Everywhere you turn, people are talking about coronavirus. They want to know what is happening and what to do about it, but where do you turn for credible information? This episode, Michelle is joined by Dr. Anna Likos:, global disease fighter and Florida’s former state epidemiologist, to discuss what useful information is out there and the steps Americans should take to keep themselves safe.

Links

Here’s is the 101 on COVID-19 from the CDC.

The World Health Organization busted some COVID-19 myths.

Here’s what VRBPAC stands for.

Some more background on R₀.

Most importantly, learn how to wash your hands correctly.

Transcript

Michelle Ubben
Hello, and thank you for joining Ubben Talkin’. I’m your host, Michelle Ubben. When you think about combating the spread of a disease like the novel coronavirus, the first things that come to mind are probably public policies and medical interventions, but communication is also a powerful and necessary tool in a public health outbreak. Joining me today on Ubben Talkin’ is a global disease fighter and Florida’s former State Epidemiologist, Dr. Anna Likos. We’ll talk with Dr. Likos about the challenges of keeping up with the public’s demand for credible and relevant information, about new tactics that public health professionals are using to reach the public and how they’re combating myths and misinformation. Dr. Likos, welcome.

Dr. Anna Likos
Thank you so much, Michelle. It’s great to be here.

Michelle Ubben
You’ve had an amazing career, battling Zika virus in the United States, polio in Africa, AIDS and Haiti, to name a few. What drew you to this profession?

Dr. Anna Likos
Oh, my goodness. I started out late, if I might explain that a bit. I was 41 years old when I decided to go to medical school. And so I went to the University of Oklahoma, I got my medical degree, I did pretty well and somehow managed to get into Yale for my internal medicine residency.

Michelle Ubben
Congratulations.

Dr. Anna Likos
And I laugh and say people are still slapping their head wondering who let the old broad from Oklahoma into Yale, but they let me stay and I did my three years of internal medicine residency and then I practiced for a while as a hospitalist. While practicing in Springfield, Missouri, I admitted a 65-year-old woman who had fallen off the deck of her home, had a deep gash in her arm and had been seen at her local hospital where it was sewn up, she was given some antibiotics and she was sent home. 10 days later she presented to my hospital, no, she presented to a regional hospital complaining of difficulty swallowing and that was interpreted as a sore throat.

Dr. Anna Likos
And so she was given some more antibiotics and sent home again. And three days later she presented to my hospital. The emergency room doctor called me, I was concerned about her, told me this whole story and I said, “I think we might need to intubate her and I’ll be right down.” And he said, “Intubate her? Oxygenation is good” and so on. And he goes, “Why are you thinking of intubating her?” I said, “I think she might have tetanus.” And so as I got down and I looked at her, I called the surgeon to come and open up the gash on her arm and take some deep cultures and yes, indeed, she did have tetanus.

Dr. Anna Likos
During the course of treating her, I came to discuss several times with the CDC treatment of a person with tetanus. And I got to talking to this woman there who was a specialist in the field and we talked several times on the phone and we got to know each other, somewhat just friends actually, although I’ve never met her in person. And so she learned that I spoke French, that I had been a Peace Corp Volunteer in my younger days and was interested in living and working outside of the United States, and so she talked me into quitting my job and becoming a STOP team member, which is Stop Transmission of Polio. That’s a volunteer position, I worked at it for three years and I went back to the country where I had been a Peace Corp Volunteer, which is the Democratic Republic of Congo.

Michelle Ubben
Wow.

Dr. Anna Likos
And so when I was there, that was my introduction to public health. And during those three months working in the Congo, I really came to see and understand how much greater of impact I could have on people’s health by doing the public health route rather than seeing patients one at a time as a clinician. And I have to say, I still have that drive and that impression of public health. I have missed seeing patients one on one. There’s a certain amount of, I don’t know, good feeling that you get when you’re really impacting a person’s life and you can see that.

Dr. Anna Likos
In public health, you don’t always get to see the people that you’re impacting, but it has a much broader and greater extent. And so with that, I came up with the motto I’ve used for my life since I’ve had the fortunate time to be both a clinician as well as a public health worker, in all honesty, I stole this from the Air Force, it says to cure diseases is glory. And It really is to help someone get over an illness is a really great feeling, but to prevent disease is victory. And I very much believe that.

