Dr. Anne Schuchat: Principal Deputy Director of the CDC (Raise the Line)
Hi, I'm Dr Rishi Desai. I'm the Chief medical officer at osmosis.
I'm honored to welcome Dr Ann Shook to raise the line. She's the principal deputy director at the CDC.
Dr Shoki has been heavily involved in combating multiple diseases in her 30 plus years that she's been at the CDC and is leading oversight of its response to COVID-19.
Thank you so much for being with us here today. First question is, can you help our audience understand the scope of the CDCs role in fighting the pandemic?
Yeah. CDC um has thousands of people involved in our pandemic response.
Um Of course, uh preparing and responding to emerging infectious disease threats is really core to our business, but we have uh staff in, in health departments all around the country and we have people in 60 countries around the world as well as um uh 100s deployed from our Atlanta headquarters to assist the state and local health departments.
We're tracking the epidemiology um working in the laboratory on assays like a new antibody test to measure zero prevalence.
Uh The amount of people who've already been infected, we're doing investigations to understand how it's spread in households and trying to provide support about investigation around nursing home outbreaks, outbreaks in shelters for the homeless in meat packing plants and in um a number of complex settings right now, providing guidance for clinicians and guidance for public health about how to really accelerate controlling the outbreak right now, really uh focused in on flattening the curve, slowing the spread, trying to understand how the community interventions are working and doing models to predict what's gonna happen in the future.
You know, speaking of models just yesterday, as you're well aware, the guidelines just dropped in terms of what we can look forward to in the, in the weeks ahead.
You know, in just a few days from now, do you feel like the public health capacity is built to a place where they could potentially enter phase one?
The um Washington state example is a good one. The leadership in Washington State announced that they were gonna work together with Oregon and California with a regional strategy.
And I personally think that's a great idea. We know that um the New York uh area is doing the same thing and the, the upper Midwest as well.
You know, it in today in America, people can live in one place, work in another, go to school on a third. And so um having um jurisdictions really work together, whether it's that macro level of the whole west coast or it's several counties around the DC metropolitan area.
Um It, it's very important to coordinate and collaborate because you um if you're not in sync, the, the spread may just ping pong across.
I think that it's really going to be important to have public health capacity, hospital capacity, or health care capacity, good availability of testing and rapid assessment of the indicators in order to open different parts of the community.
But some things may open sooner than others and they may open partially, you know, open with physical distancing, perhaps having um you know, childcare centers where the parents are in healthcare or essential work or something open or broader childcare centers.
But I think um CDC has been working on a variety of tools and a variety of metrics and connecting with the local and state health departments to see, do these make sense?
Are these practical? Could you work with them?
Contact tracing is a big deal. And of course, we're now at this rapid transmission, high levels of disease in a lot of places where you just can't possibly keep up with individual case identification, contact tracing, rapid um quarantining or isolation of the individuals.
But when we do have things open up we wanna be able to detect cases in uh in their context really quickly. And so we're working on something called a COVID response.
CORP, both CDC CDC Foundation State and local jurisdictions who have gotten about $600 million for their pandemic response to try to really staff up the public health capacity.
It may be local or state employees, it may be census takers, eco volunteers, they're already, you know, government employees and they are not doing their regular job right now and we connect them with the local health departments.
I've heard of schools of public health students being assigned to local health departments to help with contact tracing.
We know in West Africa during the Ebola response, we rapidly got call centers adapted from being usual call centers to being contact tracers uh by phone where in in societies, even in West Africa where everybody had a cell phone.
So we really need to use the tools of modern America and strengthen that public health capacity locally so that we can um keep up with um transmission.
I think that contact tracing will be really important in the low incidence areas that haven't yet been hit. And then as we see control improving in other jurisdictions to prevent uh resurgences by early detection, the clusters.
And one of the things you're getting at is this idea of increasing healthcare capacity. We've heard the phrase flatten the curve.
Uh The other phrase uh I'm not sure if you're familiar with, but is raising the line of healthcare capacity and raising the line includes all the things you just mentioned um as well as testing as well with testing.
Going back to that point, I'm just curious to get your thoughts. We saw roughly 1 million tests done, you know, in January, February and March cumulatively.
And then we saw about a million in the first week of April again, another million in the second week of April. What is your sense in terms of where we need to be to start seeing parts of America reopen up?
What, what weekly testing capacity is, is a million enough or doing any 5 million or 10 million a week? What do you think?
