, Kevin < hhs. > Disbrow Gary ( OS/ ASPR/ BARDA)w @hhs. gov> ; Redd, John (OSASPR/SPPR) < dd @ hhs.gov> ; Hassell, David (Chris)(OS ASPR l l hhs. gov Hamel, Joseph(OS R / Joseph . gov ; Lucianaio org> ; @ .org> ; nald sdcounty . ca. gov; Wade, David< d @ hq. dhs. gov ; TARANTINO, DAVID A< dano dshs gov:KAUSHIKshik @hqdhs.gov> ; Lee, Scott (OS/ASPR/EMMO) @ hhs. gov Larry Gtate . gov> ; Ryan Morhard @ weforum . org > ; Steven )@ ky gov ; Adams, Jerome (HHS/OASH) @ hhs. gov ;Mansoura,MoniqueK .ra @ mitre. org> ; Fantinato, Jessica (USDA.GOV [ . safelinks.protection.outlook.comnato usda . gov ; DC < m sda. gov da @ usuhs. edu; Cordts, Jeromerdts @ associates.hq.dhs. gov ; Schnitzer, Jay @ mitreorg>; Ignacio, Joselitoio @ .dhs.govSubject: Re: Red DawnRaging Start March 4VDuane, thanks forincludingmein the conversation.I 've beenreadingwhatI can on PubMedandin thenews, butcan' t findmanyanswers, thus I' ll asks this group. First,beingthatsomeviruses are capableofinsertingtheirDNAinto hostsgenome, is there any evidencethatthisRNAviruscan do that? Thavenothingto support this, but ask to anticipateany late term effects, i. e. Cancer,other post viral syndromes . Secondly , are there any restrictionsites in this strain that are not present in others ofthe same family , suggesting this is engineered ? Lastly , what 'sgong on in North Korea ?Folks, those of you thatknowmeunderstand 'm glad to help in any can. Please letmeknowFrom : " Baric, Ralph S"To: " Brian Benson ", Duane "Cc: "CarterMecher", Carter (VA.GOV . safelinks .protection . outlook .com ])", " Tracey McNamara " , Richard(OS ASPR EMMO)", " Richard Hatchett", "Dr. Eva Lee ", THOMAS" , " M .D .", " James V " , "David", " Tom Bossert" ,"Charity A @ CDPH ", " Gregory J" , William (STATE.GOV [ . safelinks.protection outlook .com ])", CAMERON ",@ gmail. com " , Daniel(OS ASPR SPPR)" , Kristin (OSIASPR SPPR ) " , Sally (OS ASPR SPPR)" , "Matthew JCIV USARMY(USA) " , "Lisa Koonin , MELISSA" , HERBERT" , Alexander" , MARIEFRED" , @ utmb. edu" ,Robert(OSIASPR/BARDA) " , Kevin" , Gary (OSIASPR/BARDA) " , John (OSASPR/SPPR) " , David (Chris)(OSASPR / IO ) " , Joseph (OS ASPR IO ) " "Luciana", " Dan" , @ sdcounty.cagov", David", DAVID A" ,@ dshs.texas. gov" , SANGEETA" , Scott (OSASPR/EMMO) " , " Larry G ", "RyanMorhard" , " StevenJt( ) , Jerome(HHSOASH) ", MoniqueK . ", Jessica (USDA.GOV[ safelinks. protection. outlook. ] , usuhs.edu", Jerome( CTR )", Jay J" , Joselito "Sent: Thursday March 5 2020 7:52:21AMSubject: RE: Red Dawn Raging Start March 4HiBrian,No coronavirusRNA virusesdon' t incorporatetheir genomesinto thehostDNAYes, potentialhit and run diseaseis pulmonaryfibrosis, which can occuras a resultof acute lunginjurymonthstoyearslaterNo, thereis absolutelyno evidencethatthis virusis bioengineered.RalphTo: Ralph S "Cc: "Brian Benson" Duane" , Carter (VA.GOV [ . safelinks. protection.outlook. com , " TraceyMcNamara" ,Richard(OS/ASPR/EMMO) " , "Richard Hatchett" , "Dr. Eva Lee" THOMAS" , " M . D . " , " JamesV " , "David" , " TomBossert" , "Charity A @ " , "Gregory J" , William (STATEGOV[ . safelinks.protection.outlook. coml ) " ,CAMERON"". com ". Daniel(OS ) ". Kristin (OS SPPR " . Sally ( ""Matthew J CIV USARMY(USA) ", "Lisa Koonin , MELISSA", HERBERT" , Alexander" ,MARIEFRED"edu , Robert (OSIASPRBARDA) ", Kevin" , Gary ( BARDA)", John (OSASPR SPPR)",David (Chris (OSASPR/ IO ) ", Joseph (OS/ ASPR/ IO )" , "Luciana" , "Dan", @ sdcounty. ca . gov", David",DAVID A" @ dshs.texas. gov", SANGEETA" , Scott(OS ASPR EMMO)" , " Larry G ", "RyanMorhard"," Steven Jt( ) , Jerome(HHSOASH) ", MoniqueK .", Jessica (USDA.GOVsafelinks.protection. outlook.coml) " "DC" , . edu", Jerome (CTR )", Jay J" , Joselito "Sent: Thursday March 5 2020 8:55:31AMSubject: RE: Red Dawn Raging Start March 4Impact assessment pulled together and shared with my leaders . I utilized the attack rate of 20 % that wasexperienced on the Diamond Princess so that could begin to help people get their head around what is perceived tobe a mild outbreak means . I purposely used an actual event(and actual attack rate) for comparison so as not to beperceived as fear mongering. I sense confusion among very smart people (politicians , physicians , public healthleaders hear that more than 80 % of those who are infected have mild disease and that overall case fatality ratesare on the order of 0 . 5 % . And they then equate these stats to a mild outbreak . They really don' t consider attackrates and the impact of the 20 % with something other than mild illness means .A more reasonable attack rate to plan for is around 40 % , so just double everything in the attached reports You all canlook at these projections and envision what will happen to our healthcare system if we don' t take aggressive actionsto slow community transmission now . This is not the time to get fancy or creative with and try to finesse things(ala carte implementation ). We should learn from China and the other best practice nations already fighting thisdisease. We know whatworks just need the will to do it. We should be treating this like we treat stroke and acutecoronary syndromes where time = tissue . In this case time = transmission .From : ter. net .netSent: Thursday, March 05, 2020 10 : 53 AMTo : etCc: ' . Eva Lee' ; Caneva, Duane a @ . ; ' Tom Bossert@me.com > ; Baric , Ralph S @ email.unc> ; Tracey McNamaral westernu .edu > ; 'Hunt Richard (OS ASPR EMMO ) @ hhs. gov ; Richard Hatchett@ cepi.net> ; WILKINSON , THOMAS @ hg.dhs. > ; M< M @mgh.harvard. edu > ; ' James V ' @ unmc. edu > ; 'David 'umaryland.edu > ; Charity A @ CDPH @ cdph. ca. gov>; ' Gregory J'.gov> ; Walters, William . safelinks. protection outlook.comlstate . gov HAMILTON, CAMERON g .dhs. gov ; r @ gmail.commail. com > ; 'Dodgen, Daniel (OS ASPR /SPPR ) en @ hhs. gov Bord, Kristin(OSASPR/ SPPR hhs. gov> ; ' Phillips, Sally (OSASPR SPPR) ps @ hhs. gov ;Matthew J CIV USARMY(USA .civ @ mail.mil> ; LisaKoonin @ gmai.lcom > ;HARVEY, MELISSA .dhs. gov ; WOLFE, HERBERT H @ .gov' Eastman, Alexander' .dhs.gov EVANS, MARIEFREDociates.hg. dhs.gov . edu' utmb. edu> ; Johnson, Robert(OSASPR BARDA) hhs. gov ; 'Yeskey, @ hhs. gov ; Disbrow , Gary(OSIASPR BARDA . gov > ; 'Redd, John (OS ASPR d @ hhs. gov> ; Hasse,llDavid ( Chris) (OSASPR/ ) ' < D @ hhs. gov Hamel Joseph (OSASPR/ IO ) ' @ hhs.govLuciana' < @ iqt org> ; 'Dan fling @ . org > ; 'David' < hq dhs. gov ; TARANTINO , DAVID A 'o @ cbp .dhs. gov ; da .texas. gov' hs.texas.gov> KAUSHIK,@ . gov ; Lee, Scott(OSIASPREMMO) .Lee hhs. > ; 'Larry G 'tate . gov ; 'RyanMorhard' < d @ weforum. org> ; 'Steven )tack @ ky. gov>; ' Adams, Jerome( ) dams@ hhs. gov > ; Mansoura, Monique K .@ mitre. org > ; Fantinato, Jessica . safelinks.protection.outlook. comato @ usda. gov DC' < y @ usda.gov u @ usuhs.edu'hiau @ usuhs. edu> ; ' Cordts, Jerome (CTR ) associate.hsq. dhs. gov> ; 'Schnitze,rJay Jmitre.org> ; ' , Joselito' acio fema. dhs. gov> ; WillGaskins' @ efiia .com > ;CHRISTOPHER ALLEN @msn . com > ; ' Kevin Montgomery ' < collaborate .org >Subject : Re: Red Dawn Raging StartMarch 4Listeningto CDC. Anita Patelhasjust summarizedCDC guidancere communitymitigationmeasures. They are notrecommendingclosingschools- - talking aboutreactive schoolclosure (e. g. , a studentbecomesill andthey close theschoolto disinfect) .VeryunfortunateFrom : "Dr. Eva Lee"To: Duane"Cc: " Tom Bossert" , , Ralph S" , "Brian Benson", Carter (VA.GOV[ safelinks. protectionoutlook. com " TraceyMcNamara" , Richard (OSASPREMMO" , " Richard Hatchett",THOMAS" " M . D ." " James " David" @ CDPH" , " Gregory J" William (STATE GOV. safelinks.protection outlook. com CAMERON" . " com Daniel(OSIASPR/SPPR)", Kristin(OSIASPRSPPR) ", Sally (OS ASPR/ SPPR", "Matthew J CIVUSARMY(USA) ", " LisaKoonin", MELISSA" ,HERBERT" , Alexander" ,MARIEFRED", " Robert(OS ASPR/BARDA)", Kevin", Gary(OSASPR/BARDA", John (OSASPR SPPR) ", David (Chris) ( ) , Joseph (OSIASPRIO )", " Luciana","Dan""Larry G " , "RyanMorhard", "Steven Jt( ) , Jerome(HHS/OASH) ", MoniqueK ." ,Jessica(USDA.GOV [ .safelinks.protection.outlook.com ] )" , " usuhs.edu" , Jerome (CTR )" ,Jay J" Joselito " , "WillGaskins" "CHRISTOPHER ALLEN " "Kevin MontgomerySent: Thursday March 5 2020 1:05 :54PMSubject: Re:Red Dawn Raging StartMarch 4Yes, we have a huge burden , and we are all thinking about the entire system and the cascading downstream effects .Perhaps a drawing willmake a good exercise for the policy makers. Welike to use the binary trees, since it explodesfast enough already . I think a tree with the contact rate would be great to show the policy makers so they know howmany of the elderly infected would end up in hospitals /beds and we can even show the queues!On Thu, Mar 5 2020 at 12: 02 PM Caneva, Duane @ hg.dhs.gov> wrote:Notjust the grandparents,butthehealthcaresystem functionalityfor everyone, too. There is increasedmortality inolderage groups, butthehospitalstays are 2 -3 timeslonger, resourceintense, andaffectaccessandavailability foreveryonein the community.