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  • 00:14

    MICHAEL A. STOTO: My name is Michael Stoto.I'm a Professor at Georgetown University.And I'll be speaking today about a century of pandemics,lessons learned and sometimes applied.It was only two years ago when the world recognizedthe centennial of the 1918 great influenza,which caused the deaths of as many as a million peoplearound the world.Now, a year into the global COVID-19 pandemic,

  • 00:37

    MICHAEL A. STOTO [continued]: we see many parallels.In the darkest moments of the pandemic,it sometimes seems that little has been learned.However, on reflection, we can find many exampleswhere the international community, countries in Europeand Asia, as well as regions in the United States,did, in fact, learn and apply important lessonsfrom a century of health crises.

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    MICHAEL A. STOTO [continued]: In this presentation, I will reviewsome of the lessons learned from the GreatInfluenza and the other pandemics in the last centuryto see what public health systems around the worldhave learned and applied in the COVID-19 pandemic.Specifically, I will address the outbreak identificationand information sharing, risk characterizationand surveillance, non-pharmaceutical

  • 01:20

    MICHAEL A. STOTO [continued]: interventions-- things like social distancing and contacttracing and school closings--medical advances, particularly vaccines,community collaboration and solidarity,and trust and leadership.In 1918, the world wasn't aware of a serious influenzavirus that was circulating for months in Europe.In fact, we call it the Spanish flu

  • 01:42

    MICHAEL A. STOTO [continued]: now because only the newspapers in Spain,which was neutral during the war, weren't censored.And they were the ones to publish information about it.In 2003, SARS circulated unnoticed in Guangdong Provincebefore breaking out to the rest of the world.In fact, the delays in learning about SARS

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    MICHAEL A. STOTO [continued]: led to changes in the International HealthRegulations.Among them, countries now have requirementsthat they have capacities to conduct surveillance, and alsoexpectations that they share this informationwith other countries and with the World Health Organization.In 2009, another influenza pandemic,called H1N1, or sometimes swine flu,

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    MICHAEL A. STOTO [continued]: involved virus circulating for months in Mexico and the UnitedStates.It was only until the US identified a novel influenzasub-type and information was sharedabout that because of the changes in the InternationalHealth Regulations.What specifically made a difference?

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    MICHAEL A. STOTO [continued]: Capacity in Mexico to conduct surveillance, capacityin the US to analyze laboratory specimens,and the expectations that this information would be shared.But even with these improvements,it was weeks before the global health communityunderstood the nature of the threatand was able to respond to it.

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    MICHAEL A. STOTO [continued]: This timeline shows the difference between SARS in 2003and COVID-19 in 2010.You can see that the amount of timeit took to detect and to characterize and reporton COVID-19 is much shorter than it was for SARS.

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    MICHAEL A. STOTO [continued]: But despite this improvement in learning about COVID-19,the conventional wisdom is that China hid informationabout this outbreak.When you look closely at it, however,you see that within weeks of the first cases emerging,the local officials in the city of Wuhan

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    MICHAEL A. STOTO [continued]: identified and closed the market thatseems to have been the main source of exposures.And they alerted the public.They also notified the China CDC, the World HealthOrganization, and the US CDC.And within a week or two later, theyshared genetic sequence data on global platforms.This information sharing enabled German scientists

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    MICHAEL A. STOTO [continued]: to develop and share a diagnostic testfor contact tracing to begin in Germany and SouthKorea and other countries, for some countriesto implement incoming border screening and other travelrestrictions, and for the work to start on the vaccine that,at the time that this presentation is being recorded,

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    MICHAEL A. STOTO [continued]: has just now been developed.So what happened?If you look at the situation in China,Chinese researchers published an articlein the New England Journal of Medicine at the end of Januaryshowing the number of cases by dayand the different activities that took place.

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    MICHAEL A. STOTO [continued]: One of the key things here is that the dark orange barswere-- represent cases that were associated with the seafoodmarket.And especially at the beginning, most of the casesseemed to be associated with the seafood market.So it was natural for the Chinese authoritiesthink that they had solved the problem.Another study that was done even earlier in January

  • 05:14

    MICHAEL A. STOTO [continued]: and published on January 23 investigated the early cases.And they tried to consider the evidence that supported--either supported or rejected the ideathat R0, the reproductive number, was greater than 1.If it was greater than 1, that represented community spreadand that the pandemic was growing.

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    MICHAEL A. STOTO [continued]: If R0 was less than 1, that wouldhave meant that the outbreak was really localized, particularlyto the seafood market where it was first detected.They looked at seven different epidemiological facts.Three of them didn't distinguish between the two.Three of them actually suggested that R0 was less than 1,

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    MICHAEL A. STOTO [continued]: that the outbreak was not expanding.One of them suggested that it was.But the problem was that the three that did notsupport the idea of community spreadassumed that they were really following up and identifyingall of the cases.