You know, I don't have a number. I would say there's several different opinions.
You've probably been reading many of them about a target for testing. I think the traditional public health person in me who's used to studying respiratory viruses feels like, you know, uh you can't really test your way out of a pandemic of a respiratory virus.
There are other indicators that are gonna be timely like the syndromic surveillance we're we're using. But I think that there's a huge demand for testing and we know that a lot of people who can transmit, don't have symptoms when they can spread in that nursing home environment or sometimes in the meat packing plant.
So the testing has a key role in this um we obviously need more. There's so many people who don't uh who do need to be tested, who aren't getting tested yet.
And we need to shorten the time between when a person uh needs to be tested and when they can be tested and when the result from that test available.
So the the surge in available tests and approaches to testing is good. The point of care tests the high throughput tests, But we have this supply demand mismatch right now.
So it's not really just the number, it's getting them where they need to be when they need to be there with all the supplies.
You know, it's not just having a machine that can test, it's not just having a point of care test, it's also the cartridges, the media, I think there's something called swab Force which has been created at the National Response Coordination Center to figure out how to get enough of swabs everywhere.
They need to be the right kind of swab for the right kind of test. Can we ship swabs or is that not?
Ok. Well FDA has to say it's ok to ship a swab for that type of test kit.
There's a lot of mismatch right now. We got to get beyond it.
So I don't have a number. I know the number is higher than where we are.
You know, speaking of, uh, FDA, the FDA this morning, uh, has to date, uh, authorized, I think for emergency use authorizations for serology.
And we know that in the coming weeks, serology is going to be increasingly important. There is, it feels like a bit of a logjam in terms of getting these eua uh approved for serology.
And this happened again with RT PCR in, in February, there were two, you know, available CDC and also there's one with New York.
Do you expect more eu to come through? And, and what do you sense is the, is the reason for that logjam?
Yeah, I expect many more to come through. But II think that it's gonna be very important to understand the performance of these tests.
You know, an antibody test um can lead to a lot of confusion. We don't know all that we want about the immunology of this disease is an antibody specific.
Does an antibody positive mean you had this infection and you're not gonna get it again. Um Or is it just a nonspecific finding?
You may remember uh you're probably younger than me, but the beginning of the day of the HIV antibody test, right? We have an anti HIV antibody test.
Well, it turned out when a condition is very rare, the performance of the test needs to be really, really good for it to work well in the context of rare exposure.
And it in those early days if you tested, you know, a a general population with the antibody test for HIV more times of and not, you'd be wrong.
The person who got the antibody positive didn't really have HIV. Some states were gonna require HIV testing as part of marriage certificates.
And then it was like, well, we're giving out more wrong answers than right answers and we're ruining a lot of relationships.
Let's get this figured out. And so it became a two step process screening test, follow up test.
So we're developing these antibody assays here at CDC and elsewhere, we're using a second step, a neutralization test to figure out is that antibody specific or is that just an error?
And I think the FDA may be double checking before these tests go into widespread use. So I think the UK ran into uh open the floodgates and use all these tests and then said, wait a minute, we don't even know what they're measuring.
So um we, we recognized early on with the PCR, the, the commercialization was way too slow and speed is essential when you're dealing with a new virus.
Um here, as we try to understand how we're gonna use antibody tests. Is it on the individual basis for a healthcare worker getting back to work or for population studies where being wrong isn't that cosmic because you're not taking action on the individual result.
Um So I feel for FDA and you have a tough job, what is, you know, one thing you, you've uh talked about a little bit is, you know, the need for more public health workers to go out there and do contact tracing and things like that.
You know, it kind of goes hand in hand with public education uh to understand what these tests mean and things like that.
Uh As an education company, osmosis tries to do our part around the education piece. I'm just curious, what do you see as, you know, the short term advantages of public education campaigns?
And then do you see that as, as kind of a long term strategy for CDC as well? I have so many answers to that question.
I'm really excited about the question. I am amazed and really heartened by what the American people have done recently.
You know, in response to this pandemic, there have been all these neighbors helping neighbors virtually, there's been so much um kind of correcting the record that he that people are doing online or in social media.
Um You know, we had recent polling data, I saw about the face coverings and it's amazing to me that in the United States, which was not a place where people wore masks or wore face coverings would not like a lot of places in Asia we pretty rapidly went from, don't use them to, we actually recommend a cloth face covering to people understanding that this is about me protecting you.