@ charter.netTo: "Dr. Eva Lee"Cc: Duane", " Tom Bossert" Ralph S ", " BrianBenson" , Carter(VA.GOV[ gcc01. safelinks.protectionoutlook.com ," TraceyMcNamara", Richard (OSIASPR/EMM ) ", "RichardHatchett " , THOMAS", " M . D . ", " JamesV ", "David" ," CharityA @ CDPH" " Gregory , William (STATE.GOV[ . safelinks.protection.outlook. com CAMERON",.com", Daniel(OSIASPR )" , Kristin (OSASPR SPPR)" , Sally (OS ASPR/SPPR)" "Matthew JCIV USARMY(USA)" , "LisaKoonin" , MELISSA", HERBERT" , Alexander " , MARIEFRED" , utmb. edu",Robert(OSASPR/BARDA) ", Kevin", Gary (OS BARDA) ", John (OSIASPRSPPR)", David(Chris(OSASPR ) , Joseph (OSIASPR , "Luciana", " Dan", " @ sdcounty.ca.gov" , David" , DAVID Adshs.texas. gov" , SANGEETA", Scott (OS ASPR/EMMO)", "Larry G " , " Ryan Morhard" , " StevenJt( )", Jerome(HHSOASH) ", MoniqueK . ", Jessica (USDA.GOV[ . safelinks. protection. outlook. com ] ) ", "DC" , @ usuhs. edu", Jerome (CTR " , Jay J" , Joselito " , "WillGaskins" , "CHRISTOPHER ALLEN ", "Kevin Montgomery "Sent: Thursday March 5 2020 1:50 :09PMSubject: Re: Red Dawn Raging StartMarch 4CDC is going to hold a meeting today on telehealth . Just somebackground asweprepare to gear up forimplementing teleheath ,Annually , primary care clinics see 482M patients (actually patient visits in the US (the total number ofoutpatientvisits is about 900K ). Over a 3 month period primary care providers see about 120M patient visits . So hold onto thatnumber for a moment,Let' s assume this outbreak has an attack rate of 30 % (so about 100M infected that50 % of those infected areasymptomatic (50M ) . Let' s assume the other 50 % (those 50M who are symptomatic ) are the ones seeking care. Howmanytelehealth visits perpatientdo we think will be required ? There willbe the initial presentation, then mostofe patients (35 % -38 % of those who were infected 35M - 38M ) willbe prescribed home isolation for 14days). The remainder will require hospitalization butprobably notbefore additional teleheath visits as their conditionsworsens. How many follow up telehealth visits will be necessary to monitor thehealth of these patients in homeisolation ? Let s say wewant to touch base with the patients twice per week , so that is another 4 visit per patient thatwould equate to 140M - 152M visits . Now add in the other 50M visits for initial presentation and we are up to about200M telehealth visits . That is about double the number of all primary care visits in the US over a 3 month period .This is probably a conservative estimate since any patient on home quarantine will probably also be seeking to speakwith their physician or primary care provider and chronically illand elderly patierchecks . This also does not include the background demand we see each day (for the management of chronicconditions etc . ) where we would also like to use telehealth .Wehave never done this on this scale before . Wehave people from large healthcare systems on this email, how areyou planning to scale up to meet the demand for COVID andmeet the needs ofnon -COVID patients with chronicconditions ?@ charter.netTo: " TraceyMcNamaraCc: "Dr. Eva Lee", Duane", " Tom Bossert", Ralph S ", "BrianBenson", Carter( VA.GOV[ . safelinks. protection. outlook. com ]) ", Richard (OS/ASPR EMMO) ", "RichardHatchett", THOMAS" , " M . D . " ," James V", "David", " Charity A @ CDPH", "Gregory J", William (STATE.GOV[gcc01. safelinks.protection . com ]) ", CAMERON", @ gmail. com " , Daniel (OSIASPR SPPR) " , Kristin(OS ASPR SPPR) " , Sally (OSASPR SPPR)" , "Matthew J CIV USARMY(USA) " , "Lisa Koonin" , MELISSA"HERBERT" , Alexander" ,MARIEFRED" utmb. edu" , Robert (OS ASPR / BARDA) " , Kevin " , Gary(OSASPR / BARDA) ", John (OSIASPR SPPR ) " , David (Chris) (OSIASPR /IO ) " , Joseph (OS ASPR /IO )" , " Luciana" ,"Dan" , " ounty . ca. gov ", David" , DAVID A " @ dshs. texas. gov " , SANGEETA" ,(OSASPR /EMMO) " , "Larry G " , "Ryan Morhard" , "Steven Jt ) , Jerome(HHS/OASH) " , MoniqueK . " ,Jessica (USDA.GOV [ . safelinks.protection outlook. com ] )" , "DC" , @ usuhs. edu", Jerome(CTR)" ,JayJ", Joselito", "WillGaskins", "CHRISTOPHERALLEN", "KevinMontgomery"Sent : ThursdayMarch 5 2020 3 :46: 37PMSubjec:tRE: RedDawnRagingStartMarch4Historydoesn't repeatitself,butoften does rhyme.In 1918, the pandemicstartedon the eastcoastand sweptacrossthe country from east to west. The initialcitiesthatwerehitwere understandablya little slow to react. Initially, publichealth leadersminimizedthe threat. Itwasfascinatingknowinghow the outbreakwouldunfold to readnewspaperaccountsandthe quotesand responsesbypoliticiansandhealth departments(whoearly on tried to reassureand calm the publicbycommunicatingthattheythought worsthadpassedwhen the outbreakwasjustbeginningto accelerate). These cities on the eastcoastfirst to face this threat. Other cities like St. Louis were lucky in that they had thechance to see whatwas happening to the east and actmore quickly andmore aggressively .Influenza never traveledfaster than modern transportation . In 1918 , travelwas by ship or train .In 2020 , this pandemic seems to be starting on the opposite coast. Seattle has the misfortune of being the first majorUS city to be impacted . We are seeing some of the same reassurances from political and public health leaders tocalm the public and minimize the threat. We have heard that Americans are at low risk . We also have heard it is amild disease where more than 80 % of those infected have either no symptoms or very mild disease, and only thevery elderly or those with underlying medical conditions are at risk . Only 0 . 5 % of those who become infecteagain the vast majority are very old with chronic conditions ). That description sounds even milder than flu because flualso hits the very young and anyone who had the flu would not likely remember it as a mild disease. And we hearthat this disease is not impacting children so really no need to close the schools . I suspect there will be other cities inCalifornia and Oregon up and down the west coast that will be impacted and leaders will also need to make adecision re the public health interventions . Like 1918 we willl have a natural experiment to assess the effectiveness ofthe public health interventions (both themeasures and timing). The question is how quickly will this outbreakemerge since a number of areas across the US have already been seeded and influenza can now travel at the speedof air travel. Ifwe are lucky the outbreaks willbe asynchronous and somecities will have enough time to be able tolearn from the first cities like Seattle and judge the wisdom of the decisions beingmade now . But this isn 't 1918 andI 'm not sure there will be enough time for that to happen . What is unfortunate is that they don't need to wait forresults from the Seattle experiment , they can learn from China 's experience , Hong Kong' s experience , andSingapore ' s experience . They can also go back to the body ofwork that has been done on community mitigation .Has CDC modeled the interventions they are proposing ? How effectively do these interventions reduce communitytransmission ? In short, where is the science to support these recommendations in the face of whatwe are learningfrom the experiences of China, Hong Kong and Singapore ?When history judges our response , the comparison willbeto thebestpractices. Unlike1918,wewere actually blessedto know aboutthosebestpracticesbefore COVIDarrived. Seemslike a sin notto take fulladvantageofthatknowledge.From : " TraceyMcNamara"ToCc: "Dr. EvaLee", Duane", " Tom Bossert ", Ralph S ", "Brian Benson", Carter (VA.GOV[ . safelinks. protectionoutlook. com ]) " , Richard(OSASPR ", " RichardHatchett ", THOMAS" , " M .D." ," James V", "David", " Charity A @ CDPH", "GregoryJ", William (STATE.GOV. safelinks. protection.outlook. com ] )" , CAMERON", @ gmail. com " , Daniel(OSASPR/ SPPR) ", Kristin(OSASPR/SPPR) ", Sally (OSASPR/SPPR) ", " Matthew J CIV USARMY(USA) ", " LisaKoonin, MELISSA" ,HERBERT" Alexander" MARIEFRED" Robert (OS ASPR BARDA " , Kevin" , Gary(OS ASPR BARDA , John (OS ASPR/ SPPR ) " , David (Chris (OSIASPR/ IO ) " , Joseph (OSIASPR/ IO ) " , " Luciana" ,"Dan" David" DAVID A " , " dshs. texas. gov" , SANGEETA" , Scott(OSASPR EMMO) " , "Larry G " , "RyanMorhard" , " Steven Jt , Jerome(HHSIOASH) " , MoniqueK ." ,Jessica (USDA.GOV . safelinks.protection .com " " , " usuhs. edu", Jerome(CTR)" ,Jay J", Joselito", "WillGaskins", "CHRISTOPHERALLEN" , "KevinMontgomery"Sent: ThursdayMarch 5 2020 2 :02: 25PMSubject : RE: RedDawnRagingStartMarch4Unbelievableand unfortunate.From :To: t" : " TraceyMcNamara", "Dr. Eva Lee" , Duane", " Tom Bossert", Ralp , " BrianBenson", Carter(VA .GOV . safelinks. protectionoutlook. com ]) " Richard(OS ASPR EMMO) " , "RichardHatchett", THOMAS", " M . D . ", " James V ", "David" , " Charity A @ CDPH", "Gregory J" William (STATE.GOVsafelinks.protection outlook.coml ) " , CAMERON" " Daniel (OSASPR SPPR ) " , Kristin(OS/ASPR /SPPR ) " , Sally (OSIASPR SPPR) " , " Matthew J CIV USARMY (USA) " , " Lisa Koonin , MELISSA" ,HERBERT" , Alexander" , MARIEFRED " u Robert (OS ASPR BARDA )" , Kevin " , Gary(OSIASPR BARDA )" , John (OS/ASPR / SPPR ) " , David ( Chris) (OS ASPR IO ) " , Joseph (OSASPR / )" , " Luciana" ," Dan" , sdcounty . ca. gov " , David" , DAVID A " , er @ dshs.texas.gov", SANGEETA" , Scott(OS ASPR )" " Larry G ", " Ryan Morhard" , " Steven Jt( )", Jerome(HHSOASH )", MoniqueK ." ,Jessica (USDA. GOV [ safelinks.protection outlook .coml)" , "DC" , " usuhs.edu", Jerome(CTR)",J", Joselito" , "WillGaskins", "CHRISTOPHER ALLEN " , "Kevin Montgomery"Sent: ThursdayMarch 5 2020 4: 45 :23PMSubject : RE: RedDawnRagingStartMarch4I like to ask myself, knowingwhatI know now ,whatdo I wish I wouldhavedone2 weeksago.Attachedis a slidethat show sideby side the rankingof countriesby the numberofcasesanddeathsreportedforFeb 20 andMar5 .Imaginewhatthis is going to look like in 2 moreweeks. Whatwillwehavewishedwehaddone today?From : mecheTo: "BrianBenson"Cc: James V ", Luciana" , " TraceyMcNamara", " DuaneCaneva" , " Dr. Eva Lee" , "Dr. EvaK Lee", " Tom Bossert",Ralph S" , Carter (VA.GOV" , Richard (OSASPR/EMMO) ", "RichardHatchett " THOMAS", "M . D . " " David" , "CharityA @ CDPH", "Gregory J", William (STATE.GOV) ", CAMERON" , r gmail.com " , Daniel(OS ASPR/SPPR) ",Kristin (OS/ASPR/ SPPR) ", Sally (OSIASPRSPPR) ", "Matthew J CIV USARMY(USA) ", " LisaKoonin , MELISSA",HERBERT", Alexander",MARIEFRED" @ utmb. edu" , Robert(OSASPR/BARDA) ", Kevin" , Gary(OS ASPR/BARDA)", John (OSASPR/SPPR) ", David (Chris) ( Joseph(OSASPR/ IO )", Dan",@ sdcounty ca. gov", David", DAVID A" , .texas. gov" , SANGEETA" , Scott(OS ASPR EMMO)", " Larry G ", " Ryan Morhard " , " Steven ( ) Jerome (HHS/OASH )", Monique K ." ,Jessica (USDA.GOV)" , "DC", @ usuhs. edu", Jerome (CTR )" , Jay J", Joselito " , "Will Gaskins","CHRISTOPHER ALLEN " , " Kevin Montgomery " , Gerald W " Linda L" , "LLogandakar "Sent: Saturday March 7 2020 7 :24: 25AMSubject : Re: RedDawn Raging StartMarch 4The outbreak in the US is looking more like Italy butwithout the aggressive actions [including cordon sanitaire of50,000 people, closing schools and universites , and cancelingmass gatherings taken by Italy as soon as theyidentified their first death . I pulled the numbers of cases and deaths reported by themedia at the end of each (data for today is preliminary /morning data ).Interestingto comparethetwo countriesand align the outbreaks(4th slideby the date offirstreporteddeath). TheUScasesincludethePrincessDiamondcasesofrepatriatedpassengersaswellas AmericansevacuatedfromWuhan. Iwasunable to estimatethenumberoftests performedbyItaly comparedto theUS. TheUS case countsemsto belaggingwhatItaly observed. TheUSappearsto beabouta weekbehindItaly. Timewilltell.From: mecher@To: " Brian Benson"Cc: JamesV" , Luciana", " TraceyMcNamara", " DuaneCaneva" , " Dr. EvaLee", "Dr. Eva K Lee", " Tom Bossert",RalphS " , Carter (VA.GOV" , Richard(OSASPR EMMO) ", "RichardHatchett", THOMAS" , " M . D ." , "David" , "CharityA @ CDPH", "Gregory J" , William (STATE.GOV) ", CAMERON" gmail.com" , Daniel(OSIASPR )" ,Kristin (OSASPR SPPR)", Sally (OSASPR ) ", "Matthew J CIV USARMY(USA) " , " Lisa Koonin",MELISSA",HERBERT", Alexander",MARIEFRED" , " du", Robert(OSASPR BARDA) ", Kevin", Gary(OS ASPR BARDA)", John (OS/ASPR ) ", David (Chris) (OSASPR/ IO ) " , Joseph(OSASPR )", Dan" ,.gov", David" , DAVID A ", , SANGEETA" , Scott(OS ASPR EMMO)" , " Larry G " , " RyanMorhard" , " Steven Jt(tCHFSDPH , Jerome(HHS/OASH) " , K . " ,Jessica (USDA.GOV) " , "DC" , " u", Jerome(CTR)", Jay J", ", "WillGaskins"," CHRISTOPHERALLEN" , "KevinMontgomer"y, GeraldW " , LindaL " , "LLogandaka"rSent: SaturdayMarch7 2020 7 :24: 25AMSubjec:tRe: RedDawnRagingStartMarch 4Theoutbreakin theUSis lookingmorelike Italybutwithouttheaggressiveactions[includingcordon sanitaireof50.000people closingschoolsanduniversites, and cancelingmaidentifiedtheir firstdeath. I pulledthenumbersofcases anddeathsreportedby themedia at the end ofeach (data for today is preliminary/morningdata)Interestingto comparethetwo countriesand align theoutbreaks(4th slidebythedateoffirstreporteddeath ). TheUS casesincludethe PrincessDiamondcasesofrepatriatedpassengersaswellas AmericansevacuatedfromWuhan. I wasunable to estimatethenumberoftestsperformedbyItalycomparedto theUS. TheUS case countsemsto belaggingwhatItaly observed. TheUSappearsto beabouta week behindItaly. Timewilltell.OnMar7, 2020, at 5 :42 PM Dr. EvaLee 54 @ gmail. com > wrote :How are ourtestingkits? Dowe have thetestkits and thethroughputpowernow? This is yetanothermissopportunity - about a covid- 19 casein Georgia it true thattests are only conductedon patientswhich satisfy theCDC criteria The symptomsare so diversethatwecan t befixed to a set of guidelines. Weneedbroaderscreening, thatis a must." The third case involved a 46 -year-old female wentwho went to a hospitalin RomeGeorgia ) complainingof flu - likesymptoms. Hospitalofficials said she didn' tmeetthe Centers for Disease Controland Prevention (CDC) andGDPH criteria for COVID - 19 testing, so she was treated and released. After shebegan to feelworse, thewomanwas eventually tested. The test hasnow confirmed that shehas 9. Officials say shehasbeen hospitalized. "OnSat, Mar 7, 2020 at 9:30 PM McDonald, Eric @ sdcounty. ca.gov> wrote:The longpole in the tentis testingcapacity .withoutgoingintowhy it could possiblytake so longto field tests in thiscountrywhen others seem to be able to do it, atthe operational level, if you onlyhavelimited access to testing, triageneedsto occur. So hindsightcriticism ofprovidersusingthecriteria theyhad/haveon patientswhodid notmeetthesecriteria and then were foundto be positiveis notusefulin myview . Agreethe opportunitywasmissed,butthey arebeingmissednow andwillbemisseduntilthepromisedmillion plus testsare actuallyfielded and resultsobtainedinan actionabletimeframe.Whateveris goingon/wenton betweencdc and fda and laboratory communitythat createdthis delaywillbedissectedby someonein the future, butit still is notfixedforusto beable to do whatothers countrieshave doneorformeas a localpublic health officialto get vitaldata on what is really goingon.Frustrating doesn' t capture it. You know what I am saying.EricFrom :Gruber,David (DSHS)Sent: Tuesday, March 10, 2020 9 :58 AMTo: Dr. Eva Lee;McDonald, EricCc: CarterMecher; Borio, Luciana; Brian Benson Lawler, James V ; TraceyMcNamara; DuaneCaneva; Dr. Eva KLee; Tom Bossert; Baric, Ralph S ;Mecher, Carter (VA.GOV) ; Hunt, Richard (OSASPR EMMO) ; RichardHatchett; WILKINSON, THOMAS; M . D . ; David; Gregory J; Walters, William(STATE.GOV) ; HAMILTON, CAMERON Dodgen , Daniel(OS ASPR SPPR ) ; DeBord, Kristin(OS ASPR SPPR ) ; Phillips, Sally (OS ASPR/SPPR); Matthew J CIV USARMY (USA) ; Lisa Koonin HARVEYMELISSA ;WOLFE, HERBERT Eastman , Alexander: EVANS. MARIEFRED : b .edu; Johnson, Robert(OSIASPRBARDA) ; Yeskey, Kevin; Disbrow, Gary ( BARDA) ; Redd, John (OSIASPR ); Hassell ,David (Chris) (OSASPR ; Hamel, Joseph (OSASPR IO ) ; Hanfling, Dan; Wade, David; TARANTINO, DAVIDA ; KAUSHIK, SANGEETA; Lee, Scott (OS ASPR/EMMO) ; Larry G ; RyanMorhard; Steven ) ; Adams,Jerome(HHS/OASH) ; Mansoura,MoniqueK ; Fantinato, Jessica( USDA. GOV) ; DC @ usuhs.edu; Cordts, Jerome(CTR ); Schnitzer, Jay J; Ignacio, Joselito;WillGaskins; CHRISTOPHERALLEN; KevinMontgomery; Parker Jr, Gerald W ; Logan,Linda L ; LLogandakarSubject: RE: RedDawnRagingStartMarch 4As a state public health official who is in agreement that mustbe strongly enacted early ; ' m looking for helpfrom this group to find tools thatmake the case for . The target audience is those outside ofhealth .I' m attachingan exampleslide (admittedlyandintentionallyrudimentary) thatmightbeusedto supportthisargumentand explainthe totalityofNPls. Dootherssee this as somethingthatmightaid in influencingand, if so, aretheredata sourcesthatI mighttap into showingthe impactsof directlyon epicurvesandhow these wouldimpactother communityfoundations?ThanksDaveFrom : CarterMecherSent: Tuesday, March 10 , 2020 10 : 30 AMTo: Gruber DSHS); Dr. Eva Lee; McDonald, EricCc: Borio, Luciana; BrianBenson; Lawler, James V ; TraceyMcNamara; DuaneCaneva; Dr. EvaK Lee; TomBossert; Baric, Ralph S ;Mecher, Carter (VA.GOV) ; Hunt, Richard(OSIASPREMMO) ; RichardHatchett;WILKINSON, THOMAS; M . D .; CDPH; Gregory J;Walters, William(STATE.GOV); HAMILTON, CAMERON; @ gmail.com ; Dodgen, Daniel (OSASPR SPPR ; DeBord Kristin( ): Phillips Sally (OSASPR SPPR) ;Matthew J CIV USARMY (USA) ; Lisa Koonin; HARVEYMELISSA