Michelle Ubben
That’s beautiful. So I’d like to draw some parallels between my profession of communications and your profession of disease fighting. When an outbreak occurs, getting accurate information out to the public is critical. I mean, people want to know what’s happening, who’s affected, what the risk level is, what they can do to prevent the disease affecting them. But you can’t move faster than the speed of accuracy, you have to have good information to get out to the public. And sometimes that leaves an information gap that others fill with that information. Talk to me a little bit about getting information out when a disease outbreak occurs.

Dr. Anna Likos
Oh, everything you listed there was just so right. We have to get accurate information out quickly, really rapidly to help people protect themselves and their families and just to become aware of what’s going on. It is difficult when you don’t have all the answers, but I think as the many people from your profession who have advised me over the years, I do think it’s important that health professionals, the experts speak honestly. And if they don’t know something, they have to say, “We just don’t know. We’re working on it, we’re trying to get those answers, but in all honesty, that’s an area that we are not informed about as yet.” And that’s the hole that is left open that is filled by the research and the very vital role that research, which is a word that usually conjures up math, scientists and beakers overflowing with fumes and stuff, but research can just mean collecting data and analyzing that data and seeing how that can help us in combating any new infection or infectious disease that’s causing an outbreak.

Michelle Ubben
And I think one challenge that we’re seeing right now is that journalism is under attack, science is under attack, and there is a distrust of traditional authority figures, and that makes it harder when it’s so important that people are getting their information from a credible source that’s only sharing the information that’s validated as quickly as they can, sharing answers when they have them.

Dr. Anna Likos
Yeah, I agree. I wished for… I wish there was some kind of electronic device that could kind of like-
Michelle Ubben
Truth-O-Meter?

Dr. Anna Likos
… Yeah, Truth-O-Meter. Kind of like a lie detector for people but you can use it on the internet that like, “This is a bogus site, this is a good site. Believe this one. Don’t believe that one.” That would be wonderful. But I think with all of the context of our life, freedom of speech, we can’t hamper that. And that includes sometimes the fact that we have to live with bad information that’s out there. We try to fight that with data. I’m a big data freak and I like analyzing it, I like interpreting it, and with all of that background, I try to make decisions for myself and I try to inform those around me as best I can.

Michelle Ubben
Coronavirus has been dominating the headlines. And it’s really been fueling public fears, and research says that when people are driven by fear, they don’t necessarily make the best decisions. It’s interesting to look at the World Health Organization side and the CDC side and see much of the information they’re having to put out there is not just, “Here’s what we know and here’s what to do. But no, don’t believe that.” Just kind of combating some of those fear-based actions like the run on buying face masks. So talk to me a little bit about how public health officials can combat fear-based thinking when they’re confronting an outbreak.

Dr. Anna Likos
Wow. If I knew how to do it 100% then we’d have a different situation, I’m sure. But number one is I think giving what they do know out to the public as quickly as they know it.

Michelle Ubben
So people don’t think they’re hiding information?

Dr. Anna Likos
Exactly. I know you’re right in saying there is a fair amount of distress and I remember when I completed medical school, at that time there was a phrase, I even had a button that said, “Trust me, I’m a doctor.” That doesn’t happen so much anymore. But I do believe that certain people and personality types can generate trust in a population. And I think sometimes what agencies need to do is to really look at their staff and their knowledge experts, and sometimes a person who is most knowledgeable is not necessarily the one who comes across as being the most trustworthy to the public in general.

Michelle Ubben
Very good point.

Dr. Anna Likos
And so I think you need to select people that have that savoir faire, that says, “Trust me, I’m going to level with you and I’m going to level with you so much so that if I don’t know the answer to your question, I’m going to tell you that, but then I’m going to go find out the answer if it’s a knowable, and if it’s not, we’re going to try to do some research to find out what it is.” And I think having that trust is just so very crucial to combating any kind of outbreak from the very beginning onward. I remember when I was a clinician, I used to tell the story with people I was teaching in clinical medicine that, “If I was a… I’m an internist and I have a patient walk into my office who weighs 400 pounds. He believes the three major food groups are potato, chips and French fries and-

Michelle Ubben
Budweiser.