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    MICHAEL A. STOTO [continued]: And that is what was missing.So, in fact, China's big mistake was notconducting enough active surveillanceto identify additional cases, particularlyin the community that was not associated with the seafoodmarket.Part of that is because they didn't follow upon rumors that were circulating on social media.But it's a common mistake, it turns out.In fact, the US made the same mistake

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    MICHAEL A. STOTO [continued]: in January and February, not looking for casesbecause we did not have a test available in this country.Experience in Asia and Europe has highlighted the importanceof better data to monitor the epidemiological situation.Still, more progress is needed.This is a topic I discuss furtherin my other video in this series on COVID-19 metrics.

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    MICHAEL A. STOTO [continued]: The next topic I'd like to addressis risk characterization.With COVID-19, everyone was frustratednot to know who was at risk, the case fatalityrate, the routes of transmission,and many other factors.However, if you look back at the century of experiencewe have with pandemics, what we seeis that getting this information is difficult.And it takes time.

  • 07:20

    MICHAEL A. STOTO [continued]: In fact, much of what we know nowabout the 1918 great influenza was only learned many yearsafter the outbreak itself.In comparison, advances in biomedical sciencehas enabled a much more rapid development of the science basefor COVID-19.We know, for example, that surfaces are nota major source of infection and that masks

  • 07:42

    MICHAEL A. STOTO [continued]: do prevent infection.This was aided by an unprecedented worldwidescientific collaboration and rapid risk assessmentspublished by things like the European Centres for DiseaseControl and Prevention and other bodies.Let me just give you a couple of examplesabout how we know about transmissionthat can be prevented by masks.Let's look at one example.

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    MICHAEL A. STOTO [continued]: This comes from a meta-analysis published by Chu and colleaguesin June, 2020.Each of the lines in this graphiccorresponds to one study that was done.And these were done primarily in health care settings.The figure shows the estimate and the 95% confidence interval

  • 08:25

    MICHAEL A. STOTO [continued]: for the effectiveness of masks.The horizontal line on the right correspondsto no effectiveness.And to the extent that the confidence intervalsare to the left--that suggests that masks really are effective.You can see that the majority of these studies

  • 08:45

    MICHAEL A. STOTO [continued]: actually demonstrate effectiveness and, in fact,that the effectiveness is quite strong.Another way of looking at this looks at a numberof infections over time.These are data from the Mass General Brigham Hospitaland Health Care System in Boston, Massachusettsduring the outbreak in March and April, 2020.What this shows is the number of COVID cases in the health care

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    MICHAEL A. STOTO [continued]: system in the pink period, before maskwas started, and then over time, as mask restrictions becamemore strict.And you could see that the number of infectionsfirst grew and then leveled off and then fell as the maskingrestrictions came into place.And finally, one set of data looking at mask restrictions

  • 09:34

    MICHAEL A. STOTO [continued]: in the broader community-- what this shows isthe impact of state mandates for community face maskuse in the United States.And the figures show the percentage changein the daily COVID cases.And that corresponds to a savings of 200,000

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    MICHAEL A. STOTO [continued]: COVID cases by the end of May in 2020.Since that time, masks will have prevented many more cases.Now, masks are actually one exampleof what we call Non-PharmaceuticalInterventions, NPIs.In 1918, without a vaccine or effective medical treatments,the world relied on NPIs to mitigate

  • 10:20

    MICHAEL A. STOTO [continued]: the spread of influenza.This includes social or, sometimes more appropriatelycalled, physical distancing, things like restrictionson public transportation and cancellation of group eventsto limit social interaction--also includes quarantine of infected individualsand contact tracing and related activitiesas well as masks and school closings.

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    MICHAEL A. STOTO [continued]: An analysis of past epidemics, as well asmathematical modeling studies, have demonstratedthat NPIs, especially if applied in multiple layers,can indeed mitigate the spread of the virusand reduce morbidity and mortality associated with it.And since, COVID-19 studies in the US and Europe and Asiahave confirmed these findings.

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    MICHAEL A. STOTO [continued]: Let me give you a couple of examples.This is a study done in Wuhan, China,in the very early days of the outbreak.And what the top figure shows is the number of cases of COVIDthat were ascertained over time between January 1 and March 7.

