Some of the individuals included in these emails

Surgeon General of the United States.

++ Dr. Jerome Adams

HomelandSecurity
++ Dr. Duane Caneva, DHS Chief medical officer
++ Dr. DavidS Wade, medical officer, Departmentof HomelandSecurity,previously on NSC
++ Dr. Thomas Wilkinson, Medical InformationOfficer DHS
++ Herbert O. Wolfe director and actingchief of staff of the Office of the Chief Medical Officer at the U.S.
Departmentof HomelandSecurity.
++ Dr. DavidTarantino, senior medical adviser for CBP and coordinator of the protectionpart of CBP's
responseto the opioid crisis.
++ Dr. Gregory J. Martin,State Department
++ Dr. Alexander L.Eastmansenior medical officer HomelandSecurity
++ Dr. SangeetaKaushikis an emergency medicinephysician at DHS

STATEDepartment
++ Dr. Larry G.PadgetJr. StateDepartment

Health and HumanServicesand Centers for DiseaseControland Prevention

++ Brett Giroir,Assistant Secretary for Healthat the U.S.Departmentof Healthand HumanServices
++ Dr. Anthony Fauci,director of the NationalInstituteof Allergy and InfectiousDiseases
++ Dr. RobertKadlec,Assistant Secretaryof Healthand HumanServices
++ Dr. RichardHunt,senior medicaladvisor
++ Dr. RobertR. Redfield,Director of the Centers for DiseaseControl and Prevention
++ ChristianHassellSenior ScienceAdvisor at U.S. Departmentof Healthand HumanServices
++ DanielDodgen,director of ASPR Divisionfor At-Risk Individuals,BehavioralHealth,and Community
Resilience.
++ KristinL.DeBord,Director of StrategyOfficeof the AssistantSecretary for Preparednessand
ResponseU.S. Departmentof Health and HumanServices
++ RobertJohnson,Ph.D.,is the Director of the Influenzaand EmergingInfectiousDiseasesDivisionof
BiomedicalAdvanced ResearchDevelopmentAuthority
++ KevinYeskey,M.D.currentlyserves as the PrincipalDeputy AssistantSecretary to the Assistant
Secretaryfor Preparednessand Response(ASPR)at the Departmentof Healthand HumanServices
(HHS).The office leads the nationin preventing,respondingto and recoveringfrom the adversehealth
effects of manmadeand naturally occurringdisaster and public healthemergencies.
++ Dr. Gary Disbrow is the Deputy Director (Acting)of the BiomedicalAdvancedResearchand
DevelopmentAuthority
++ Dr. John T. Redd,a medicalepidemiologistwith the U.S. Centersfor DiseaseControl and Prevention

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

++ Dr. Carter E. Mecher, Senior Medical Advisor
++ Paul Kshemendra, chief data officer and executive director for data governance and analytics

ACADEMICS/PrivateSector/Former Government Officials

++ Eva K Lee: American operations researcher who applies combininratorialoptimizationand systems
biology to the study of healthcare decision making at Georgia Tech
++ Tom Bossert former Homeland Security Advisor to U.S. President DonaldTrump.
++ Dr. Dan Hanfling, MD, Clinical Professor of Emergency Medicine at George Washington University
also with In-Q-Tel
+ + Ralph Baric, PhD, Professorin the DepartmentofEpidemiologyUNC, leader in the studyof
coronaviruses
+ + Richard HatchettCEO Coalition for Epidemic Preparedness . Servedin the WhiteHousesof
PresidentsGeorgeW . Bush and Barack Obama
+ + Dr. JamesLawler, infectiousdisease doctor atUniversity ofNebraska, served as a memberof the
HomelandSecurity Councilfor PresidentGeorge W . Bush and as a memberof the NationalSecurity
Councilfor PresidentBarack Obama.
+ + Dr. DavidMarcozzi
, formersenior advisorfor EmergencyPreparednessand Acute Care within the
Centers ofMedicare andMedicaid Services and memberofWhite House NationalSecurity Council.
+ + + MichaelWargo is vice presidentofemergencypreparednessat HCAHealthcare.
+ + Herbert O . Wolfe ofPennState, formerNationalSecurity Councilstaff at the White House

STATEOFFICIALS
+ + Dr. Charity A Dean, California DepartmentofPublic Health
+ ++ David GruberTexas Departmentof StateHealth ServicesMobile Associate Commissionerfor
Regionaland LocalHealth Operations
, BorderHealth, Emergency Preparednessand the Texas Center
for InfectiousDisease.
+ + Dr. Jeffrey S . Duchin, Health Officerand Chief, CommunicableDisease Epidemiology Immunization
SectionPublicHealth - Seattle and King County Professorin Medicine, Division ofInfectiousDiseases,
UniversityofWashington

EMAILS

: Carter Mecher <

Sent: Tuesday, January 28 2020 9: 10 AM

To : Hepburn, Matthew J CIV USARMY (USA ) > ; Caneva, Duane < Caution
Caution-mailto > Lawler , James V > ; Wargo Michael
< : Michael h > RichardHatchett
brian . HARVEY , MELISSA
Wade , Dave S . EOP /NSC < > : Lisa

Koonin , David
> ; Marcozzi WOLFE, HERBERT

Subject: RE [Non -DoD Source] RE: 2019- (UNCLASSIFIED )

Updated numbers. Changed things around to better compare current outbreak to SARS and H1N1
. From :

Richard Hatchett -mailto Caution- :

Sent: Tuesday, January 28 , 2020 2 26 PM
To : Carter
Cc: Hepburn , Matthew J CIV USARMY DOD JPEO CBRND (USA ) > ; Caneva
Duane V > ; Lawler, James > ; Lisa Koonin
Marcozzi
, David
Subject: Re
: [ Non- Source] RE: 2019- UNCLASSIFIED
)

Carter

Am goingthrough an interestingexercisenow of the whatwillyou wish you would have done if . with two
scenarios
:

1) The virus lands in the range of 0. 1- 1. 0 % CFR , which seems themostlikely severe scenario

2) The virus turns out, like H1N1, to be much more widespread than initially appreciated and thus be associated with
a much lower mortality than initially thought ( the crying wolf scenario )
 In my case this boils down to three areas of concern:

Status of vaccine development

: how much ?
Organizational reputation/accusationsofmismanagement of funds
*

Potentialpoliticalembarrassmentfor currentand future donors

Grappling with both horns of the dilemma here - would welcomeyou wrapping your brain around how to proceed in
themost prudentway

