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Peter Attia MD#106-Amesh Adalja, MD: COVID-19 vs. past pandemics, preparing for the future, & reasons for optimism
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CHAPTERS
- 0:11 – 4:04
Introduction and Dr. Adalja's Pandemic Preparedness Background
Peter Attia introduces the episode and why he wanted Amesh Adalja's historical perspective on pandemics. Adalja describes his career focus on pandemic preparedness, prediction, and emerging infectious disease.
- •Adalja is a senior scholar at the Johns Hopkins Center for Health Security
- •His career has centered on pandemic prediction, H1N1, Ebola and bioterrorism agents
- •He had this outbreak on his radar before it made headlines
- •Attia expects another pandemic is inevitable and wants to discuss what could be done better
- 4:04 – 5:46
First Impressions in December: Human-to-Human Spread
Adalja recalls taking China's early reports at face value but becoming skeptical of the animal-market explanation. The Lancet paper showing a case with no market contact convinced him the virus was a transmissible human respiratory pathogen.
- •China produced the virus sequence quickly, enabling diagnostics and vaccine work
- •Forty-one patients infected from one market seemed implausible to him
- •A first case with onset December 1 and no market contact signaled human-to-human spread
- •The virus had a head start, spreading since mid-November before anyone knew
- 5:46 – 6:49
Was the Virus in the US Before 2020?
Attia asks whether the virus was in the US before December 31. Adalja says phylogenetics suggest widespread presence before about January is unlikely, but sporadic mild cases hidden in flu and cold season are possible and worth checking in stored samples.
- •HKU1 was found everywhere as soon as it was discovered, unlike this virus
- •Genetics from New York and Washington don't show earlier widespread circulation
- •Banked samples should be examined for sporadic early cases
- •He thinks a large number of early cases would have been noticed
- 6:49 – 8:11
Why Containment Failed in the US
Adalja explains he knew the virus would reach the US but underestimated how hard containment would be. Limited testing of mild cases allowed about two months of unabated spread.
- •He expected it to reach the US as soon as human-to-human spread was clear, as with H1N1 in 2009
- •Testing, case finding and contact tracing were worse than expected
- •Mild cases, arguably more contagious, weren't being tested
- •US resilience was overestimated
- 8:11 – 12:03
Lessons from Past Flu Pandemics and the Avian Flu Threat
Comparing this pandemic to 1957, 1968 and 2009 flu pandemics, Adalja notes similarities in respiratory spread and symptoms. He stresses that COVID-19 is additive to seasonal flu and that influenza, such as avian flu with a roughly 65% fatality ratio, remains the biggest pandemic threat.
- •1957 and 1968 flu pandemics each killed about 100,000 Americans in the US
- •People factor flu into daily risk, unlike this virus, which is on top of seasonal flu
- •Avian influenza like H7N9 could be far deadlier if it transmitted efficiently
- •He calls this a trial run, yet is worried about pandemic resiliency given how poorly a roughly 1% fatality pandemic was handled
- 12:03 – 15:22
Waves, Seasonality, and a Fifth Seasonal Coronavirus
Adalja describes pandemics as many staggered local outbreaks and expects ebbing and flowing as social distancing changes. He thinks this virus will become the fifth seasonal coronavirus, unlike SARS and MERS, which transmit poorly between humans.
- •Outbreaks are staggered by introduction time, density, hospital capacity and distancing
- •Places like Pittsburgh can learn from New York and Seattle
- •Four existing coronaviruses cause about 25% of colds
- •SARS and MERS are mostly zoonotic and didn't sustain human transmission
- 15:22 – 16:27
Prospects for a Coronavirus Vaccine
Adalja explains that current vaccines target this virus's specific protein but may cross-react with related beta coronaviruses. Coronaviruses are more stable than influenza, so a pan-coronavirus vaccine might be feasible.