WOLFE, HERBERT Eastman, Alexander: EVANS. @ utmb.edu; Johnson, Robert(OSASPR BARDA) ; Yeskey, Kevin; Disbrow, Gary (OSASPR/BARDA) ; Redd, John (OSASPR/SPPR) ; Hassell,David (Chris) (OSASPR Hamel Joseph (OS ASPR ; Hanfling, Dan; Wade, David; TARANTINO, DAVIDA ; KAUSHIK, SANGEETA; Lee, Scott (OSASPR EMMO) ; Larry G ; RyanMorhard; Steven Jt( ) ; Adams,Jerome(HHS/OASH) ; Mansoura, Musuhs.edu; Cordts, Jerome(CTR ; Schnitzer, Jay J; Ignacio, Joselito; WillGaskins; CHRISTOPHERALLEN; Kevin Montgomery; Parker Jr , Gerald W ; Logan, Linda L ; LLogandakarSubject: RE: Red DawnRagingStartMarch 4Backin 2007, there wasmodelingfor estimatingtheeconomicimpactofa pandemic(unmitigatedwith no anda mitigatedpandemicplusthe costs of . I can seeif can dig that up. Thebottom lineis thatwhen you add inthe costassociatedwith lives lostin an unmitigatedpandemic, additional healthcarecosts due to greaternumbersofthose who areillandhospitalized, economiccosts dueto lostproductivitydueto increasedillness, the costs palein comparison. I willseewhatadditionalinfo I can find to helpyou.'m listening to the arguments for not closing schools : (1) kids maynot be important in disease transmission andwhen kids do become infected their illness is mild; 2 ) closing schools is too disruptive , it will require parents to stayhome from work to mind their children (and this absenteeism could adversely impact critical sectors such ashealthcare ); (3 ) large number ofkids depend upon school meals and the closure of schools could have seriousconsequences ; (4 ) by keeping kids home, they havemore time to be around older adults in the household andpotentially transmit disease to more vulnerable groups the thinking is that itwould be safer to keep them at school forat least 8 hrs of the day to decrease contact time with older adults in the household ); and (5 ) kids will just mix againthe community (that kids will out at malls ).Just somethingto think about.Schoolsareclosingnow for 1week for springbreak(manythis week andsomein thenextweek or two). This ishappeningat a criticalpointofthe accelerationof this outbreakin theUS. In the nextcoupleofweeksourhealthcaresystem is likely to be stressed. A goodnumberof parents take timeoffoverspringbreakto bewith theirkids (manytimesboth parentsfor twoparenthouseholds). Below is a graphof annualleaveusagerates in VA. Itis veryconsistentfrom yearto year(looks a lotlikean EKG tracing. You seea spikeat Thanksgiving, anotherhugespikeround Christmas/New Years, anothersmallbumpin the spring (springbreak), and anotherbroadbump(thatlookslike a T waveon an EKG) in the summermonthswhenfamilies tend to take vacations(becausekids are outofschool.Given the argumentofthose opposedto closingschools, shouldwe cancelspringbreakand keepthe schools openso thatparentsdon 't haveto stayhometo mind theirkidsat this psystem is aboutto behammered? Shouldwealsokeep the schools open so thatkidsare keptawayfrom olderadultsin thehouseholdformuch of the day duringthis periodofacceleration? Thatis prettymuchthe extensionofillogicallogicWeclose schools for 1week for spring break and the world does not fall apart. The nutrition of children does notsuffer. Dowe think if schools closed for two weeks , that the world would come crashing down ? Why not close fortwo weeks and then reassess least it gives us time). Wecan never get that time back .Last thing. Many ofyou have kids, do any of them hangout atmalls ? In myneighborhoodI don't even see kidsoutside— they are all inside texting, on Instagram , playing games with their friends online orwhatever they do thesedays. Hardly see them riding their bikes around. I understand that going to themall is code for kids recongregating outside of school. Even ifthey do they are in a less socially dense environment and in much smallergroups. The whole schooldoesn 't all go together anywhere, except to school.From : Dr. EvaK LeeSent: Tuesday, March10, 2020 1:46PMTo: CarterMecherCc: Gruber,David (DSHS) ; Dr. Eva Lee;McDonald, Eric; Borio, Luciana; Brian Benson; Lawler, JamesV ; TraceyMcNamara; DuaneCaneva; Tom Bossert; Baric, Ralph S ; Mecher, Carter (VA.GOV) ; Hunt, Richard(OSASPR EMMO); RichardHatchett; WILKINSON, THOMAS; M . D . ; David; ; Gregory J ; Walters,William (STATE.GOV) ; HAMILTON, CAMERON; @ gmail .com ; Dodgen, Daniel(OSASPR/SPPR); DeBordKristin (OSIASPR ) Phillips, Sally (OSASPR SPPR) ;Matthew J CIV USARMY(USA) ; Lisa Koonin HARVEYMELISSA , HERBERT; Eastman, Alexander; EVANS, MARIEFRED; .edu; Johnson , Robert(OS ASPR / BARDA ) Yeskey Kevin Disbrow Gary (OS ASPR /BARDA) Redd John (OSASPR /SPPR ) .David (Chris ) (OS ASPR IO ); Hamel, Joseph (OS ASPR IO ; Hanfling, Dan; Wade, David ; TARANTINO , DAVIDA ;KAUSHIK , SANGEETA ; Lee , Scott (OSASPR EMMO ) ; Larry G ; Ryan Morhard ; Steven ); Adams,Jerome (HHS/OASH );Mansoura Monique K ; Fantinato , Jessica( USDA. GOV ; DC @ usuhs.edu; Cordts, JeromeCTR ); Schnitzer, Jay J; Ignacio, Joselito; WillGaskins; CHRISTOPHERALLEN; KevinMontgomery; Parker Jr,Gerald W ; Logan, Linda L ;LLogandakarSubject: RE: Red DawnRagingStartMarch 4Europegivesmean extraordinarygood example. Germanyheld outreallywellwhen itwas infectedfrom the oneChinese subject. But the few casesand verymild natureallowedhealthcareto contain them in notime.With Italy so well-connected to all its neighbours, it viral spread triggers a radialcascading effect that is another textbook example .We are just like Europe in terms of connectivity by air (and lessby trains ). Wemay be a little slowerbecause ofournormal distance from each other. But if you go to any university or any school, you will noticeeveryonepacks together and intertwines so tightly .Churches , synagogues ,mosques , temples , we need to encourage theworshippers to do all these onlines . Thesesites have high percentage of volunerable populations , we need to spread the words . I think the religious leaders cantake the lead .From : CarterMecherSent: Tuesday, March 10 , 2020 12:52:56 PMTo: Dr. Eva K LeeCc: Gruber,David DSHS) < D @ dshs. texas.gov> ; Dr. Eva LeeMcDonald, Eric county .ca . > ; Borio , Luciana > ; Brian BBeennssoonn@ icloud. com > ; Lawler, James V @ unmc.edu > ; Tracey McNamara@ westernu .edu > ; Duane Caneva 4 @ . gov ; Tom Bossert @me.com >Baric, Ralph c @ email.unc.edu> ; Mecher, Carter(VA.GOV < @ va. gov ; Hunt, Richard(OS ASPR / EMMO) t @ hhs. gov > ; Richard Hatchett t @ cepi.net ; WILKINSON ,THOMAS hg. dhs. gov > ; M . D . @ mgh harvard. edu > ; Davidsom umaryland .edu > ; Charity A @ CDPH < @ cdph. ca.gov> ; Gregory JWalters. William STATE GOV @ state . gov HAMILTON , CAMERON@ hg. dhs.gov > ; ; Dodgen, Daniel(OSASPR SPPR)@ hhs. gov ; Kristin (OSASPR hhs. gov> ; Phillips, Sally(OSASPR SPPR) s @ hhs. gov> ; Matthew J CIV USARMY(USA) . civ @ mail.mil> ;Lisa Koonin n1@ gmail. com > ; HARVEY, MELISSA ha.dhs.gov WOLFE , HERBERT< FE .dhs. gov > ; Eastman Alexander < EVANS, MARIEFRED@ associates. . dhs.gov> ; b . edu c @ utmb.edu Johnson , Robert(OSIASPR BARDA) nson @ hhs. gov Yeskey, Kevin . Disbrow, Gary(OS ASPR/BARDA) w @ hhs.gov> ; Redd, John (OS/ASPR /SPPR) < . gov> ; Hassell,David (Chris) (OSASPRO @ hhs. gov ; Hame,l Joseph (OSASPR hhs. gov ;Hanfling, Dan @ igt. org> ; Wade, David @ .dhs.gov ; TARANTINO, DAVID Ao @ cbp.dhs. gov> ; KAUSHIK SANGEETA @ .dhs. gov ; Lee, Scott(OS ASPR ) . gov> ; Larry G @ state.gov> ; RyanMorhard@ weforum.org>; Steven Jt ) @ ky. gov> ; Adams, Jerome(HHS/OASH)@ hhs. gov>; Mansoura, MoniqueK . mitre .org > ; Fantinato, Jessica (USDA. GOV)o usda. gov > ; DCy @ usda. gov u @ usuhs.edu @ usuhs. edu>; Cordts, Jerome(CTR)s @ associates. .dhs. gov > ; Schnitzer Jay J er @ mitre. org> Ignacio, Joselito@ fema.dhs.gov WillGaskins @ efiia . com > ; CHRISTOPHER ALLEN10 . com > ; KevinMontgomery @ collaborate.org > ; Parker Jr Gerald Wr @ tamu.edu> ; Logan Linda @ cvm .tamu.edu>; LLogandakar mail.com >Subject : RE: RedDawnRagingStartMarch4I see thatNJjust announced its first death (man in his 60s). Don' t know the details butif this is not a travel relatedcase , they ought to be ready to implement NPls .NY Governor announced need for school closures in New Rochelle (NY is now up to 173 cases with 31 new casesannounced today ). The superintendent does not agree .https:/ /www .msn. com / en -us/news/us/cuomo -says-new -rochelle -schools -may-close - superintendentdisagrees ar BB10X67FFrom : GruberDavid (DSHS)Sent: Tuesday, March10 2020 2 :03 PMTo: CarterMecher; Dr. Eva K LeeCc: Dr. Eva Lee McDonald, Eric , Luciana; BrianBenson; Lawler, JamesV ; TraceyMcNamara; DuaneCaneva; Tom Bosser;tBaric, Ralph S ; Meche,r Carter(VA. GOV) ;Hatchett;WILKINSON THOMAS M . D .; David CDPH ; Gregory J ; Walters William(STATE.GOV); HAMILTON , CAMERON ; m ; Dodgen, Daniel(OSASPR/SPPR ); DeBord, Kristin(OSASPR SPPR ) Phillips, Sally (OSASPR SPPR) :Matthew J CIV USARMY(USA) HARVEYMELISSA WOLFE HERBERT Alexander , MARIEFRED utmb.edu; Johnson Robert(OSASPR/BARDA) ; Yeskey, Kevin Disbrow,Gary (OSASPR/BARDA) Redd (OSASPR/SPPR) HassellDavid(Chris (OS ASPR ; Hame, lJoseph (OSASPR ; Hanfling, Dan; Wade, David; TARANTINO, DAVIDA KAUSHIK, SANGEETA; Lee Scott(OS/ASPR/EMMO) ; Larry G RyanMorhard; Steven Jt Adams.Jerome(HHS ) MansouraMoniqueK Fantinato, Jessica(USDA. GOV) ; DC @ usuhs.edu; Cordts , Jerome (CTR ); Schnitzer , Jay ; Ignacio , Joselito ; WillGaskins CHRISTOPHER ALLEN ; Kevin Montgomery ; Parker Jr Gerald W Logan , Linda L ; LLogandakarSubject: Re: Red Dawn Raging Start March 4Another strategic approachto looking at the situation.Applying the, Adano Principles" to manage an adversity such as COVID 191. Recognitionand acknowledgemenotf the existenceorpotentialof an adversity2. Identifyingthe specific characteristicsof the adverse environment3. Applyinga networkcentric/systemsapproach to counteringthe adversityto includedevelopmentofprocessandassociatedmetrics thatdefine successpointsand end-state4 . Incorporating continuous analysis and quality improvement to maintain progress and preventreversion fromsuccess5 . Recognition of when the adversity is neutralized or eliminated to allow forreturn to baseline operationsFrom : CarterMecherSent: Tuesday,March 10 2020 3:01PMTo: Gruber DSHS) ; Dr. Eva K LeeCc: Dr. Eva Lee McDonald Eric Luciana; BrianBenson Lawler James V TraceyMcNamara; DuaneCaneva; Tom Bossert; Baric, Ralph S Mecher, Carter(VA.GOV ; Hunt, Richard OS ASPR EMMO); RichardHatchett; WILKINSON THOMAS M . D . ; @ CDPH ; Gregory ; Walters William(STATE .GOV HAMILTON , CAMERON com ; Dodgen Daniel(OSASPR SPPR) ; DeBord, Kristin(OSASPR SPPR ); Phillips, Sally (OSASPR SPPR) Matthew J CIV USARMY(USA); Lisa Koonin HARVEY,MELISSA;WOLFE, HERBERT Eastman, Alexander: EVANS. MARIEFRED: @ utmb.edu; Johnson, Robert(OSASPR/BARDA) ; Yeskey Kevin Disbrow Gary ( BARDA) ; Redd John (OSASPR ) Hassell,David (Chris) (OSASPR/ IO ; Hamel , Joseph(OSASPR IO ) ; Hanfling, Dan; Wade, David; TARANTINO, DAVIDA ; KAUSHIK, SANGEETA; Lee, Scott(OS/ASPR/ EMMO) ; Larry G ; RyanMorhard; Steven Jt( ) ; Adams,Jerome(HHSOASH); MansouraMoniqueK .; Fantinato, Jessica( USDA. GOV) ; l @ usuhs. edu; Cordts, Jerome(CTR); Schnitzer Ignacio Joselito; WillGaskins; CHRISTOPHERALLEN; KevinMontgomery; ParkerJr, Gerald W ; Logan, LindaL ; LLogandakarSubject: RE: RedDawnRagingStartMarch 4Italy is aboutwhere Hubeiwas on Feb 2. Feb 2 was day 62 on the graph below . Imagine that. The question iswhether Italy retraces HubeiorWuhan ? That means we are at about day 50 or so .< B5B96EDAA5B54CFAAAD14BD37A0849.0pCng>From : @ charter.net>Date: Wed, Mar 11, 2020 at 12: 15 PMSubject: Re: Red DawnRagingStartMarch 4To: .net>Cc: RichardHatchett @ cepi . net> , Gruber David (DSHS) r @ dshs. texas. gov Dr. Evah @ pm .me> , Dr. Eva Lee .lee64 @ gmail. com > , McDonald, Ericd @ sdcounty. ca.gov Borio, Luciana < @ . org> , Brian Benson n icloud. com > ,Lawler, James @ unmc.edu> , TraceyMcNamara < @ westernu. edu> , DuaneCanevava @ . . gov , Tom Bossert rt @ me. com > , Baric, Ralph S @ email .unc.edu ,Mecher, Carter(VA.GOV < @ va. gov Hunt, Richard(OS/ASPR/EMMO) < t @ hhs .govWILKINSON , THOMAS < @ hq.dhs. gov M . D . @ .harvard . edu > , Davidzi@ som . umaryland.edu > , CDPH n @ cdph.ca. gov Gregory@ state. gov Walters, William (STATE.GOV @ state. gov HAMILTON, CAMERON@ hg. dhs. gov @ gmail. com < @ gmail. com > , Dodgen , Daniel (OS ASPR )@ hhs. , Kristin (OSIASPR SPPR ) @ hhs. Phillips, Sally(OSIASPR SPPR ) @ hhs. gov , Matthew J CIV USARMY (USA ) < m mail .milLisa Koonin 1 @ gmail. com > , HARVEY , MELISSA < m vey @ .gov WOLFE, HERBERTFE @ .dhs.gov Eastman, Alexander @ . dhs. gov EVANS , MARIEFRED@ associates .hg. dhs. gov utmb.edu uc @ utmb. edu > , Johnson , Robert(OSASPR BARDA) < n @ hhs.gov Yeskey , Kevin <ke @ hhs. gov , Disbrow , Gary(OS ASPR/BARDA) < . gov Redd, John (OSASPR/ SPPR) < @ hhs. gov> , Hassel, lDavid( Chris) (OSIASPR @ hhs. gov> , Hame, lJoseph (OSASPR/ el hhs.govHanfling, Dan g @ igt.org> , Wade, David de @ .dhs. gov TARANTINO, DAVID A.dhs. gov , KAUSHIK, SANGEETA <sa kaushik hq.dhs. gov , Scott(OSASPR/EMMO) < e @ hhs. gov , Larry G LG @ state. gov Ryan Morhardrd @ weforum .org> , Steven Jt( ) k @ky. gov Adams, Jerome(HHSOASH)hhs.gov Mansoura, MoniqueK . r mitre.org> , Fantinato, Jessica (USDA.GOV)nato @ usda. gov > ,olby @ usda. gov u @ usuhs.edu < d @ usuhs. edu> , Cordts, Jerome (CTR )@ associates.hq . gov , Schnitzer, Jay J < er @ mitre.org> , Ignacio, Joselito.dhs.gov WillGaskins ns . com > , CHRISTOPHER ALLEN10 @ msn .com > , Kevin Montgomery < collaborate .org > , Parker Jr, Gerald W@ . tamu. edu > , Logan , Linda . tamu. edu> , LLogandakar r @ gmail. com ><I notice a lotofHHS emailaddresseson this emailand group andyou allhavebeen quietformostofthe discussionover the paste severalweeks. Iwould urgeyou to readthe article I just sentout and upriefyourboss. This is thekeymessagethat they needto hearand theyhave little timeleft to act.derstand what happened in China and what has happened in Hong Kong andSingapore . COVID doesn ' t fade away on its own. The reason is reMore data for forecastingreport : https: //www .who . int/docs /default -source / coronaviruse /who-china -joint-mission -on -covid - 19-final-report.pdf2 . South Korea has done an extraordinary effort to test its ciizens (more than 222,000 tested to date ). South Koreahas a population of51M . An equivalent effort in the USwould equal . 4 M tested . How many have we tested in theUS to date ?3 . Italy is really struggling rightnow and time will tell if their extraordinary efforts they now are employing willmitigatethe outbreak . A lot of eyes are watching and hoping they are successful.4 . The US (along with most of Europe) is less than 2 weeks behind Italy . We should be learning from the experiencesof China , Hong Kong, Singapore , South Korea and Italy . Ifwe fail to learn from them , we do so at our peril. Historywill long remember what we do and what we don 't do at this criticalmoment. It is the time to act, and it is past thetime to remain silent. This outbreak isn' t going to magically disappear on its own. If that is the conclusion some aretaking , they are misinformed and dead wrong .From : Tom Bossert @me. com >Sent: Wednesday, March 11, 2020 23: 05To: CarterMecherCc: Dr. Eva K Lee; RichardHatchett; GruberDavid(DSHS); Dr. EvaLee; McDonald, Eric; Borio, Luciana; BrianBenson; Lawler, James V ; TraceyMcNamara; DuaneCaneva; Baric, Ralph S ;Mecher, Carter (VA.GOV) ; Hunt,Richard (OS ASPR EMMO); WILKINSON, THOMAS; M .D .; David Charity A CDPH; Gregory J; Walters, William(STATE.GOV); HAMILTON, CAMERON; @ gmail.com ; Dodgen, Daniel(OSASPRSPPR); DeBord,Kristin(OSASPR SPPR); Phillips, Sally (OSIASPR ); Matthew J CIV USARMY(USA); LisaKoonin; HARVEY,MELISSA; WOLFE, HERBERT; Eastman, Alexander; EVANS, @ utmb.edu; Johnson , Robert(OSASPR BARDA); Yeskey, Kevin; Disbrow, Gary (OSASPR/BARDA); Redd, John (OS ASPR/SPPR); Hassell ,David (Chris) (OS ASPR IO );Hame,l Joseph (OSIASPR ; Hanfling, Dan;Wade, David; TARANTINO, DAVID A ;KAUSHIK, SANGEETA; Lee, Scott (OS/ASPR/EMMO); Larry G ; RyanMorhard; Steven Jt(tCHFStDPH ; Adams,Jerome(HHS/OASH) ; Mansoura, MoniqueK . ; Fantinato, Jessica (USDA.GOV);DC; . edu ;Cordts, Jerome(CTR ); Schnitzer, Jay J ;Ignacio, Joselito; WillGaskins; CHRISTOPHERALLEN; KevinMontgomery;Parker Jr, Gerald W ; Logan, Linda L; LLogandakarSubject: Re: RedDawn Raging StartMarch 4Can anyone justify the Europeantravelrestriction, scientifically? Seriously, is there anybenefit? I don't see it, but 'mhopingthere is somethingI don' t know .From : Parker Jr, GeraldWI . tamu. eduSent: Wednesday, March 11, 2020 23: 15I do not see it. Nouse now . I saw it for China. Butnotnow . We should focus on targeted, layered communitymitigationmeasures. Maybewe could use a hurricaneanalogy thatmany understand. COVID19 is like a stormcomingto ourcommunities, butrather than evacuation or shelterin place orders, the analogousmove is communitymitigation. Atthis stage they mustbe aggressivebecause we do nothave the timeluxury ofa hurricanein theAtlantic .On Thursday, March 12, 2020 12: 09 AM , Lawler, James @ unmc.edu> wrote:Fuck no. This is the absolute wrongmove.JamesLawler, MD, MPH, FIDSADirector, InternationalPrograms& InnovationGlobalCenterfor Health Security, andAssociateProfessorofMedicineDivisionofInfectiousDiseasesUniversity ofNebraskaMedicalCenterFrom : Parker Jr, Gerald WSent: Thursday, March 12, 2020 12 16 AMNotto worry .. . is a large group of friends cleared to car pool confidentiallevel.On Thursday, March 12, 2020 12: 20 AM , RichardHatchett @ cepi.net> wrote :Nojustification that can see, unlesswe to putup similar geographic cordons in the US- there is plenty ofdisease already in the USto cause spread domestically.On Thursday, March 12 2020 12: 26 AM, RichardHatchett @ cep.ni et> wrote:Gerry - I thoughtyesterday aboutthe incominghurricaneanalogy as wellandthink it is a good one. This is a Cat5threatto safety thatis coming too Jr. communities andfast, andwe can either prepareand do the epidemicequivalentofevacuate to safer ground(i. ., TLC/CMG) or takeour chances. It's a lotharder to evacuatewhen thewindsare above 100miles an houron their way upto 190 atthe eyeball.On Thursday, March 12, 2020 12: 28 AM , Dr. Eva K Lee > wrote:I washopinghewouldmention about schools, governmentandprivate sector tele-work, community gatherings,things thatreally need everyoneto actively engage in And also extra resourcesfor healthcare providers.Wereallyneed to protectproviderswho care for covid- 19 patients.Wemustprotectthem becausetheyare invaluableresourcesandwe don't have enough. They are notlike equipmentthatthe Presidentcould ask a manufacturertoproducemore.Herein Georga,i students arepartitioningthe universitiesto do lecturesonline, butuniversitiesarenotagreeingsofar. I am sure theywould llisten to thePresiden. tButnow they willwaituntila teacherhascovid- 19. Springbreak is adangeroustime, aswecan see from Italy.I wonder, closingallflights from Europewould mean thatmany Americanswill bestuck in Europe. Or allthose whowantto comehomewillrace and get a ticket to fly back on Fridaybefore closing. And theywill be quarantinefor 14days.On Thursday, March 12, 2020 12: 38 AM CarterMecher wrote:There is no value to these travelrestrictions. A waste of timeandenergy. The lesson from Mann Gulchwas to dropthose things thatare notessential. Thatlesson wasnotheeded. I wouldn't waste a momentof timeon travelrestrictionsortravelscreening.Wehavenearly asmuch disease herein theUS as the countries in Europe.Wrt communitymitigation, I thinkweran out oftimefor Seattle. Butthere are other citiesand communitieswherewestill canmakea difference. I don' t understandwhy CaliforniaandNYC are notactingmoreaggressively. Timetofocus on other parts of the countrywheremitigationmeasuresmightstillwork and where governors,mayors andpublic health officials aremore receptiveto doingwhatworks. It feels like a replay of 1918. Somestateand localleaderswillmakepoordecisionsand unfortunately theAmericanswho live in thosecommunitiesare goingto paydearlyforthe choicesbeingmadeby their leaders. Itis a shamethose lessonswere notlearned.On Thursday, March 12, 2020 12: 56 AM , Dr. Eva K Lee > wrote:Yes, aggrssive communitymitigationwill work in somestates, and somewe are losing thebattleground. Tam stillvery confused by testingability. Whatexactly is ourlevelof throughputnow ? 10,000 a day? Or 100,000 a day ?WhenI talked to localtoday, they hadno idea and their requestsfor test are stilldelayed. Who is in chargeoftestingresourceand statistics? Maybe there's a leaderwho is in chargeof all the vendors, andhe/she can tellus thethroughputstatistics Now, we can strategizetesting, or perhapsitis too widespread across the US and wejusthaveto test a lot, like S . Korea. Somestates are stillbetter than others.I know always talk about 1 case" or " 1% infection". Inmathematics,wealways look for the smallestthingsthat areofgreatsignificance. And thenwelook forlargestthings thatwe can solve. I think " 1" is a very good numberyetavery dangerousnumberthatrequireshard decisionswhen it comes to infectiousdisease. I understandhaving 1 as atriggerfor actionis a very hard decision. Butin infectious disease, 1= 1+manyunknowns, henceit is ratherbigalready. I really learn a lotfrom allofyou. I found thatyou are all very mathematical: ). Now I will go back to myequationsagain to see which cities are stillin good shapeto contain successfully.On Thursday , March 12, 2020 7 : 08 AM , Tom Bossert me. com > wrote :Wearemaking great progress. Mymessage today on US TV willbe as follows:•Thebiggestmisunderstandingabout# coronavirus interventionsis they are an à la cartemenuof optionsto beselectively implemented. This is dead wrong. They ALLmustbe implementedto achieve a layered effect. Removingany onecan defeat all. For instance, close schools AND cancelevents.•There' s little value to European travel restrictions. Pooruse of time & energy. Earlier, yes. Now, travel restrictionsand screening are less useful.Wehavenearly asmuch disease here in theUSas the countries Europe.WeMUST focus on layered community mitigationmeasures-Now!TomOn Thursday, March 12, 2020 7 : 34 AM , Lawler, James @ unmc. edu> wrote:Like it Tom . The message is : let' s be Singapore and HongKong, not Italy. And given the currentstate of ourpublichealth infrastructureweneed to implementall in affected communitiesJamesLawler, MD, MPH, FIDSADirector, International Programs& InnovationGlobalCenterforHealth Security, andAssociateProfessorofMedicineDivision ofInfectiousDiseasesUniversityofNebraskaMedical CenterOn Thu, Mar 12, 2020 at 1: 14 PM Hunt, Richard(OS/ ASPR/EMMO) @ .gov> wrote :Reflectingon this from Tom , They ALL must be implementedto achieve a layered effect."Asmy24 y / o toldme, " the nation needsto go to war against this virus.RickOn Thursday , March 12, 2020 1: 16 PM , Dr. Eva Lee @ gmail.com > wrote:Indeed, systems inter-dependencies give you the holistic benefits. You can see isolated actionsare not sufficientbecausethe brake has to be very big!! ! Weare too late, wehaveno choicebut to roll them all out.From : "Lawler, James V "Date : Thursday ,March 12, 2020 at 1:28 PMTo: Carter Mecher Dr. Eva KWeare making every misstep leaders initially made in table -tops at the outset of pandemic planning in 2006 .Wehadsystematically addressed all of these and had a plan that would work - and has worked in Hong Kong/Singapore . Wehave thrown 15 years of institutional learning out the window and are making decisions based on intuition .Pilots can tell you what happens when a crew makes decisions based on intuition rather than whattheir instrumentsare telling themAnd we continue to push the stick forward ...James Lawler, MD , MPH, FIDSAFrom: EvaLee < om >Thursday , March 12, 2020 1:28 PMTo: Lawler , James V u >Yes, very very sad -- it' s all theplanningandwemustexecute andwecan' t execute!From : Carter MecherThursday, March 12 , 2020 1:28 PMTo: Lawler, James du, Dr. Eva K Lee <Plan continuation bias. Rightinto ground.On Thursday , March 12, 2020 5: 46 PM , Dr. Eva K Lee < > wrote:Great! Ifwe can onlymakethe president, or someofthese leaders, to say somethingatnewsconferences -- so thatevery infected State could respond in a timely manner, thatwould truly work.Weare all connected, so weneed tosynchronize, thatway, there' s no room for the virus to wriggle.From : CarterMecher <Date: Thursday, March 12, 2020 at 8:08 PMTo : "Dr. Eva K Lee"Cc: "Lawler, James V " Tom Bossert.. .This coming Saturday willmark twoweeks since the first death in theUS. On Saturday (likely by then we willhave500 cases and 75 deaths given the currenttrajectory) , ask yourself, what do you wish wewould have done 2weeks earlieron Feb 29 ? don' t think shutting down travelwith Europewould have made the list. If you can answerthat question truthfullynow , then whatare we waiting for ?- - - - - - -OnMar 13, 2020, at 6 :04 PM , Parker Jr, Gerald W > wrote:Carter and others - article just published in Politico Pro. CDC suggests school closures will nothavemuch impact.There is a discussion of short term versus longer term ... Is thismisleading? What are your thoughts ?<pastedImage. >From : Tom BossertSent: Friday,March 13, 2020 6 :07:00 PMThat article snippet seemsmisleading. I wonder it the CDC guidance it's based on is equally unclear.