Richard

On 28 Jan 2020, at 18 :04, CarterMecher < > wrote :

The chatteron the blogsis thatWHO and CDC are behindthe curve. I' m seeingcomments from people asking why
WHO and CDC seem to be downplayingthis. I' m certainlyno public health expert ( just a dufusfrom the VA ) , butno
matterhow I look at this, it looksbebad. If we assumethe samecase ascertainment rate as the springwaveof 2009
H1N1 , this looksnearly as transmissibleas flu (butwith a longerincubationperiod and greaterRo) . Theprojected
size of the outbreak alreadyseemshard to believe, butwhen I think of the actionsbeing taken across China thatare
reminiscentof1918 Philadelphia, perhaps those numbersare correct. And ifwe acceptthatlevelof transmissibility,
the CFR is approachingthe rangeofa severe flu pandemic. But ifwe assumethe case ascertainmentrate is better
than H1N1
and transmissibilityis less than flu ( it is stillmuchmore transmissiblethan SARS) , and theCFR goes
accordingly(1918 pandemic ) . And if weassumethe case ascertainment rate is evenworse than 2009
H1N1 , this is really unbelievable(higher transmissibility than flu . Anyway you cutit, this is going to be bad. You
issibility than
guysmadefun of mescreamingto close the schools. Now m screaming, close the colleges and 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 [mailto

Sent: Tuesday, January 28 , 2020 8 :56 PM
To: Hepburn, Matthew J CIV USARMYDOD JPEO CBRND (USA) Richard
Hatchett Carter Mecher
Cc : Caneva , Duane < v ; LisaKoonin > ; Marcozzi, David

Subject: Re: [ Non- Source] RE: 2019- UNCLASSIFIED)

GreatUnderstatementsin History:
Napoleon' s retreat from Moscow - “ just a little strollgonebad

Pompeii - " a bit of a dust storm

Hiroshima - summerheatwave

AND

Wuhan - bad flu season

James Lawler, MD , MPH, FIDSA

Director, InternationalPrograms & Innovation Global Center for Health Security , and Associate Professor ofMedicine
Division of Infectious DiseasesUniversity of Nebraska Medical Center

From : Hepburn , Matthew J CIV USARMY DOD JPEO CBRND (USA )

Sent: Tuesday , January 28 , 2020 8 : 37 : 25 PM
To : Richard Hatchett > ; Carter Mecher
Cc: Caneva , Duane v ; Lawler
, James Lisa Koonin
> ; Marcozzi
, David
Subject
: RE : Non- Source RE: 2019- (UNCLASSIFIED
)
Non-UNMC email
CLASSIFICATION: UNCLASSIFIED

Team ,
am dealing with a very similar scenario , in terms of not trying to overreact and damage credibility . My argument is
that we should treat this as the next pandemic for now , and we can always scale back if the outbreak dissipates , or is
not as severe .

I also have clinicianssaying ' it is like a bad year, butpeopledon' t overreactto that.' Mythoughtis thatmaybewe
shouldbemoreaggressivewith flu as well. AND a bad flu year layeredunto a badflu is pretty awfulfor the world.

Matt

On Jan 29, 2020, at 8 :55 AM , Carter Mecher > wrote:

You are correct. All this stuff is complicatedand messyand imperfectfor all thosereasons. The early data is also a
little goofy sincethe early deathscould havebeen picked up after somebodydied(meaningthattheywentback and
lookedatrecentresp deaths and then confirmed the death postmortem). As time goeson things start to even outbut
the throughoutdynamicsof screeningandtestingare complicatedtoo just likeyou said.

This really underscores how all those tabletopexerciseswe do wherewehave a CFR builtintothem are really so
artificial
. I wish there was somebetterway offiguringthis out quicker. I justam notsmart enoughto see how . The
uncertaintyandthe fog are like the air aroundus is just a partofit all.
suspectsomebodywho knowsqueuingtheory couldhelp unravelthe issues you raise. Theimpactsare nonlinear.
(Considerhavingan answeringservicewith 10 operators to handle calls with an average call time of 3 minutesand a
volumeof 200 calls perhour, what amountof time do callers spendon hold waitingto getan operator? Mostpeople
would say you havejustenough, howeverwhen the numberof channelsin thequeuebecomessaturated, waiting
natically . We use these concepts for clinic scheduling. Could do the same for testing. Just need to
engage some smartmathematiciansto help you understand impacts. That is at the core of the problem you are
describing. It is a nonlinearaffect that is huge. I would betthat Eva Lee could help unravel. )

From : Carter Mecher <

Date: Wednesday, January 29, 2020 at 9 :04 AM
To: "Lawler, James V "
Cc: "Hepburn, Matthew J CIV DOD JPEO CBRND (USA) " @ mail.mil> , Richard
Hatchett "Caneva, Duane" @ . gov Lisa Koonin
> "Marcozzi, David" umaryland
. edu
Subject: Re
: [Non- DoD Source RE: 2019- UNCLASSIFIED
)

Non-UNMC email
Duanewas watching Africa .

Zambia just confirmed a case.

UAE also confirmed a case today .

Sent from my iPhone

From : Carter Mecher

Sent : Wednesday , January 29 , 2020 10 : 39 AM
To : Lawler, James V
Cc: Hepburn , Matthew J CIV USARMY DOD JPEO CBRND (USA ) ; Richard Hatchett; Caneva , Duane; Lisa Koonin ;
Marcozzi, David
Subject : RE : [ Non - Source ] RE: 2019- (UNCLASSIFIED )

Here is how explain all this to myself (hope itmakes sense) using queuing theory and the example of the phone
callers , operators answering the calls , and number of callers 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 ' s
telephone call center . The problem though , is the number works, but the phones are not manned (no operators are
there 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, your
call 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 but have symptoms suggestive of
infection — thatis why a simultaneousflu outbreak takingoff will throw a monkeywrench into all of this ( not to mention
the usualbackgroundresp illness and other febrile illnesseswe see withoutanotheroutbreak to consider ) . If we look
at the % of confirmatory tests thatare negativewe can get a senseofhow importantthis group is. Thesecallers tie
up the operatortimeand prolong the amountof time infectedcallerswaiton hold.]