You know, I like to say, um I got you covered by the face covering that I wear, protects you. Um And so I think that people are, are hungry for information.
They're stuck at home to the most part, a lot of them are connected and connected with each other and they're talking about important issues and solutions and they're finding solutions and sharing them with the decision makers and we're trying to listen.
Um So I think public education has a huge role and the public voice of what the issues are and the concerns are, is really important.
It's important for us to know what those questions are, see if we can address them. Um The other thing I was gonna say about uh public education is kind of about students.
I think um you know, I am really heartened that um this need for a huge surge in public health capacity comes at a time of so much interest in public health.
You know, the last several years, undergraduate education has really emerged. Um Public health has emerged as a very popular major and a huge interest for young people around the country.
And you know, yet there was well, I'm really interested in public health, but there are no jobs because public health had been so under invested in.
I think we're seeing right now the the consequences of not investing in public health are slow responses and not having the innovation that we need or the modernization that we need.
And now we have an opportunity to really rebuild even if it's just short term, getting more staff connected with their local or state public health and helping solve this pandemic, what a meaningful thing to have early in your career, to get to be part of ending an epidemic.
I thought that'll never happen here. It's happening here.
They were contact tracers, they were helping with our vaccine trial. I think young people today have a chance to help stop this epidemic and help life get back to normal in their communities.
You know, you touch on so many things in your comments. It's hard to know which one to go after.
But you know, you mentioned the international aspect of this and I'm curious to get your thoughts in terms of what role the CDC plays in the who and all these and Gavi and these other groups in terms of making sure that we have vaccination available worldwide and, and not just for the US population because obviously uh protecting people everywhere, protects everyone everywhere.
Yeah, when you have a pandemic. It means the human population has not been exposed to this thing and it's totally new and everyone's at risk and I am really concerned about what this virus is gonna do in resource poor settings where people live in very crowded conditions and, and we're social distancing.
It's just, you know, it's pretty much impossible. You know, you can restrict the buses and you can, you know, but just to eat, you really are in very crowded circumstances and your home may be a home with many families really packed in together.
So it's, it's really scary to think of uh the challenges there. CDC is working in 60 countries with people on the ground and many of our people assigned for something else are helping with COVID.
But um we really need uh each country to be able to find stuff and prevent epidemics. We need the global community to come together to help.
We need the research community, the R and D that makes vaccines to work really fast. And whether it's G who's buying up uh or stockpiles of vaccines for Ebola or investing in the future vaccines against threats or it's something like CP or Barta here in the US, really investing in those new technologies to get us vaccines.
It's not just for Americans that those vaccines are gonna be important. We're gonna need the whole world to protect it.
You know, there have been some creative solutions that we've seen along the way, you know, recycling N95 masks and I just came out with a paper about that as well.
Stanford has a protocol um batch testing. So you, you know, do multiple swabs for one RT PCR test.
What are some creative solutions that you guys have have come across that you, you feel uh has reached kind of the the level of accuracy and, and reliability to where the CDC can really kind of put their force behind and say, hey, we should all be doing uh this creative thing.
Yeah, the um the batch testing has been uh absolutely something that we've all been looking at whether it's for PCR or for the antibody testing, you know, that issue of, of doing a batch of five or 10 and then honing in on the positive batches, you can save time, you can speed the throughput.
So that's for sure. Being looked at, you know, our labs also been looking, you know, so many supplies have been in short supply.
They've been looking at Alterna, you know, there's not that transport media can saline work. Can you do it instead of the extraction kits?
Can you boil? You know, they're, they're trying a lot of these home brew things to figure out what's, what, what could bridge that gap while they're in, in other parts of government.
They're really incentivizing industry to, to, you know, get their, to get their um products out there early with the eu A so that, so that they're of use.
Um It's such a complex supply chain right now where to do a lab test, you know that you need a swab, you might need PPE.
If you can't just do a nasal swab and PPE is in short supply, you need the transport media or you need FDA to say it's ok to just mail a swab in.
Um, you need the equipment and then you need the supplies for the equipment and you need the trained people to run the equipment and, or you can, you know, have a, a point of care test that may be very simple to use.
There's a lot of things there and even just, um, you know, we talk about vaccination, you need the needles, the syringes as well as whatever that magic potion is that's gonna go in them.
So, um we're faced right now. With the US, not in control of our supply chain.
Most of this stuff is not made here. We're very interdependent.
No state can supply itself with everything they need. No, in our nation can't supply itself with our homegrown or home manufacturer products.