  • 11:24

    MICHAEL A. STOTO [continued]: And then in the bottom graphic, itshows what the R, the reproductive number,is in each of a couple of different time periods.So on January 23, the city locked downand suspended traffic.And home quarantine was started.And so up until that point, the number of cases

  • 11:45

    MICHAEL A. STOTO [continued]: was growing exponentially.And it started to level off.On February 3, centralized quarantine and treatmentwas started.And medical resources were improved.We start to see some benefits.But really, it wasn't until February 17that centralized quarantine and universal symptom survey

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    MICHAEL A. STOTO [continued]: was implemented.And we see, really, R dropping off to below 1.So we can see each of these different stepsthat the authorities in Wuhan tookmade a contribution to stopping the spread of COVIDin that city.Another modeling study looked at interventions in--

  • 12:29

    MICHAEL A. STOTO [continued]: non-pharmaceutical interventions in Europe.This graphic shows the results from Germany and Italy,which both took very different approaches to addressingCOVID in February and March.You can see on the left a number of infections projected in blue

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    MICHAEL A. STOTO [continued]: and the number of actual ones in brown,and same thing for the number of deaths for both Germanyand Italy.And on the right, what it shows is R with a 95% confidenceinterval and how that has changed over time as eachof these non-pharmaceutical interventionshas come into play.It really took the combination of them to get it down to 1

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    MICHAEL A. STOTO [continued]: so that the outbreak was no longer growing.When you think about non-pharmaceuticalinterventions, it's important to recognizethat they carry economic burdens and the potentialfor social disruption.This is especially true for vulnerable populations,which are affected more by the epidemic in the first place.They're also hard to maintain for long periods, a phenomenon

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    MICHAEL A. STOTO [continued]: we call pandemic fatigue.And they are often not universally acceptedby the population.What this means, as we've seen going back to 1918and still see with COVID-19 in 2020,is that NPIs must be used judiciously.We need to think carefully about when they start

  • 13:56

    MICHAEL A. STOTO [continued]: and when they stop and target thatto the spread of the virus in individual communities.We need to find the right combination of interventionsthat, in context, balance efficacy and controllingspread of the virus in the populationwith the economic and social disruption that they cause,and particularly to make sure that we

  • 14:17

    MICHAEL A. STOTO [continued]: protect the most vulnerable.Just to bring home the point about the most vulnerable,what this shows is data from a survey done by the US CensusBureau about the Black and Latino households--are more likely to experience food insufficiencyduring the pandemic than whites or Asians.

  • 14:39

    MICHAEL A. STOTO [continued]: And this is something we have to be very mindful ofand think carefully of as we implementnon-pharmaceutical interventions.Now that we're almost a year into COVID-19,a number of studies are beginningto emerge where researchers are looking carefullyat what we have learned from this thatcan be used as we continue to deal

  • 14:60

    MICHAEL A. STOTO [continued]: with it and for future outbreaks as well.One study published in The Lanceta few months ago looked at lessons learned in countriesin Asia-Pacific and Europe.They talked about the need for a clear and transparent plan thatexplicitly states levels or phases of easing restrictions,

  • 15:21

    MICHAEL A. STOTO [continued]: criteria for moving from one level to the next,and the containment measures that will be usedat each one of these phases.They reminded us that countries should not ease restrictionsuntil they have robust systems in place to closely monitorthe infection situation, that an effective systemto find, test, trace, and isolate and support

  • 15:44

    MICHAEL A. STOTO [continued]: those who are found to be positive needs to be in place.And this needs to be sustained by investment in public healthcapacity and health system capacity.There needs to be an adequate health system capacityto cope with the possible surges in infectionsafter lockdowns are lifted--and that communities need to be fully engagedand empowered to protect themselves

  • 16:06

    MICHAEL A. STOTO [continued]: from the virus and the effect of the crisis, especially the mostvulnerable populations.That last point, I think, is especially important.But it's hard to really get informationfrom quantitative studies about that.But some very good qualitative studieshave been done as well as a numberof good reports in the media that have looked carefully

  • 16:29

    MICHAEL A. STOTO [continued]: at this.This is a report that looked carefullyat what has happened in some of the US statesin the spring outbreak in the United States--the photo of Governor Mario Cuomoof New York, which is one of the US statesthat was hit the most hard.The key findings for this is the needfor consistent messaging about how and why

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    MICHAEL A. STOTO [continued]: a policy or a set of policies is being implementedhelps people to appreciate why these changes are occurringand how they can support them.Secondly, the need to craft a message to the local context--the narrative around these policiesmust appeal to and resonate with a varietyof people in that environment.And then finally, to align talk with action--

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    MICHAEL A. STOTO [continued]: the narratives that accompany the policy implementationmust accurately explain the policy decision.Likewise, the policy actions must support the narrative.Perhaps the biggest change between 1918and the current day is all of the medical advancesthat have taken place.It goes without saying how much medicine has

  • 17:33

    MICHAEL A. STOTO [continued]: advanced in the last century.In fact, scientists didn't even really understandthe concept of viruses in 1918.It's also remarkable how much has been learned since COVIDhas emerged and how to apply that knowledgeabout available therapeutics and services to treat patients.And we already see dramatic improvements