Butevery two days the number of infectedcallers on hold listeningto music doubles. someperiod oftime, a
diagnostictest is developed thatmighttake weeks, in which case the numberof callers on hold is staggering,
increasing 10 fold each week untilthe testisready and the operators are availableto answercalls) . The length of
timeon hold is pretty staggeringtoo. Someof the callers hungup (diedor recovered). When the operatorsbegin to
answer , they alreadyhave a massivebacklogand they don' t take the calls thathavebeen hangingon the
longest. They prioritizethose calls that seem to be themosturgent( the equivalentof testinghospitalizedpatients, ER
een waiting on the line for a very longtime, justlingeron hold).
Andas the operatorsbegin to ramp up increasingmore capacityandmorethroughput
), the numberofpeople
callingkeepsincreasingdoublingevery 2 days and increasingby an orderofmagnitudeof everyweek). The
operatorhas to feellike a checkerworkingthe cashieratWalmarton Black Friday (no matterhow hard they work, the
linekeepsgettinglongerand longer). Even if you addmoreoperators, you willneedto increasethem atthe same
rate as the epidemic (doublingthe numberofoperatorsevery 2 days, increasingtheir numberby 10 each week , just
to staywhereyou are). Now you begin to understandthe dynamicsand the challenge
. So as thoughtaboutit,
there is no waywe are workingdownanybacklog are growingthe backlogexponentially
.

Now think of how this translates to surge capacity for healthcare during an epidemic . The dynamics are totally
different 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 most people do not appreciate .

What found interesting during the 2009 H1N1 spring wave in the US is that case ascertainment fell over time (the
hard time gettingour headsaroundexponential
growth and geometric
progression mindsare linear (just like peoplehave a timewith compoundinterest(why they getinto debt
trouble or are shockedwhatthey payfor a house over the lifeof a loan), orwhathappens when startwith a penny
and double it every day for a month and realizehow many $ thatbecomes, or take a pieceofpaperand fold itin half
again andagain ( 30 times) and hearhow thick it is , etc. ).

From : "Dr
. Eva K Lee"
Reply -To: " Dr
. Eva K Lee"
Date: Friday
, January 31
, 2020 at 3 :48 PM
To: "Lawler
, James V
Cc: CarterMecher , " Broadhurst
, Mara J" < > , "Caneva, Duane"
> , Lisa Koonin Hepburn, Matthew J CIV USARMYDOD JPEO
CBRND(USA)" , Richard Hatchett
Subject: RE: [Non- DoD Source] RE: 2019 - nCoV (UNCLASSIFIED)

Non -UNMC email

James , some reports that for 2019 - has increased significantly from 1. 4 - 2 . 5 on Jan 1, 2020 to 3 . 3 -5 . 37 ( Jan
30 , 2020 ). This huge value may be testing artifact as you mentioned . I did some lab experiments , when slightly
improved the assay process time distribution in the lab processing model that I built , the testing efficiency improves
by 45 % under the same labor availability . Hence suspect you are going to see rapid uptake in total infectivity and
slower growth in death confirmed . As iti s now , with over 11, 000 confirmed cases and over 220 deaths , CFR is still
2 % , 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 haveneverseen

those meatmarkets( only been to China 3 times in mylife when GT sentme to PekingU ) , so everythingon mymind
is just by imagination regardingthosemarkets. Can youbelieveover50 % of these cases comedirectly from animal
contact? I don't believeit. I wonderif these animals are live or dead to begin with . The marketworkersdestroyed so
much valuable information, itisa puzzle still. But if it can transmitwith few casesin US, then it is going to
transmit.

From : Dr. EvaK Lee

Sent: Monday, February 3, 2020 1: 45 AM
To: Krohmer
, Jon (NHTSA) @ dot
. gov

Cc: Caneva, Duane @ . gov > ; Carter Mecher > ; Lisa Koonin
> ; David Marcozzi 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 @ . gov
Subject: [EXTERNAL ] Firstsetofresults- NationalED OvercrowdingStudy(NEDOCS
) and theMedical
/ Public
HealthInformationSharingEnterprise

Colleagues, I want to update you on the -nCoV analysis. Please see 7 itemsbelow

1. Transmission mechanism : From my analysis on the vector-host interplay , and confirmed by a local investigator ,
the real transmission is probably jumped from bats (carrier) to other animals that are easier to transmit to human . In
my calculation , about 80 -88 % of the reported cases are human -human transmission (by that, it includes direct
droplets and indirect surface ). News is that there ' s possibility offecal-oral infection . We can't confirm since so little
data 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 assayspostedon WHO website( link below ) takesabout2 hours to confirm . If it is positive, they
will repeat2 more timesbefore confirming . So it takesabout 1/ 2 day for a positivecaseto be announced( excluding
the timeit takes to send the sample to the lab). The assays are beingsentto othercountries for diagnostics. I hopeto
secure somefor us in US. At somepoint, weneed to compareif there' s any difference in diagnosisin the
confirmationprocessandthreshold.
https: / academic.oup. com / clinchem/ advance-article/doi/ 10. 1093/ clinchem / /5719336
trictisolation) : urgethat the quarantineof those (evacuated individualscomingback from China -
- shouldbe 14 days. Since themilitarybaseis used, it is very importantthat every individualis isolated, andnotbe
placed in groups. Tests can be done in laterperiodsformultipleintervals, since in early stagetheremaynotbe
enough viral counts to render it positive. So it could be a false negative.

I ran mymodels assuming 1,000 people staying in the military base , using a \ 3 (with mean incubation time 5 . 2 . If
there are 5 asymptomatic infection among them , without proper isolation , after 14 days , there could be as high as 160
people infected (no symptoms )! Even if there is only 1 infected asymptomatic person the total infected is over 11
people . So quarantine must be strategic and done properly with good individual separation . Or else it would result in
undetected infected individuals spreading the disease at the end of the quarantine period .

5. CFR: From thenews, 360 peoplehavediedwith 17, 205 infection, CFR remainsat 2. 1. Accountingfortesting
delay, my estimationofinfectionhoversover 110,000 ( in linewith NeilFergusonfrom ImperialCollege) CFR may
bedroppingdown ( 0 . ), stillbad. I have derivedseveraltestingmodelsandwill run thelarge-scale disease
propagationanalysis. Willupdateyou with my findings.

6 . Protectionof operators: trust thathealthcareproviderswill take everyneededprecautionto protectthemselves.

Screenersatports of entry should use gloves ( n addition to facemasks .