- •Vaccine development targets a specific immunogenic protein
- •Cross-reactivity with other beta coronaviruses is possible
- •Coronaviruses are more stable than influenza, which has resisted a universal vaccine
- •A broad vaccine could take MERS and SARS off the table
- 16:27 – 18:20
Estimating the True Case Fatality Rate
Using H1N1's fall in fatality rate as a backdrop, Adalja discusses how severity bias and uneven testing make the CFR hard to pin down. He estimates a range of roughly 0.3 to 0.66% overall, with large differences by age.
- •Severity bias comes from heterogeneous testing
- •Imperial College modeling put CFR at 0.66%, and Germany's data were around 0.3%
- •His estimate is about 0.3 to 0.66%, possibly drifting
- •Risk ranges from about 15% above age eighty to about zero for an eight-year-old
- 18:20 – 22:27
Critiquing Early Epidemic Models
Asked about early doomsday projections, Adalja says models rest on assumptions and he thinks hospitalization rates were set too high. He argues models are tools to be revised against real data, not ironclad predictions.
- •Diagnosed cases are likely understated by a factor of at least 10
- •The 15-20% hospitalization figure used the wrong denominator; he thinks about 5% is more realistic
- •Westchester County data showed under 5% hospitalization
- •Real hospital data should supplant models that don't match reality
- 22:27 – 27:32
Federal vs. Local Roles and the Testing Failures
Adalja explains that US public health power sits mainly with states and localities, with the federal government as coordinator, and that local health departments are underresourced. He says federal leadership was missing, and CDC testing criteria and bureaucratic hurdles hampered testing.
- •Local health departments do case finding, isolation and communication but are often underresourced
- •He favors a locally managed, federally coordinated response
- •CDC guidance limited testing to those with China travel and lower respiratory symptoms
- •New York's introduction came from Europe and slipped through the criteria
- •Emergency authorization rules kept labs from making tests freely
- 27:32 – 30:23
Will Pandemic Preparedness Be Remembered?
Attia asks whether this response will make emergency readiness a lasting priority. Adalja hopes the personal and economic cost will push the public to demand preparedness, breaking a cycle of reactive funding and neglect.
- •This pandemic touched people personally in a way Ebola, Zika and H1N1 did not
- •H1N1's low death toll bred complacency
- •Past scares like anthrax, bird flu and Ebola led to funding then neglect
- •Preparedness should be a campaign platform issue
- 30:23 – 34:11
Reopening Strategy and the Risk of Mass Gatherings
Adalja argues that reopening should be tailored locally, easing restrictions where hospitals aren't overwhelmed, since unmodeled health and economic costs are growing. He explains why mass gatherings are especially risky until a vaccine exists.
- •Not every place is New York City; localities can relax distancing and elective surgery limits
- •Decisions depend on transmission, antibody status, hospital capacity and testing
- •Mass gatherings draw people from wide areas and involve shouting and close contact
- •Choir practice and Hajj pilgrimages illustrate the risk
- 34:11 – 39:19
HKU1, Sweden's Experiment, and Masks
Adalja uses HKU1 to illustrate how poor diagnostic curiosity lets respiratory viruses hide. He then gives his concerns about Sweden's herd immunity approach and his skepticism about public mask use.
- •HKU1 was found widely after SARS, having flown under the radar
- •He calls undiagnosed respiratory illness 'biological dark matter'
- •Sweden's low ICU capacity and the difficulty of cocooning the elderly worry him
- •He supports masks for sick people but doubts their public benefit, citing possible downsides
- 39:19 – 44:23
Reasons for Optimism and Closing
Adalja says he is most optimistic because of plateauing in New York, Seattle and California and ventilators and field hospitals being returned or closed. Attia closes with concern that society will forget and hopes for a future conversation.
- •Plateaus in New York, Seattle and California
- •California sent ventilators to other states and Washington returned ventilators to the stockpile
- •Good news stories are underreported
- •Attia fears human amnesia about pandemics
- •Membership program outro follows