Dr. Anna Likos
… Yeah, and Budweiser. Yeah. And exercise is watching a football game and sits on the couch and… But he comes to see me because he has an ingrown toenail. I’m going to treat that ingrown toenail with just all the dedication I can muster in the world. It’s not his biggest problem, by far it’s not. But he’s not going to listen to me unless I take care of that toenail, unless I take care of his concerns first. And once that is done, then maybe we can develop that relationship that’s going to result in addressing his activity nutritional needs.

Michelle Ubben
And being influential.

Dr. Anna Likos
Exactly.

Michelle Ubben
Your point about putting the right messenger out there that can be trustworthy, the choice of a messenger and then the nuancing of the message is so critical in a public health emergency. We do media training and so we collect interview segments where we show somebody doing something right and someone doing something wrong and not to get political at all, but one of the segments that we love to use was back during the H1N1 outbreak and again public fear was high and Vice President Joe Biden was sent on the morning show circuit to just tamp things down and give people a sense that, “We’ve got this, it’s okay.” And so the interviewer asks him what he would advise members of his own family about air travel…

Joe Biden
I would tell members of my family, and I have, I wouldn’t go anywhere in confined places now. It’s not that it’s going to Mexico, you’re in a confined aircraft, when one person sneezes, it goes all the way through the aircraft. That’s me.

Michelle Ubben
Well, I’m sure the administration was just dying, this was the opposite of what they sent him out to do, but it just shows that the messenger has to be prepared and they’ve got to be able to be accurate. But at the same time tamp down fears.

Dr. Anna Likos
That’s correct. During H1N1, I was actually living in Africa in Ivory Coast. And so I was watching all of this go on in other places. And the thing with the airplanes, I mean I remember, oh, back when I first started looking, I was a medical student actually in looking at public health, and there had been a study about tuberculosis transmission on airplanes. Now tuberculosis is an airborne bacterium, it can be transmitted fairly easily. And yet what they found on airplanes, and people always talk about the recycled air and so on. Yes, it’s recycled, but on an airplane, if a person with tuberculosis gets on a plane, the people that are most at risk are those like three people in front and on the sides of him or her, it doesn’t spread. We also found that it really… people don’t get infected from a person on an airplane unless it’s like a transcontinental flight.

Michelle Ubben
Long time with them.

Dr. Anna Likos
Long time in the air. So you’ve got to have not just somebody who’s infectious there, but you have to have time and distance factored into the transmission of that.

Michelle Ubben
One of the things that I’ve heard about the run on face masks and everyone deciding whether they should wear a face mask when they get on an airplane, that was interesting to me is that face masks are less effective for the person who’s not sick to not catch it. More effective if you are sick and get on an airplane and you’re wearing a face mask to avoid transmitting to other people. So maybe the education point needs to be, if you’ve got any kind of an illness at all, stay home if you can, but if you can’t, wear a mask.

Dr. Anna Likos
Thank you so much for bringing that up. I have watched so many news clips in Asia and I did an outbreak response and Vietnam and everybody there was wearing these cloth made face masks and if it makes you feel more protected, fine, do it. But I think people really need to understand that when you wear one of those rectangular face masks, the elastic goes over your ears, like you see doctors wearing in surgery, a surgical medical mask. That type of mask protects the world from you, not you from the world, but the world from anything you have. That’s why doctors wear them in surgery is that you’ve got a body open, you still got to breathe and it’s catching anything you that doctor might have from dropping down into the body in front of them.

Dr. Anna Likos
If you want to protect yourself from the world, what you need is commonly referred to as a N95 respirator mask. And if you look at the… I saw some of the newsreels from the passengers from the Diamond Princess coming back and they had masks on and there was a little central hole. I looked at those and I thought, “That looks like the N95 respirator.” And that would be appropriate.

Dr. Anna Likos
You’d never want to put an N95 respirator though on someone who has respiratory symptoms. I’ve worn N95 respirators, they are tiring, there’s a work of breathing to get air to move through that mask and after several hours, it can get tiring. So someone who’s got respiratory compromise is going to have a hard time breathing through that mask. If they’re sick, if they have respiratory symptoms, what they should be wearing is a surgical type of mask that’s going to protect the world from them.