7 . ED issues: There is a realneed and concern to treat these patients separately from hospitalED. Sincemost
deaths reported have coexisting health conditions, these 2019 -nCoV infected patients should stay far from hospital
for obviousreasonof crossinfection (or absolute isolationhas to be ensured). The fact Chinarapidly set up
massivetemporaryhospitalsmay signalthatweneedto do the same- setupappendix outsidehospitalsfor special
care of these patients. This also ensuresrapid learningand sharingofknowledgeamongworkersas they take care
ofthesepatients.

More in 2nd round.

On Thursday, February6 , 2020 3 19 PM , 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 am
seeing in the analysis . Either we have 28 , 363 reported and confirmed infection as oflast night, or it is n the order of
50 , 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 every
single day), it seemsto methatthey are only reportingthose infectedcasesthatresultin deaths. They are missingall
othercasesin which patients did not seek medicalattention, or simplydie withoutany postmortem confirmation. It
could bethatthey' re overwhelmed , or simply, deathrate is notreliablyreported
. Eitherway, we could have a higher
than 1 % (countingat least50, 000 of infection).

2. Make -shift hospitals : Carter , I saw the picture of the make -shift hospital tent , itlooks very much like the shelters
helped the local health departments setup here to house the Haitievacuees and also those came to Atlanta escaping
the hurricanes in Houston . I got some on -the -ground clinical parameters and will optimize to identify how much
resource and how to operate to get the best outcome. We need to know (hopefully CDC on -the -ground team ) how
people die , if it is because of lack of medical care , insufficient care process , ineffective ad -hoc treatment regiment , or
simply the organs fail after all attempts . Everything thathappens in the clinical side is of great importance .

3 . Transmission: I am very bothered by the Japanese Cruise' s findings and actions: The story is that a guestsailed
from Yokohamaon Jan . 20 before disembarkingon Jan . 25 . He showed no symptomsaboard the ship , but tested
positive for coronavirusin a HongKonghospitalsix days later. Since then 300 people on board were tested with 20
positive cases. First, we can' t tellhow long this man was infectiouswhile on board. Butclearly from allmy analysis ,
us at that time If he was, then it was notpossiblefor 20 people to
be tested positive (notfrom the 5 days he s on board and not from how rapid and infectiousit is, I putin all
outrageousvalues). So this is not a single pointsource. Hecan only be a single point- source if he is a super
spreader - and thathe' s contagiousby Jab 21and then he spreadsvery effectivelyacross with at leasteveryone
else also becomesinfectiousafter 24 hours upon infection (as in theGerman firstcase) . I don' t know if the Japanese
intends to testall remainingpassengersor not. Butit could be a very good case to analyze in detail, if they can afford
to do so. Regardless
, I don' t think 300 contact-tracingis sufficient
. think they need to samplemore. Ifhe' s not a
pointsource, allthemore criticalto testmore passengers.

Best, Eva

Monday, 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 these
additional comments :

Incubation : This data fits perfectly with the husband of US patient # 2 (USP2 ). One of the issues we are facing is
having to furlough employees . Along with PH and CDC we tracked unprotected exposure to USP2, and into
those that were to be home furloughed for 14 days , and those that had daily sx check . That resulted in 147 contact
reviews , of which 61were placed in active monitoring , 29 furloughed with monitoring (asymptomatic ), 7 PUI (home
quarantine ), 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 of USP2), he was not initially placed on any restrictions by
PH and CDC , and had visited a cardiology office as well as had visits to the hospital. Fortunately , we had decided to
take extra precautions with USP6 , so we only had 17 contact reviews, but 15 are furloughed with monitoring , and 2
are resolved . Of all the contact reviews, most were nursing with 2 registration and 1 biomed staff. The contact
review criteria is changing ( for the good , but think it should be a standardized checklist for better support and
process 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 prioritized
the confirmed cases over the 's . This is delaying our process to discharge or remove from furlough . We are told
confirmed cases will now be a priority , but having local tests will be critical in moving people off of
furlough /quarantine /PUI and keeping our health systems functioning .

Protection of Operators : Great point. We are using PPE monitors , 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 something
we do every day, butunfortunately , we know that while it is done every day, it is many times done poorly . This has
helped 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 notification
and scheduling , exclusive entry and exit , masking PUI, and placement in a negative pressure room . Ithas worked
well without any issues , but it has to be a formalized , trained process.

Community Perception: This has been interesting. Two of our nurse have been asked by their churches not to
attend services (these are smaller community churches while we have confirmed cases. They do not work with the
confirmedpatients. ManorCare, a nationallongterm care company, hasnotifiedus that they willnotaccepta patient
from ourhospitalthathasthe two confirmedcases for 14 days. Wehave 7 patients ready fordischarge, so that is
tyingup beds. Our attorneysare lookinginto this, butnotsureifwecan do anything. It hasn't affectedourpatient
volumeor procedures , which is goodnews.

Scott Cormier
Vice President, Emergency Management, EC , & Safety
Medxcel

On Friday, February 7, 2020 2: 36 PM , Dr. Eva K Lee @ pm .me> wrote:

HiJames, I wantto follow up more on lastnight's discussion. I have answeredyour questionsbelow. After that
thoughtaboutstrategiesfor communityscreening, what's the bestway to do so . And I did a little optimizationto cast
a neston whatwewantto test andhow to testacross the community. This is very crude, but you can see the
differentstrategies:

1. Assuming the 14 -day period of incubation , we can reach out to the cohort travelers for the period Jan 24-Feb
7 [ [note this lastweek is redundant, since 11airports have started testing. ] through airline operators . Basically they
only need to send a text to those who have traveled to at-risk areas. In this case , I will cover all international travellers
where their flight of origin is China , not just Wuhan . Individuals who are willing to provide nsal swab and sputum
samples can report to the nearesthealth department. We can also give them a little form to do contact tracing
themselves . This is like population sampling, not everyone will be eager to do it. But some are willing and you will get
a sample size. Samples can be shared across all state labs that have the testing capabitiy to ensure timely
processed .

To capure potentail cascading effect on the 2nd generation infection , we can move to Jan 17 - Jan 24 cohort and so
forth . Clearly they may nothave any viral activities if they have already shed and passed it onto someone else. But
the contact tracing form willbe useful.

[ [You can do the same for Cruises. ] ]

This ismore of a global approach using travel and the risk factors as a means to prioritize screening.