  • 17:53

    MICHAEL A. STOTO [continued]: in outcomes for COVID patients.But let me focus specifically on vaccines.The vaccine was developed with astonishing speed.Something that typically takes yearshas been developed in less than a year for COVID.This was based on the fact that the Chinese sequenced the virus

  • 18:15

    MICHAEL A. STOTO [continued]: and shared that on international platforms.And that allowed vaccine researchersto start in January to develop a vaccine.It also reflects the fact that over the last coupleof decades, really, because of our concern for the possibilityof pandemics, researchers have been developingwhat are called vaccine platforms so

  • 18:36

    MICHAEL A. STOTO [continued]: that once a new virus emerges, itcan be made into a vaccine as quickly as possible.And the technology that's being used for the first threevaccines that have been shown to be effectiveis precisely one of those technologies.And then finally, we have a global vaccine infrastructure,

  • 18:60

    MICHAEL A. STOTO [continued]: companies, non-governmental organizations,that are working together to bringthe vaccine to development and laterto make sure that it's shared equitably around the world.Nevertheless, there are going to bevery severe challenges in how it is delivered,questions about who has priority for the vaccines that become

  • 19:23

    MICHAEL A. STOTO [continued]: available, logistical questions about delivering it,to getting it around, and concernsaround the world of people concernedabout the risk of vaccine, a phenomenon we call vaccinehesitancy.But we actually learned quite a bit about these factors in H1N1in 2009 and other experience over the years

  • 19:43

    MICHAEL A. STOTO [continued]: that have shown us how we can do this betterand that this-- these learnings have been factoredinto the global, the national, the state, and the local plansfor a pandemic vaccine that have been developed.The last topic I want to speak aboutis community collaboration and solidarity.Masks, social distancing, testing

  • 20:04

    MICHAEL A. STOTO [continued]: are really about protecting others in the community ratherthan the users.We wear masks to protect ourselves-- othersfrom being infected.We even get tested so we know to be isolatedso we don't infect others.And indeed, even when the vaccine becomes available,we will still need to take the vaccine so we don't

  • 20:24

    MICHAEL A. STOTO [continued]: spread the virus to others.What this means is that communities must come togetherin solidarity to effectively implementnon-pharmaceutical interventions and, later, to deploy vaccines.We've seen examples of this in San Francisco in the UnitedStates, all throughout the Northeast United States.

  • 20:45

    MICHAEL A. STOTO [continued]: Vermont in-- the state of Vermont in the USand the country of Australia have been well-studiedand have shown how this has worked welland made a difference.We see the same thing at the global level, where countriesshare one another and are sharing informationwith one another.What this requires is trust.When we think about trusting one another,

  • 21:07

    MICHAEL A. STOTO [continued]: it's a subject we call social capital.And at the national and international level,we think about it in terms of leadership.And some of the examples that have emerged--in Germany, Angela Merkel and Jacinda Ardern in New Zealandare really good examples of that.Sadly, we see in the United States

  • 21:27

    MICHAEL A. STOTO [continued]: the example of President Trump using masks and other topicsas a wedge issue to drive us apart.And probably, this has created a bigger problemthan anything else that we've seen in this country.So in conclusion, as the case counts and the deaths mount,it's easy to despair about the stateof the national and the global response

  • 21:47

    MICHAEL A. STOTO [continued]: to the COVID-19 pandemic.But when you think about it, the worldhas actually learned quite a bit from research on past events,and during the COVID-19 pandemic itself, about biologyand epidemiology and the diagnosis and treatmentand about the development and implementation of a vaccine.We also know about the effectiveness, as well asthe social and economic cost, of non-pharmaceutical

  • 22:11

    MICHAEL A. STOTO [continued]: interventions and the inequities involved with NPIs, as wellas the pandemic itself, and the importance of communitycollaboration and trust.And we've applied these lessons effectivelyin many countries and many states in the United States.Going forward, what we need is solidarity

  • 22:32

    MICHAEL A. STOTO [continued]: and strong leadership at the global, national, and locallevel to make sure that we effectively applythe lessons we've learned.Thank you so much for allowing meto walk through this history of a century of pandemics,what we've learned, and what we can learn.[MID TEMPO MUSIC]


Michael Stoto, Professor of Health Systems Administration & Population Health at Georgetown University, discusses lessons learned during a century of pandemics including: outbreak identification and information sharing; risk characterization and surveillance; non-pharmaceutical interventions and medical advances; and community collaboration, solidarity, trust, and leadership.

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A Century of Pandemics: Lessons Learned and (Sometimes) Applied

Michael Stoto, Professor of Health Systems Administration & Population Health at Georgetown University, discusses lessons learned during a century of pandemics including: outbreak identification and information sharing; risk characterization and surveillance; non-pharmaceutical interventions and medical advances; and community collaboration, solidarity, trust, and leadership.

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