Michelle Ubben
Well, I think I may start carrying them and handing them out on airplanes when I hear people sneezing next to me.

Dr. Anna Likos
What a great idea. I think though the other point you brought up is one of my biggest bugaboos is if you’re feeling sick, if you have a fever, if you have a cough, if you have a runny nose, if it’s just a common cold, please stay
home. Just, you know…

Michelle Ubben
Do the world the favor.

Dr. Anna Likos
… There’s a lot of discussion about vaccines and some people believe in them, some people don’t, but believe me, staying home, separating yourself using what we call social distancing is another great way to protect other people in your community. Be that in your household or your neighbors or your school or your work site, please stay home.

[COMMERCIAL BREAK]

Michelle Ubben
One thing I find a little ironic is that the public has this hyper elevated concern about coronavirus, but they’re almost nonchalant about the flu. Why do you think that is?

Dr. Anna Likos
It’s new. I mean I’ve looked at the coronavirus and I was having an initial same kind of reaction, like why are we doing so much about coronavirus when we’ve got all this flu? And I think the numbers I last saw with flu is that we’ve had about 26 million, 25 million cases of influenza just this season and we’re not done yet, it’ll go on until at least March. And I believe 14,000 deaths due to flu this season. And when I really sat down and I thought about it, there are three reasons why I think we’re taking such measures against coronavirus. The first is we know absolutely nothing about this virus. It’s new, it’s novel, it’s kind of related to SARS, it’s kind of related to MERS which we’ve got some experience with, not so much in this country, but worldwide. But really we don’t know anything. Whereas with the flu, we know it’s seasonal, it’s going to go away in March, or happen in the southern hemisphere during their summer, our summer months, their winter months.

Dr. Anna Likos
We know what to expect with flu. We know how it’s going to behave in a population. The second thing about coronavirus is since it’s new, absolutely everybody is susceptible, nobody’s immune unless they happen to be somehow innately resistant to the virus and we don’t know that those people exist or not. So everybody is susceptible. So it can go through a population theoretically quite quickly and that seems to be what’s happening in China. One of the terms that I think listeners should become somewhat familiar with is in epidemiology we call it R0, and you see it written as a capital R with a little subscript zero. So R0. And R0 is a mathematical number that describes the average number of people who could become infected from a single infected person in a population that is not infected and not immune.

Dr. Anna Likos
Basically what we’ve got with coronavirus right now. Calculations for coronavirus are ranging… Right now I’ve seen 1.6 as a low to about 5.6 or 6.6 I believe it was. And so that means one person could theoretically infect as many as 6.6 people around them in a totally naive population. Influenza tends to run around to 2.5 to 3.5, if I remember correctly, it’s been a while. So R0 is influenced by how people behave in a population, how much they move around, the means of transmission and coronavirus appears to be by respiratory droplets, so about three feet, four feet out, you can be subject to being infected.

Dr. Anna Likos
All of that plays a role in why do we respond to coronavirus? It appears to be rather infectious. It’ll move quickly. Will it change genetically as it moves? Right now it doesn’t appear to be very lethal, it’s more lethal than flu in terms of the case fatality rate, it’s running, yesterday calculated to be about 2.5%, 2.6%. Flu is usually about less than 1% so about 0.5% I think. And so it’s not as lethal as SARS was, SARS was about 10% at the end of that epidemic. So it got a lethality that could become worse at a moment’s notice, we just don’t know. There’s so much we don’t know. So it’s worth taking an aggressive stance against this virus entering our country and the world.

Dr. Anna Likos
The third reason for responding is that we have no vaccine. With influenza we do have a vaccine, some years it’s good, some years it’s not as good, but with coronavirus, we don’t have a vaccine and it’ll be quite a while before we ever get one.

Michelle Ubben
Let’s follow up on that. We did a survey recently of Florida voters to see if they had gotten the flu vaccine and about half of the people had and half hadn’t. Of the half who did not get vaccinated, a third said they didn’t do it because there’s just not a great track record of the vaccine working, a quarter of them said, “I never get the flu so I don’t need to.” And a similar amount said that they forgot or procrastinated. Through communication, through public health messaging, how do you persuade people to get past those barriers and get the vaccine every year?