2 . For a regional
-basedapproach, one can approachcommunities- e . ., schools, religiousorganizations
, private
businesses , etc, to promotetestingamongthosewhohaverecentlytraveledout of the country to China. Workforce
travelis commonin this connectedworld. Myfeelingis thatitwillbe heterogreneous
acrossthe nation since some
regionshavemore foreignstudentsfor exampleand others don t . Butoutreach via the universityhealthservice
shouldbevery feasible andeasy. In the same token regardingprivatebusiness . Although students/workersmay fear
that if they're tested positive, theywouldbeforcedinto self-quarantine
. My feelingis thatwe can themessage
in a positiveway ( as a meansto protecttheirhealth) to promotetheir participation(or the organizational
participation
).

This approachleveragesorganizationsinfrastructureto help systematicallyrecruit the righttype of high- risk

individualsfor testing.

3. On the ground, I do notknow how much testing capability and capacity each state has. Wedo want to ensurethat
samplescan be processedin 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 strategically
choose some with high passenger volumes, or those with connecting routes .

Just somethoughts. I unxderstandyou are probablybusywith the evacueestestingnow .

Best
, Eva

From : " Dr. Eva K Lee" @ pm .me>

Reply- To : " Dr. Eva K Lee" @ pm me>
Date: Sunday, February 9, 2020 at 8: 29 PM
To: " Lawler, James V " < @ unmc. edu
Cc: Carter Mecher RichardHatchett< @ cepi. net> , "Caneva , Duane"
 @ hq. dhs. gov> , Hepburn , Matthew J CIV USARMY DOD JPEO CBRND (USA )"
@ mail.mil
Subject: Re: [ Non- Source]RE: 2019- UNCLASSIFIED) - - NPI
, Flu vs 2019- , Scalingof testing
throughput

Non-UNMCemail
understandall of you is an expert in this area. Justmy 2 cents from thecall

1. Carter, I think we can strategically rollout someof the social distancing recommendations. This can bepart
of the public messanging. I think different communities have differentwillingness to start. It doesn' t hurt them and
ense of comfortand awareness. Public health is already doing isolation and quarantine. This is
a good timeto test how well the digital infrastructure can support teleworkbeyond the currentcapacities. Makeit into
part of thenation' s health security response drills may allow for dualpurpose( and secure of necessarygovernment
funds).

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 % mortality
201-9 - 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 . Even
when 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 times more deadly than seasonalflu . Moreever, this is only a lowerboundbecause the
fgovernmentbasically shut down and isolate the entire infectedzone. I think this givespeople a sense of risk . It is not
to 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 / reagents
andmake 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 you
also want to scale up by boradening what can be allowed . At some point, we can do result validsation to ensure
everyone is happy with what they are using .

4 . Community testingpriority: Hospitalizedpatientscertainly can and should be tested. Butthat' s too late for early
intervention( exceptcontacttracing) . Primary care wouldbe great. Universitiesandpharmaciesare good to include.
Strategicsamplingis a mustbecauseyou won' 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 andbe felt .
Thailand 's flood and Japan Fukushima delayed the sequencer s production by 2 years, affecting some of the medical
researcn . That' s very specialized . The current impact is more general as it covers many different industrial sectors .

Eva

On Sunday, February 9, 2020 10:59 PM , Lawler, James @ unmc. edu> wrote:

Eva your data fit wellwith othermodelers. We are in mitigation phase and goalis to drive down Ro.

James Lawler , MD , MPH ,

@ unmc. edu

Sunday , February 9 , 2020 11: 16 PM , Dr. Eva K Lee @ pm .me> wrote :

Yes , absolutely ! And we need public engagement now . We need the citizens to know and practice social distancing in
a way that best protect them . Every action counts . Communities can help a lot. The aging population with such high
percentage of individuals with multiple chronic conditions make it very hard to fight on the treatment front (alone ). It's
too late and too costly with lower chance of success . Wehave to move the action timeline forward to the pre - empt
stage. Whatever we can do to prevent and mitigate will take us a long way. We also need to help China to fight and
contain rapidly (so we can learn more how and what s happeneing ), or else the global implact on supply - chain and
the economy will be sustantial.

China also has bird flu outbreak now , very close to the epicenterof 2019- All thesezoonotic activitiesare
worrisome
. Andwe can ' t controlwhere all thebirdsare 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 of
cases outside Wuhan /Hubei and positivity rates in folks repatriated from Wuhan in last 10 days ? Those look to have a
prevalence rate of 1- 2 % that would presumably reflect community prevalence in Wuhan at the time they were
extracted . This obviously suggests a much higher number of true cases and would match the data that say most
cases are mild/moderate URIand and that we are only mostly counting hospitalized pneumonia . Certainly affects
the CFR prediction quite a bit and our assessment of healthcare surge requirement. I think everybody agrees we are
dramatically undercounting the real denominator question is by how much . I think we also mostly agree thatwithout
dramatic can expect 30 -40 % infection rate by end of community epidemic - and even with dramatic NPI, that
total may only be slightly reduced . Any thoughts there ?

James Lawler , MD , MPH, FIDSA

From : Dr. K Lee

Sent: Monday , February 10, 2020 7 : 10 AM
To : Lawler
Cc: 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 truly want to get a good sense ofwhat' s happeningto the infection in the
community levelandhave an ability to prepare the citizens, the community, and the hospitals. [ [That is partof
managing the expectation. ] ]

Diamond Princess - - as I said from the start - - offers the biggestopportunity to study in multiple levels and I am afriad
with missingopportunities andmissteps. And it showswhy strategic
( community) testing is amust, andwhy testing - - mustbemade effective andmustbeheterogenouswith all
possibilities.

The Cruiseship is a tiny community of itself, and it showswe haveno ability to test even just that.

- - 136 confirmed casesout of 336 testedthus far.

- Japan stillmaintainsthey are going to test those with synptomsand the elderly. They should andmusttest all, and
truly use that opportunity to get a good sense of symptomsvs no- symptomsand patternsof allpotential
manifestation.

- The spread - - no doubt - - involves those withoutsymptoms. Who know, they mightbe just so effective to spread.
Japan MUST test in a nonlinearmanner, it cannot prioritizein a one - side pattern as it hasdoneat the beginning and
continue.

- Some ,850 passengers made medication requests and about 750 received thus far . A very good example for us to
take note. So many people need medication - - notjust on the cruise , but everywhere because of prevalence of
chronic diseases .

It shows they can' t even contain one cruiseship, notto mention the consequenceof their disembarkment
.

- Imaintain those without symptoms must be tested , even if we can' t cover all, we must sample . That s the only way
to fill in the gaps .