So innovation is crucial. And, um, you know, II think, you know, I love the cloth face covering because you can make it yourself with socks or t-shirt or a bandanna, You don't need um you know, to order it online.
Um But I think, I think innovation is gonna be very important in not just the diagnostic testing or the, the masks and, and PPE but in our strategies to stop the epidemic, I II feel like um the way people are handling the mental health aspects of this, the um the heart hardships, you know, the being, being at home or not having to go to work because your job is one of those ones that has to, you have to go to work, finding ways to help each other.
I think that's a really crucial area for innovation where we find ways to overcome the physical distance and stay socially connected, where people who are really suffering from the economic impacts or the physical impacts of, of uh uh of their, their circumstances that we find ways to bridge those gaps that, that work, that's keep them safe and that keep them protected.
You know, the thing that keeps me up at night. These days, I have, I have a young son and in my community, things seem to be quite flat as is the case in many communities.
And the thing that I worry about is that, of course, going back to the earlier point is that we'll de isolate too early and see a resurgence.
You know, I'm just curious to get your thoughts in terms of what keeps you up at night. What, what are you most worried about these days as we're at this kind of juncture in the pandemic?
Well, um, let me see, t two things. 11 thing about, um, I II think it bears saying because some of us have been saying, well, this is like the nightmare virus.
Could, they have made a worse virus than this in, in terms of thinking of something that would be spread so easily before, um, you know, transmitted before you have symptoms and, you know, can be so severe and so forth.
But one, there's one good thing about this virus so far that it doesn't seem to affect Children, um, adversely that it's very rare for young people under 18 to be hospitalized and, and, and just a handful of fatalities so far.
So, you know, that's the only silver lining that we have right now. But, um, but I think that's really, um, there is one silver lining.
So perhaps a nightmare is that it'll mutate and suddenly become much worse for Children, but usually my thing that keeps me up at night is an influenza pandemic.
And we're basically having the equivalent right now with a new viral strain that spread so easily through respiratory means that is just very difficult to control.
Um You know, the CDC is working 24 7 to do all we can. And I know that um the American public, the the countries around the world, you know, their solidarity is we're all battling this really tough virus.
You know, we have a lot of audience uh members who are gonna be on the front lines or future clinicians, uh nurses, doctors, et cetera.
And I'm just curious what advice you'd have for them uh given, given uh where we're at right now. Yeah, I mean, don't be dissuaded from that career in health or public health.
It's, it's just such a meaningful thing to get to do to, to be able to help solve the problem when there's a crisis. I know that um I, I'm just grateful to, to have work that is meaningful that um it may be hard, it may be really hard, but that's meaningful and that I know contributes.
Um So, you know, I did my clinical training uh back in the early eighties, I was in med school in the early eighties and, and did my medical re residency in New York City in the mid eighties when the AIDS epidemic was um just emerging.
And, you know, I look at the numbers. Now, you know, uh 20% of the patients in the hospital or 30% of the patients in the hospital have COVID-19.
That was kind of what we had with AIDS when I, when I was an intern in New York City and um you, we'll get through it and you're gonna find meaning and you're gonna help now, hopefully on those front lines and then you're gonna have that experience for the rest of your life to really be able to contribute.
It's so meaningful to me to have started my career in the middle of a pandemic essentially. And see that we can, um, we can treat people who are HIV infected and they can live long and healthy lives.
We can prevent the spread of HIV from one person to another person with effective preexposure prophylaxis with, you know, male circumcision and so forth that we can end that epidemic.
You know, I think, I think for you, um, take heart, keep up with those plans have an open mind because maybe you wanna do public health and not clinical.
But, um, but it's a wonderful profession. That's fantastic.
Listen, Doctor Sh Sh I know you're extremely busy. So we, you know, tremendously appreciate your time.
Is there anything else that we should talk about that we haven't talked about yet? Cdc.gov, check that out.
It's got the best information updated regularly. We're getting our interactive web stuff going pretty soon.
We're gonna have a model dash dashboard that's gonna post information about a variety of models that we're collaborating with to try to uh see what's going on, not just one at a time but all the different models.
So um keep an eye on that site will do again, cdc.gov. Thank you so much, Doctor Trick for your time.
I appreciate it. Great.
A pleasure talking with you. Thank you.
I'm doctor. Thanks for checking out today's show.
Remember to do your part to flatten the curve and raise the line. We're all in this together.
Be well.
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