- - - - - --From charter.netTo: " net"Cc: "Dr. Eva Lee" , James V " , " Dr. Eva K Lee" , " CHRISTOPHER ALLEN " , @ gmail.com ", " Tom Bossert",Gerald W ", " Richard Hatchett", David (DSHS )" , Eric ", Luciana ", "Brian Benson ", " Tracey McNamara" , " DuaneCaneva", Ralph S ", Carter (VA .GOV)", Richard (OS ASPR /EMMO)" , THOMAS " , " M . D ." , " ,"Gregory J", William (STATE.GOV) " , CAMERON" , mail com " , tDanielt(OS ASPR SPPR )" Kristin(OSIASPR ) " , Sally (OS ASPR SPPR ) " , "Matthew J CIV USARMY (USA) " , "Lisa Koonin " ,MELISSA" ,HERBERT" , Alexander" , edu , Robert(OSIASPRBARDA)" , Kevin", Gary(OSIASPRBARDA)", John (OSASPR SPPR)", David (Chris) (OSASPR )", Joseph (OSIASPRIO )" , Dan", David",DAVID A" , SANGEETA, Scott(OSASPREMMO)" , "Larry G ", "RyanMorhard", " Steven Jt( ) ", Jerome(HHSOASH)" , MoniqueK . ", Jessica(USDA.GOV)", " DC" , . edu ", Jerome (CTR )" , Jay J" ,Joselito ", "WillGaskins", "Kevin Montgomery ", Linda L" , " LLogandakar"Sent: FridayMarch 13 2020 7:09: 26AMSubject: Re: Red Dawn RagingStartMarch 4This is whatleadershiplooks like."Wewhole-heartedly endorsethe bold and decisivedecisionsofourGovernorheretoday. This is notaboutahealthcaresystem; this is about ofus.Wecan all fightback againstthis virus, andin fact, weneedto . The healthcare system can treatthose who are ill; and acrossall ofMaryland, we' re readyingourselvesin case weneedtoHowever, byputtingaggressivesteps in placethat theGovernorjustoutlinedwith regard to socialdistancingclosuresofschools, teleworking are stepswecan alladopt.. . the earlierwedo this, themorelayersweputinplace, the less this virus can be transmitted. Tha'ts thekey. Marcozz, iat a press conferencehostedbyGovernorLarryHoganannouncingmajorsteps in the state ofMaryland' s COVID- 19response. Those stepsincludedMarylandEmergencyManagementAgency increase activation to highestlevelActivate national guardstate governmentis raisedto elevated level 2 - allnon- essentialemployeeswho can telework required to do soPublic access to state buildingsrestrictedo Nogatheringsofmorethan 250+ people includingsports andreligious gatherings)seniorcentersclosedAll state and local governmentbuildings withmore than 250 + peoplemust follow socialdistancingcruise ship terminalin Baltimoreofexpiration dates on permits including drivers licenses, license plates , professional licenses, until 30days after end of state of emergencyAllhospitals adopt new visitor policies to stop spread of COVID -19prisonswillsuspend visitsnon-essentialfunctionsof governmentare now managedby LtGov Rutherford so Gov Hogan can focus solelyon COVID - 19Monday,March 16 through Friday, March 27 - allpublic schools closedMeasurestaken to providechild care for essentialworkers/firstrespondersOn Friday, March 13, 2020 6 : 30 PM, Lawler, James V < > wrote :CDC is really missing themark here. By the time you have substantial community transmission it is too late . It' s likeignoring the smoke detector and waiting untilyour entire house is on fire to call the fire dept. Plus, how are yousupposed to know when you have community transmission when they haven' t been able to provide a diagnosticassay that canbeused widely and athigh volume?- - - - - - - - - - - - - - - - - - - - - - - - - - - -From : CarterMecherSent: Friday, March 13, 2020 7: 13: 19 PMTo : Dr. Eva K Lee;Lawler, James V ; Parker Jr, Gerald W ; Caneva, Duane; Tom Bossert; Hanfling,Dan ; Gruber,David DSHS); Dr. Eva Lee; CHRISTOPHER ALLEN;Hatchett;McDonald, Eric ; Borio, Luciana; BrianBenson; TraceyMcNamara; Baric, Ralph S ;Mecher, Carter (VA.GOV) ; Hunt, Richard(OSASPR/EMMO) ; WILKINSON, THOMAS; M . D. ; David; Charity A @ CDPH; GregoryJ Walters, William (STATE.GOV ; HAMILTON CAMERON:DodgentDanielt(OS ); DeBord,Kristin (OS ) ; Phillips, Sally(OS ASPRISPPR) Matthew J CIV USARMY(USA) Lisa Koonin HARVEYMELISSA.edu;Johnson, Robert OS/ASPR/ BARDA) ; Yeskey, Kevin , Gary(OS ASPR BARDA) ; Redd, John (OS ASPR SPPR); Hassell, David (Chris)(OS ASPR IO ) ; Hame,l Joseph (OSASPR IO ) ;Wade, David; TARANTINO, DAVID A ;KAUSHIK, SANGEETA; Lee, Scott (OS ASPR EMMO) ; Larry G ; RyanMorhard;Steven Jt( ; Adams, Jerome(HHS/OASH) ; Mansoura, MoniqueK .;Fantinato Jessica (USDA.GOV) : DC edu Cordts, Jerome(CTR) ;Schnitzer, Jay ; Ignacio, Joselito; WillGaskins; Kevin Montgomery; Logan LindaL ;LLogandakar takeda.comSubject: RE: RedDawnRaging StartMarch 4I don' t think the intent is to close schools for only 2 weeks. Longer term school closure will be necessary.What CDC is not accounting for is that we have been flying blind for weeks with essentially no surveillance . This was due to the delays associated with the diagnostic test developed by CDC and the very narrow CDC definition of a PUI that really hampered our ability to even identify community transmission . We have this concern repeatedly . Our general sense was that community transmission was already occurring several weeks ago (and we stated so at the time over email and on conference calls ), but nobody could prove it because CDC would only perform confirmatory testing on cases meeting the PUI definition . And the PUI criteria by definition excluded any potential case of community transmission . It was very circular. CDC placed state and local public health in a bit of a Catch 22 .So after a long delay we finally have the ability to test more broadly. If you recall , CDC only expanded the PUI incrementally at first to include severely ill patients with no travel hx or link to a known case. It was only later that testing was opened up more broadly. Can a model incorporate that amount of confusion into the initial conditions?Once testing began in earnest, the numbers of cases exploded. It was like popcorn (also as we predicted) . Cases were appearing everywhere. I would challenge anyone to provide an accurate estimate of prevalence in the US. I' d be interested in howcertain they would be of that estimate + / - ?The difference between models and real life is that with models we can set the parameters. How would they model what happened in Italy ?The difference between models and real life is that with models we can set the parameters as if they are known. In real life , these parameters are as clear as mud.Tocheck theaccuracyof themodelforpredictingreallife, Iwouldask thatthey run Italy for usto show ushow wellhandwashingand isolationwouldwork. Howwould theymodelwhathappenedin Italy? On Feb 20, Italyhad 3 casesandnodeaths. On thatdaythemodelersand theguidanceCDCjust releasedwouldnotadviseto take anyaggressiveaction. On Feb 21, they had 1 death and 20 caseswith 6 patientsin theICU. This is a countryof51M . WhatwouldCDC guidancehaveadvised Italy to do on Feb21? OnFeb 22, Italy hada cumulativetotalof 2 deaths,63 caseswith 7 patients in theICU. Howwould CDC describedwhatwas goingon in Italy? Would thismeettheir definitionof widespreadcommunitytransmission? doubtit. CDC and theCDCmodelerwould have recommended sitting tight. Italy responded extremely aggressively. This is what happened since. I think the public health officials and political leaders in Italy acted very quickly and very aggressively more quickly and aggressively than what we did when the outbreak began in Seattle two weeksago. I would ask themodelerandCDCwhen theywouldhavepulledthe trigger in Italy. We have the actuald ata. Themodelercan runhismodelsandcan pointout whathe/shewould do and when it should be done. I suspect early on in Italy we would have heard exactly whatwe are hearing now.I don' t pretendto have perfectknowledgeof the extentof disease in theUS. There is a lotofuncertainty. Butgiven this uncertainty, isn ' t the safestapproach to close the tilweknowmore? We can alwaysreopenthe schools. Ifwedelayour responseand the outbreaktakes off likeItaly, wewillhavemadea terriblegamblewith the livesofAmericans, overwhat, an extendspringbreak? Which sideofthebet wouldyoutakeifyouwere the responsibleofficial(mayor, governor, public health official )?Again , nobody is advocating a short closure of schools . I don ' t think it would be prudent to play it cute and try to play chicken with this virus and hold outto the last moment to pullthe trigger. It is like thinking you can time the market. You don' t do that when thousands of lives potentially hang in the balance . That is what would tellmy mayor, or my governor , or my President.
-----------------------------------------------------------------------------------From : "Parker Jr, Gerald W " @ cvm . tamu. eduDate: Saturday, March 14, 2020 at 1: 16 AM
CDC school closure guidancehttps://www. cdc. gov/coronavirus/ 2019-ncov/downloads/considerations-for-school-closure.pdf
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From : CarterMecherSent: Saturday, March14, 2020 7:58 AMTo: Parker Jr, Gerald W ; Dr. Eva K Lee; gmail.comCc: Lawler, James V ; Caneva, Duane; Tom Bossert; Hanfling, Dan; Gruber David(DSHS); Dr. Eva Lee CHRISTOPHERALLEN; @ gmail.com ; RichardHatchett;McDonald , Eric; Borio, Luciana; Brian Benson; Tracey McNamara; Baric,Ralph S; Mecher, Carter (VA.GOV); Hunt, Richard (OS/ASPR /EMMO); WILKINSON,THOMAS; M .D ; ; Gregory J; Walters, William (STATE.GOV);HAMILTON, CAMERON; Dodgen,tDanielt( SPPR); DeBord,Kristin(OS ASPR ); Phillips, Sally (OSASPR ) ;Matthew J CIV USARMY (USA);Lisa Koonin; HARVEY, MELISSA; WOLFE, HERBERT; Eastman, Alexander; EVANS,MARIEFRED; b .edu; Johnson, Robert(OSIASPRBARDA); Yeskey,Kevin; Disbrow, Gary (OS ASPRBARDA); Redd, John (OSASPR/SPPR); Hassell,David (Chris) (OS ASPRIO ); Hamel , Joseph (OS ASPR/IO );Wade, David;TARANTINO, DAVID A ; KAUSHIK, SANGEETA; Lee, Scott(OS/ASPR/EMMO); LarryG ; RyanMorhard; Steven Jt(tCHFStDPH) ; Adams, Jerome(HHS/OASH); Mansoura,MoniqueK . ; Fantinato, Jessica (USDA.GOV); DC; du; Cordts,Jerome(CTR); Schnitzer, Jay J; Ignacio, Joselito; Will Gaskins; Kevin Montgomery;Logan LindaL ; LLogandakar; akeda.comSubject: RE: RedDawnRagingStartMarch 4Most of you have been involved in table top exercises of an outbreak . In thoseexercises they commonly show a map of the US with the number ofcases noted andextent of spread . At various points in the scenario , a facilitator will ask the participantswhat actions should be taken . I took the graphic of the USmap from the NYTimes andcreated a PowerPointmovie from Mar 4 (the first day that the NYTimes presented thatmap ) through today.In this scenario, the facilitatorpausesnow on March 14. Atthis pointthe virushasalready spreadtomore than 120 countries. Thevirusis highlytransmissiblewith anRoof about2 . 