- Carter- - this also re - enforces the notion thatNPIas in socialdistancinghas to begin now , notlater -- cannot
preparethefuture by acting in the future, wemjustrolling it outnow . There' s noharm to do it, butthere can be a lot
regretif not. And the very concern regardingtesting capabilityremainscritical. Butwith limited testing ability, we
betterbe smart in how to sample.

- James, perhapsyou and otherscan givemethelaboratoryinformationnow of locations

, varioustestand
associated I can startoptimizing.
On Monday, February 10, 2020 7: 21 AM, Carter Mecher r. net> wrote:

Eva, below is our review of the cruise ship outbreak.

The case count aboard cruise ship is now up to 136. This is unbelievable.

Go back to the originaldata on this.

DiamondPrincess cruise ship with 2 ,666 passengersand 1,045 crew members

Date/ Time
20 17 00 from Yokohama Tokyo, Japan
22 00- 21:00
Jan 0700 23 HongKong China
27 07 00 :00 Da Nang Hue
28 10:00 18. 00

31Jan 07 00 :00
01Feb 13 30- :00 Naha Island

04 in Tokyo hotel

Data:
Jan 20 : Departed from Japan
Jan 25 : 80- year- old passengerwho disembarked on Jan 25 in HongKong tested positiveon Feb 1.
Feb 1: Quarantineprocedure at a port in Naha
Naha (quarantine
(quarantineofficial
officialshad issuedcertificatesallowingpassengersand
crew to land; nooneonboardat that timeshowed any symptomsand the case of themanwho disembarkedin Hong
Kongwasnotknownatthat time . When resultsknown, certificateoflandingcanceledand second quarantine. Tests
for the viruswould be administeredto three groups: thosewith symptoms
, thosewho gotoff in HongKong, and those
whohad close contactwith the infectedpassenger .
Feb 3 Arrivesin portof Yokohama
Feb 5 Japan reports 10 passengersconfirmed+
Feb 6 : Japan reports 10morepassengersconfirmed+ (totalof 20); Japan laterreportsa totalof41passengers
now
confirmed+ for nCoV
Feb 7 Japan reports a totalof61 passengersnow confirmed+ for
Feb 8 Japan reportsa totalof64 passengersnow confirmed+ for
Feb 10: : Japan reports a totalof 136 passengersnow confirmed+ for

Index case of 80 year old passenger is Hong Kong Case# 14

Case no . Date of laboratory confirmation ; Gender; Age ; Nameof hospitaladmitted ; Discharge status Hospitalised
14. 01/02/2020 M 80 PrincessMargaretHospitalHospitalised
Over a span of 21days ( from 20 - Feb 10) , this outbreak has expanded to 136 confirmed cases. Thatis a
prevalenceof 3 . 7 % over the span of 3 weeks. Thatis unbelievable.
Butgo back and comparethe dynamicsof thenCovoutbreak to the springwave of H1N1
, this outbreak is even
faster

Comparison of2009 and 2019-

Numberof Cases & Deaths Reportedfrom Dateof 1stKnown Case

Cumulative H1N1Cases and Deaths in US

Through 118 Days from First Case Symptom Onset

Cumulative 2019- and Deaths Through 68 Days from

FirstCase Symptom Onset

ed
R

We are 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 weeks
from operational. Moving forward through healthcare systems is a greatoption , themore the better. If Kaiser, HCA ,
DOD, VA can be leveraged, it's a case ofbeer to the first one to find the case.

What happened to 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 PM
To: "Lawler, James V @ unmc. edu

Cc: 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- Strategic testingis a
must- - testing capacity - -

Non -UNMC email

Guys

I just talkedto the KaiserEastCoast askedhim aboutKaiserlaboratory ( James, I wrote him severalweeks
ago when we talked aboutlab testingsin December). He said thatKaiserhas labs, mostly on the West Coast.
askedhim if the governmentcan outsourceto them the lab tests, he said it should be doable

Just 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 will need to make / entice private
sectors to come in and take over the testing responsibility . I am most certain Charity is that the lady on the call from
California ) knows how to access Kaiser resources . She can ask them . I can facilitate if needed . I have done some
clinical 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 tons
of 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: 21 AM , Dr. Eva K Lee @ pm .me> wrote :

I found it very odd that China is now rolling out the clinically diagnosed cases. All these time as they reported over
47 , 000 + confirmed positive cases, they stillhave over 187 ,000 + cases that they are observing clinically . Fair enough ,
they can ' t confirm yet .

Last night they reported 242 more deaths, which would have driven the CFR close to 2 . 9 % again . Butconveniently
they are adding 13, 332 of the new cases from the " clinically diagnosed " pool. That keeps the CFR at 2 . 3 % . This
seemsmore 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 US keep saying that they cannot confirm the extent of human -to -human
transmission ? I think the public is confused by all these experts saying conflicting things . If human -to -human
transmission is still in question , how was the transmission in China ? It' s one thing that predicted based on the social
human interact, I got that people don ' thave to believe . But now it is very clear --based on
published 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 whatwe have to fight, not COVID - 19.

Tradeoffs on Decision - Public Health and Emergency Response National ED Overcrowding Study (NEDOCS)
and theMedical/Public Health Information Sharing Enterprise.
Sent: Friday, February 14, 2020 8: 08 PM
From : Dr. Eva K Lee @ pm .me
To : HARVEY , MELISSA @ hq. dhs. gov
CC: 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. com

gwu. edu edu, Firoved, Aaron @ . DHS.GOV, Quitugua, Teresa

@ HQ .DHS. GOV Kshemendra gov , Eastman ,

Alexander @ . gov , CHRISTOPHER ALLEN Luke

Stephen @ hq.dhs.gov, Nathaniel Hupert @ med. cornell.edu

I 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 the
healthcare workers and the operators . The latter are not as knowledgeable and as well equipped and they can
be very exposed . Wemust train them well so that they can be protected in the best possible manner .
Infectivity and mortality : again review the models as we put in the dots onto the graphs . It remains within
our zone of prediction , since the models did include asymptomatic cases . The total infection ranges from
400 ,000 to 9 million 6 months starting Nov 15 2019 , andmortality from 9 ,000 - 150, 000 . The Chinese is
helping. I don ' t really care if they want to report the clinically diagnosed cases , they just have to separate the
confirmed positive vs clinically diagnosed . That is important, even though everything seems like a blackbox and
the 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 health
conditions to assert different types of symptoms making it hard to treat and to diagnose . In that case, itcan
comeback with morepower.
Publichealth strategy (andpublic perception): I understandthere continuesto bedebateson we
shouldputin full throttle of effort. Myfeelingis -- Publichealth alwaysfaces such a dilemma.
a . Nothing
badwillhappenandwe puttoomuch resourcesand effort
b . Something reallyhappensand thatwemitigateandmakeit go away -- this is a goodeffortandresult,
butunderstandablyit will be underappreciated
becausenoonewould know how itwould playoutwithout
interventionandhow bad it is. So successfulmitigationis often under-valued. [ [peoplewill think it is just (a . ] ]
c. Something badhappensandwe did notdo enough -- that is a big fallouteveryoneknows
I think itis very important wetakepath (b ) and treat (a ) as a realtest ofhow goodwe canmounta full fight.
The lab tests are the firstbottleneck(besidesallthe biologicaland clinicalunderstanding ofthe virus). We
shouldlay it all out allsequencesofeffort anddevelopa full plan. Itis notgoingto belike a flu plan - because
we don' t know mucn abotu this virus. Butwe certainly can adaptit.