Dr. Anna Likos
Oh, I wish I had a great answer to that question. I worked for influenza for the CDC for several years and trying to get people to get the flu vaccine, it’s always a challenge. So current recommendations this year we have… This year we have vaccines that are for everybody. We’ve got trivalent, three kinds of flu strains in it. We’ve got quadrivalent with four kinds of flu strains in it. We’ve got killed vaccines, we’ve got recombinant vaccines where only a small piece of the gene for the flu virus is used. And we’ve got attenuated live vaccines that are used intranasally. So we’ve got a vaccine for just about every age group and lifestyle that’s out there. And still 50% actually I was somewhat happy with that.

Michelle Ubben
Better than without.

Dr. Anna Likos
Yeah, I would like to get it up higher. The comment that it doesn’t have a great track record, I have to say that that’s probably… There’s some truth to that. Some years it’s a good year, a match and other years it’s a not. So the way this works is that there are two meetings worldwide, they’re called VRBPAC and I can’t even begin to remember what the letters stand for. But in January I believe is the VRBPAC for the northern hemisphere where experts from all over the world, from Asia, from the US, from Europe, they all get together and they look at the data on what viruses were circulating the previous flu season. And from that they try to predict what are going to be the major flu strains for the next flu season. And then they start building their vaccine. What happens with some strains, even a little bit more than others, is that from the time the decision is made, we’re going to include this strain and the vaccine production starts, and then the flu season starts is that the bugs may have changed a little bit.

Dr. Anna Likos
And so what happens is that some years we don’t have what we call a good match between the vaccine and the circulating strains.

Michelle Ubben
It’s a best guess.

Dr. Anna Likos
It’s a best guess. It’s a predictor. Now one thing CDC is doing and I haven’t been working with this for a while, so I really I’m not an expert on this, but it’s on the CDC website, if you go to it to learn more about it, is a real-time flu predictor model. So they’ve got several groups across the nation that are providing real time information and they have several teams that are taking that information and trying to predict what will happen. And they actually have a little contest between all these teams to see who predicts most accurately. And there are several teams that are doing quite well and that may help us in the future, I would expect, in terms of getting a really good match between circulating influenza and the vaccine.

Michelle Ubben
Besides the beliefs that are based on fact, then you also have the myths to deal with and that’s difficult too. In our survey, one in five people said that the flu shot can give you the flu, and there were 8% who believed that flu shots were a conspiracy or a scam. And I know you as a global disease warrior also deal with myths in the greater population, of course the anti-vaxxer movement is an example of that in the US, but the belief by some in Africa and the Middle East that health workers are trying to sterilize the population or spread HIV, I mean wild rumors. That can have serious health consequences as we’ve seen with the rise of childhood illnesses in the US that were previously thought to be under control.

Dr. Anna Likos
Correct. And some of those myths, some of them can be dealt with if public health officials are really committed to doing their job. You brought up the polio virus that was some of the imams in Africa especially were saying that that polio vaccine was designed to promote sterility and so on and that it was a Christian or non-Islamic effort to reduce the Muslim population. And so one thing we did, World Health Organization did, I believe they was them, was that we had the polio vaccine made by a Muslim nation. So vaccine that is produced by Muslim hands is given to a Muslim.

Michelle Ubben
Again, trustworthy source.

Dr. Anna Likos
Again. Now that took some extra work and I imagine some extra cost, I don’t have details on the cost, but that’s a kind of step it takes to deal with that kind of mythology. Some of the… I’ve spent part of my life arguing with the anti-vacciners, and I have used my innate intellectual ability to look at data, analyze and make a decision for myself. I believe in vaccines, I believe very much that’s not a belief, for me the data is there. But I’ve also come to realize that for some people it’s a belief, it’s a fervent belief and that I even with all my data, I am never going to change their mind.