5 andhas a CFR of 0 .5 % - 1. 0 % . Theelderly and thosewith chronicmedicalconditionsare at greatestrisk. Theresponsehasbeen hinderedby seriousdelays inthe ability to confirm diseasewith diagnostictesting. This testingcapacityis limited.Case ascertainmentis limiteddueto the testing constraints. Itis believedthatoverthenexttwoweeks capacity for testingshouldimprove. However, thedemandfortestingisse exponentially over the next 2 weeks. A few areas in the UShavebeen particularly hard hit Washington and California . The currentUS casecount is 2 ,654 with 49 deaths. Whatactions would you take on March 14 ?- - - - - - - -- - - - - Saturday,March 14, 202012:43 PM , . Eva K LeeThis is so very sad, yes, everythingwetalked aboutand everythingwehave anticipated. Yes, you cansee from the curvesin the graphswhen they have the first confirmeddeath, they're at least2 weeksbehind. I don't understandthe screening atthe airport, noteven a little adviceon self-quarantinecomingin from any countries. Yes, children will die too if they haveno support in thehospitals. Therearemanywith co - existingconditions. Beds are critical . Thatis all I am counting(when wehaveonebed, we need everythingthat goeswith it in the ). Healthcareworkersand anyonein serviceto assistthis covid- 19 operationsmuststay healthy. Butof courseweknow they willbequarantinedatay think school closure is over-reacting. It isn not if you think about theinter-dependencies. You can imagine a million different scenarios. Just a simply one -- a litlechild got infected from school. He camehome and infected his mother who was a nurse. The nursewent to work without any noticeable symptoms, and she infected the ICU patients that she cared forOk, this is one case -- and again -- one case is ALL we need to worry about. The cascading effect --we don't wantto even think about.But as a country , wemust fight for everyone and every state . I truly believe and in mycalculations ,those states that took the pre-emptive steps -- they are going to have the resources to contain theirown infection and at somepoint, can help those states in needs. Herewe go about sending patientsaround -- not 7 - - butmany -- when wemust lend the help when needed ( and if we could do so at all).Now , everyone is fighting their local fire , and it's already quite stressful for everyone. I don' t even knowif anyone has extra resources. It is really resource - intense. Can you imagine --India, and the Africancountries start to pick up ? It frightens me. Hence pre -emptive is a must.From : Carter MecherSent: Saturday, March 14 , 2020 4: 32: 54 PMTo : Parker , Gerald W > ; Dr. Eva K Leee gmail.com >Cc: Lawler, James V r @ unmc. edu> ; Caneva, Duane@ hq.dhs.gov ; Tom Bossert @ me.com > ; Hanfling, Danorg> ; Gruber DSHS) @ dshs.texas.gov>; Dr. Eva> ; CHRISTOPHER ALLEN@ msn . com > ; @ gmail . com @ gmail. com > ;Richard Hatchett @ cepi.net>;McDonald, Eric@ sdcounty.ca. gov> ; Borio, Luciana .org>; Brian Bensonicloud.com > ; TraceyMcNamara westernu.edu> ; Baric,Ralph c @ email.unc. edu> ; Mecher, Carter (VA .GOV) @ va . govHunt, Richard (OS ASPREMMO) hhs. gov> ; WILKINSON, THOMASN @ hq. dhs. gov > ; M .D . @ mgh.harvard. edu> ;David m umaryland.edu> ; Charity A @ CDPHn @ cdph.ca. gov ; Gregory J state.gov>; Walters, William(STATE.GOV) < @ state . gov> ;HAMILTON , CAMERON@ hq.dhs.gov > ; Dodgen ( SPPR ).In hhs.gov > ; DeBord Kristin (OSIASPR SPPR )hhs. gov > ; Phillips, Sally (OSASPR SPPR ). gov > ; Matthew J CIV USARMY (USA)mail.mil> ; Lisa Koonin il. com > ; HARVEY,MELISSA @ hq. dhs. gov ; WOLFE, HERBERTV Eastman Alexanderv > ; EVANS,MARIEFREDassociates.hq.dhs @ utmb.edu @ utmb. edu> ;Johnson , Robert (OSIASPR BARDA ) @hhs. gov > ; Yeskey,hhsgov> Disbrow, Gary (OS / BARDA)@ hhs. gov > ; Redd, John (OS ASPR ) < @ hhs. gov > ;Hassell David (Chris ) (OS ASPR IO) . gov>; Hame,l Joseph(OS ASPR IO ) hhs. gov> ; , David < @ hq.dhs.gov> ;<TARANTINO, DAVID A < @ cbp .dhs.gov > ;KAUSHIK , SANGEETAhq. dhs.gov > ; Lee , Scott (OS ASPR /EMMO ). gov > ; Larry G ; Ryan Morhardweforum . org > ; Steven ( ) @ govAdams, Jerome (HHS/OASH) . gov> ; Mansoura, MoniqueK .< @mitre. org> ; Fantinato,usda.govusuhs. edu < . Cordts, Jerome(CTR )< jerome@ fema.dhs. gov> ; WillGaskins@ efiia.cvm .tamu. edu> ; LLogandakartakeda .com >Subject: RE: Red Dawn Raging March 4Non-UNMC emailIs anyoneatCDCmonitoringILI?Here is the latest flu surveillance for HongKong, South Korea , US; the states of CA,OR , WA, TX ; and the cities of Seattle ,NYC , and Chicago (LA hasn ' t reported week 10yet).Whydid theUS ILIcurvedeflectup thisweek, while influenzapositivetests are tracingdown? Seeingthe samewrt increasinginWA, OR , Seattle, Chicago, andNYC.this influenzaA , COVID, orboth? ChicagoandNYC are concerningbecausetheirinfluenzavirusdetectionis goingdownand isgoingup.From : Dr. EvaSent: Tuesday,March 17, 2020 7:03:58 AMTo : CarterMechera @ gmail.com .com >, "Caneva, Duane" @hq.dhs. gov" McDonald, Eric" . ca. gov Richard Tubb @ gmail. com >, " Rob Darling,MD patronusmedica. clom > , William Lang @ worldclinic. com >, "Mecher, Carter"r @ . gov Tom Bossert @me. com >, RichardHatchett< @ cepi.net" Lawler, JamesV " < r unmc. edu>, "Parker Gerald W @ cvm . tamu. edu , "Hanfling, Dan"@ iqt.org>, " Gruber,David(DSHS)" @ dshs. texas. gov CHRISTOPHERALLEN@ msn.com >, " Borio, Luciana"@ iqt.org>, TraceyMcNamara .edu > , " Baric, Ralph S" email. unc. edu ,"Hunt,Richard (OS/ASPR / EMMO)" @ hhs.gov> "WILKINSON , THOMAS "@ hq. dhs. gov " M mgh.harvard.edu>, David@ som umaryland. edu , . ca. gov Gregory@ state.gov " Walters , William (STATE .GOV) " <walterswa2 @ . gov > , "HAMILTON , CAMERON "@hq.dhs.gov > , " Dodgen, tDanielt (OS/ASPR / SPPR )" n @ hhs. gov , " DeBordKristin(OS/ASPR/SPPR) " < K d @ hhs.gov>, " Phillips, Sally (OS/ ASPR/ SPPR)" .gov>, "MatthewJ CIVUSARMY(USA) " mail.mil Lisa >, " HARVEY, MELISSA"@ hq.dhs.gov "WOLFE, HERBERT" @hq.dhs.gov>, "Eastman, Alexander"@hq.dhs.gov " EVANS, MARIEFRED " <m @ associates.hq.dhs. gov@ utmb. edu" < @ utmb.edu>, "Johnson, Robert(OS/ ASPR/BARDA) " < R n @ hhs. gov" Yeskey, Kevin" @ . gov>, " Disbrow, Gary (OS/ ASPR/BARDA) " < o hhs. gov> , " Redd,John (OS/ ASPR / SPPR )" s. gov> " Hassell, David ( Chris) (OS/ ASPR/ 10 ) " < D @ .gov"Hamel, Joseph (OS/ASPR/ ) " <Jq @ hhs.gov> , "Wade, David " <da .dhs.gov> ," TARANTINO , DAVID A cbp .dhs.gov> , "KAUSHIK , SANGEETA "ik @ hq. dhs.gov , " Lee, Scott (OS/ ASPR/EMMO) " < .gov Larry Gv>, Ryan Morhard < weforum . org>, " Steven Jt( "k ky.gov>, " Adams, Jerome(HHS/OASH)" <Je Adams@hhs.gov>, "Mansoura, MoniqueK ."@ mitre.org> (USDA.GOV) " @ usda. gov>, DCby @ usda.gov > , " d @ usuhs.edu" <danny.shiau @ usuhs. edu >, "Cordts, Jerome(CTR) "ts @ associates.hq. dhs.gov @ mitre. org>, " Ignacio, Joselito"cio @ fema.dhs.govSubject: Re:Red DawnResponding, Start 16 MarchCarter, this truly frightens me. one case is one too many, I hope political leaders can act and act quickly. We must do so or else we can't help these other cities that are escalated so rapidly. And globally, every country has to tighten, because we are running out of resources to do proper quarantine.We are already running out of healthcare resources, NYP has already canceled all elective procedures March 16 . And many other hospitals who need care for covid-19 are facing the same issue. The medical tents appendices are needed and must be planned. I don' t know what medical reserve we have and we have multiple fires burning simultaneously!
-----------------------------------------------------------------------------------On Tue , Mar 17, 2020 at 9 :53 AM Carter Mecher
Bossert said on GMA thismorning like 1918, this willbe a tale ofmanycities. What happensin the cities impacted the earliest in the USincludingSeattle, San Francisco, andNYC will likely be very differentfrom whatwe see in other cities (just like 1918, timing of implementing TLC in individualcities in their individualepi curves will matter). The hardestmessage to convey to politicalleaders, publichealthleaders, and the publicwas theneed to take action before the storm arrived and when the sun was shining.Interesting to look atthe regionalvariationin Italy.Itis looking just like what we observed in Hubei(includingWuhan) vs. WuhanIt willbe important to look a little more closely inside the the aggregate numbers miss the real story . The storyline of the articles written about the variation in outcomes in US cities in 1918 , is now unfolding and writing itself in real time before our very eyes.