incorporatethediseasemodelswithin the networkof criticalinfrastructures(Duane

, I showedyou the
cascadinginterdependence multi-layergraphswith risksatvariouslayers). This virus could disruptmanylayers
the supply-chainnetworks
, truly affectingthewholeworld. Considerit a realugly testthatwe can blanketit and
win it it is a must.
Clinicalcases: Please safeguardclinicaldata andtreatmentresponse. Thatwillbe invaluableandI would like
to perform machinelearningto uncoverpatternsand correlations

Best
Eva

From : Caneva , Duane

Sent: Sunday , February 16 , 2020 9 : 39 AM
To : Dodgen , Daniel ( OSIASPR SPPR ) @ HHS. GOV> ; DeBord Kristin (OS ASPR/ SPPR )
hhs. gov ; Phillips, Sally (OS ASPR / SPPR) @ hhs.gov David Marcozzi
@ 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 , HERBERT
hq.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, Gary

OS ASPR/ BARDA @ . gov> ; Redd, John ( OS ASPR SPPR ) @ hhs. gov > Hassell
,

David ( Chris) ( @ hhs. gov Hamel

, Joseph (OS/ASPR/ IO ) @ hhs. gov

Tracey McNamara @ westernu. edu > ; Dean @ cdph . ca . gov Caneva ,

Duane @ . dhs. > ; Richard Hatchett @ cepi.net> ; Lawler, James V

@ unmc.edu> ; Kadlec, Robert(OS ASPR @ hhs . gov Martin , Gregory J

@ state . )' @ state . gov ; Borio , Luciana @ igt

.org> ; Hanfling
, Dan

@ . org> ; McDonald
, Eric @ sdcounty
. ca. gov Wade
, David @ . gov ;

TARANTINO, DAVID A @ cbp. dhs. gov > ; Baric, Ralph S .

unc.edu> ; WILKINSON
THOMAS @ . dhs. gov ; Hassell
, David ( Chris
) (OS ASPR/ @ hhs. gov> ; David

Gruber dshs. texas. gov) ; KAUSHIK , SANGEETA

@ hg.dhs .gov
Subject : Red Dawn Breaking , COVID - 19 Collaborative , Feb 16 start

Purpose : This is a new Red Dawn String to cut down the size from the previous string , opportunity to provide
thoughts , 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 , MS
ChiefMedicalOfficer
Departmentof

ExecutiveAssistant
: Nichole Burton
( U ) Warning
: This documentisUNCLASSIFIEDI FOR OFFICIALUSE ONLY( U ). Itcontains informationthat
maybe exemptfrom public releaseunderthe Freedom of InformationAct

From : CarterMecher
Sent: Monday, February 17, 2020 8 :57 AM
To: McNamara ; Dr. Eva K Lee
Cc: Caneva, Duane; Dodgen, Daniel(OS ASPR /SPPR ); DeBord, Kristin (OSASPR SPPR); Phillips
, Sally
( OS ASPR SPPR) DavidMarcozzi ; Hepburn,Matthew J CIV USARMY(USA) ; Lisa Koonin WargoMichael ; Walters,
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 (OS ASPR / SPPR ) ; Hassell,
David (Chris) (OS ASPR IO ) ; Hamel, Joseph (OS ASPR IO ) A @ CDPH ; RichardHatchett; Lawler
James 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: Nathaniel
Subject: RE Red Dawn Breaking, COVID - 19 Collaborative, Feb 16 start

NPls are goingto be centralto our responseto this outbreak ( assumingour estimatesof severity prove
accurate) This email group has grown since webegan (not quite epidemic- levelgrowth, but gettingthere . Looking
ate wemight encounterpushback over the implementation of NPls and would expectsimilar
concerns/ arguments as were raisedback in 2006 when this strategy first emerged. It was one of the reasons
shared the updated data on US households from American Community Survey, data on USDA programs for
nutritionalsupport( includingschoolmealprograms), data on schools and enrollment, and even data on juvenile
crime. The data thatwas gatheredback in 2006 on socialdensity in various environments (homes
offices/workplaces, schools, daycare, etc . , is unchanged). Foradditionalbackgroundand context, we attached are 3
papers on and TLC for those who are interested. Richard Hatchett deserves full credit for birthing the idea of
TLC ( it was actually developedin response to the threat ofH5N1and later adopted for pandemic influenza
response). Duane, perhaps you can store these documents on MAX for safe keeping and access?
The first paper is an historicalreview of the 1918 pandemic (the comparison of Philadelphia and St. Louis is
emblematic ofthe lesson from 1918 thattimingmatters when deploying to be early ). The second paper
is modelingwork thatwas done to evaluate these strategies. At the time, modelerswere focused on how best to
contain an outbreak overseas (really focusing on using antivirals primarily for treatment and prophylaxis). They
focused their models to evaluate the effectiveness of various strategies and quantities ofantiviralmedications
required to quench an emergingoutbreak. There were 3 groupswho were doing this work back then . They each
presenttheir 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 reduce overall attack rates. The
modelers also looked at timing of implementation(see figure 3 ) At the time there was a great dealof skepticism
was hard for people to believe this was possible. Or even if TLC could be effective, was implementationpractical
given the challenges trying to implementand the 2nd and 3rd order consequences (especially of closing schools). But
themodeling data combinedwith the historicaldata was the tippingpoint. Marty Cetron from CDC and Howard
Markelfrom U of Michigan, published a more extensivehistoricalreview of the 1918 pandemic showingmuch the
same. Since then , a group within CDC continued to work on this (collectingadditionaldata from the 2009 pandemic
and elsewhere). They published an update ofCMG in MMWR in 2017 . https:/ /protect2 fireeye. com /url? k = 3985fc87
65d1e5fb - 3985cdb8-Occ47adc5fa2-bb4a28993b5aa9e0& u https:/ /www .cdc. gov/media/dpk/ cdc- 24 -7 / preventing
pandemic-influenza/ community-mitigation- guidelines- for-preventing-pandemic-flu . html