Dr. Anna Likos
And so I came to start promoting, when I was state epi, that we have to accept these people where they’re at and we respect their beliefs. And so vaccination is not the only way to prevent a disease, we have several behavioral interventions that we can do. So if you don’t believe in a vaccine, I disagree with you respectfully, but I respect your right to believe that, and if you would do things like wash your hands frequently, if you’ll are stay home when you’re sick, if you’ll cover your cough appropriately, dispose of tissues immediately when you cough or sneeze, do everything that you can to prevent transmission of an infectious agent from you to the community or if you can do everything you can to make sure you don’t get an infectious agent from the community, then I think we’re all on the same boat here. The main boat is to prevent disease.

Michelle Ubben
I’m so glad you said that because I think it’s been so interesting to look at the public health communication around the coronavirus and we’re seeing use of a lot of videos and animations because we know that that’s what people are consuming information in that mode more than others, but so much of it has focused on how to wash your hands properly. And it’s funny, people are looking for the silver bullet and the hidden information and it’s so basic that people just don’t wash their hands right.

Dr. Anna Likos
Every so often. It used to be, I haven’t seen one in quite a while, but there used to be a company that would just hang out in public bathrooms and count how many people did not wash their hands.

Michelle Ubben
That’s the job I want.

Dr. Anna Likos
Oh, no. It was somewhat surprising the number of people, the percentage of people who did not wash their hands after using the bathroom, I’ve taken actually that caring when I travel, I carry wipes with me to make sure I always have something to wash my hands with or even to wipe down surfaces. People can cough. I mean used to be you would… My mother taught me to cough in my hand and stuff and now we cough our elbow and the coughing in your hand, if you think about it, you cough in your hand, and then you use the handrail to go down the stairs. And then I follow behind you and I use the handrail and I’m picking it up and I wipe my eyes or my… rub my nose or something and I’m infected.

Dr. Anna Likos
So, I think people need to remember that bugs are all around us all the time and not to create fear, we usually maneuver through the day pretty well without any major instances of getting sick. But we can protect ourselves quite easily with some simple behavioral changes and the most important one is wash your hands and keep your hands away from your face.

Michelle Ubben
We talked earlier about reaching different populations through communication. And I’m a big believer in the power of communication if the message is right, if the messenger is trustworthy, if you’re reaching people in the places that they seek out information and as in the information age where you have such segmentation and where younger people go for information is different than a baby boomer for instance, but one of the things I’ve found so interesting in the battle against the coronavirus is Reddit is an extremely influential platform but it’s user moderated. So myths and rumors can really spread like wildfire.

Michelle Ubben
But one of the things I was so impressed in how they’re handling the coronavirus is that there are 30 epidemiologists who have taken over the subreddit community of like 1.2 million people who are in that space talking about coronavirus, spending hours every day flagging misinformation and correcting it and being an influence in that group because they know that these are people who are interested in coronavirus, who are going to be spreading information. And so right there at that little hotbed of interest, they’re being a voice for truth and data and in a trustworthy expert voice. It’s impressive to see the public health community evolve and morph as quickly as maybe the viruses are morphing to use communication tools effectively to reach people.

Dr. Anna Likos
That’s great. I was not aware of that. I’m not very familiar with Reddit. But I think one of the exciting things for me and… I mean, I don’t know if you’ll use it, I’m pushing 70 years old, so I’m in the older generation, but I’m fascinated with all these different ways of communicating today and I really look to the younger generation to help us with how do we communicate to different subpopulations, different age groups, different occupations, different… Just different walks of life in some cases. Podcasts are good. I grew up with TV and radio and now I don’t even own a TV set. I get most of my information from the internet and listen to podcasts and so on. But Instagram, Twitter feeds, all of those have become a really major part of communicating through public health that I think is essential, I wish I understood it better. I think I’m excited that public health will be in the hands of some really creative young people coming along the line.

Michelle Ubben
Well, you’re a wonderful communicator and you do a great job of translating the complex into terms that people can understand. So thank you so much for spending time with us on Ubben Talkin’ today.

Dr. Anna Likos
Oh, this has really been fun. Thank you so much, Michelle for inviting me.

Michelle Ubben
I hope you’ll come back.

Dr. Anna Likos
I hope so too.

Michelle Ubben
Today you’ve been talking public health with my guest, Florida’s former state epidemiologist, Dr. Anna Likos. If you want to read more about our conversation, visit sachsmedia.com/podcast, and make sure to subscribe for more episodes on communication breakthroughs in unexpected places.