The third paper, is a more recentpaper(from 2017) thatRichardshared with me

. The paperis a littledense, but
I found this paperusefulbecauseit provides a vocabularyforstrategiesthatwehave raised (Symptom Monitoringvs
Quarantineofpotentially infectedbutsymptom- free contacts duringan epidemic) . This paperidentifiesthose
conditionswhere SM or Q ispreferred . Figure 1 is usefulfor understanding
thechallengesgiven the picture that
seemsto be emergingwith this virus. This outbreak seemscloserto pandemicflu than SARS in termsof
bobtransmissiondynamics( and hence the wewould needto employ) .
Lastly, anotherperson, Bob Glass atLos Alamos, also did work on this separately from theMIDASgroup. Heactually
nce fair project for his daughter (using social contacts of his daughter and her
classmates at school to model disease transmission ). He knew someone at VA who forwarded his work to us (chain
of transmission ). Early on (even before the MIDAS group modeled TLC ) , we had a Eureka moment we
graphed his data in Excel ( can share that single graph to anyone interested ). Bob Glass was also interested in trying
to determine when you could let up on the NPls during a pandemic . Here is a story aboutBob Glass and that work
published in Fast Company will see if can find his work on when to reopen schools . Decisions in terms of letting
up on NPls could be critical down the line .
From : CarterMecher
Sent: Monday , February 17, 2020 2: 57 PM
To : Tracey McNamara; Dr. Eva K Lee
Cc: Caneva, Duane Dodgen, Daniel(OS/ASPR SPPR ); DeBord, Kristin (OSASPR/ SPPR); Phillips, Sally
(OSIASPR/ SPPR) David Marcozzi
; Hepburn, Matthew J CIV USARMY(USA) ; Lisa Koonin Wargo Michael ; Walters,
William (STATE.GOV) ; HARVEY
, MELISSA;WOLFE, HERBERT Eastman, 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 (OS ASPR ; CDPH ; Richard Hatchett; Lawler,
James V ; Kadlec , Robert (OS ASPR IO ); Martin , Gregory @ state. gov Borio , Luciana; Hanfling
Dan ; McDonald, Eric ; Wade, David; TARANTINO , DAVID A ; WILKINSON , THOMAS David Gruber
; KAUSHIK , SANGEETA ; Nathaniel @ gmail. com
Subject: RE: RedDawnBreaking
, COVID- 19 Collaborative
, Feb 16 start

Trying to estimate severity by bringing a number of pieces together .

The DiamondPrincess Cruise Ship had a crew of 1,745 and 2 ,666 passengers( totalpf 3, 711) Approximately 400of
the passengersare Americans (11% ). Severaldays ago (Feb- 13) we attemptedto estimate disease severity using
the currentdata beingreported by the media ( numberofconfirmedcases and ICU cases) as wellas data on the
outbreak in Singapore ( numberof confirmed cases, numberhospitalized
, and number in ICU ) ( see attachedWord
file )

Given the additional information becoming available ( including more specific information being reported by the media
of Americansinfected) I was interestedin an updated crude estimate of severity ( and to see how
well the early predictionsof severitymatchedwith whatwasbeingreportedby themedia on illness in the
Americans. See latestre the cruise ship outbreakbelow stories) . Wecan glean from these stories that the
numberinfectedis now up to 454. And 14 positive passengerswere includedamong the Americanswho were
evacuated to the US . Canada, South Korea, Italy and Hong Kong announced Sunday that they would also arrange
charter flights to evacuate their citizens . A few additional pieces of data . News reports yesterday stated that 73 of the
355 confirmed cases from the cruise ship were asymptomatic 20 % ). Also , yesterday themedia quoted Dr. Fauci
that the totalnumber ofAmericans who were confirmed to have COVID yesterday and who remained athospitals in
Japan at44. Assuming that this number doesnot include the 14 confirmed cases that were evacuated, suggests that
the totalnumber of Americans with confirmed COVID is 58. An earlier news report from Feb - 12 re a couple from
California , noted the husband was in the ICU in Japan (so at least 1American in the ICU ). [ . remained in a
hospital intensive care unit and has been able to communicate with his family , his wife said in a phone interview from
the ship , where she remained in quarantine ." https:// protect2 fireeve .com / url? k = -075555bf-5b017dfc
Occ47adc5fa2
5be62cf1a816fc6d & u = https :/ /web .archive .org /web /20200212093725 /https :/ /www .ocregister .com / 2020 /02/11/souther
n -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 cases
Assuming that proportion of asymptomatic cases in Americans is similar to the proportion of asymptomatic cases for
the entire ship (73/ 355 or 20 % ), we would estimate the number of Americans with asymptomatic infection at
Symptomatics would be 46 . If 2 % of cases result in ICU admission (based on earlier estimates on Feb -12 where 4
ICU 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 of whom treated in intensive care
units ." (Would be helpful to quantify " some" the earlier data , we would estimate about half that number would
require ICU care at some point ). For the 54 Americans confirmed to have COVID , we would estimate 1 would require
ICU care if 2 % of cases required ICU care (we are already aware of at least 1 American who was receiving ICU care
in Japan ).

So estimates of severity looking only at the American passengers :

400 total American passengers
58 confirmed to have COVID - 19
12 Asymptomatic( 20 % )
46 Symptomatic( 80 % )
total cases mildly ill (hospitalized for isolation only ) 31cases )
- 25 % of total cases 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 thosewhobecome
infectedwith 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 have
actual numbers from Japan on ICU admissions , number requiring mechanical ventilation , n
because they are acutely ill and number in the hospitalbecause of isolation only (mildly ill or asymptomatic ). Also
would be helpful to have more granular information on the Americans (hospital data in Japan including number
acutely ill number needing ICU admission , and number only in the hospital for isolation ). Would also be critical to
gather / compile the same information from Canada , South Korea , Italy , Hong Kong, and other nations as they also
evacuate their citizens . The cruise ship is a circumscribed population where it is possible to get a handle on severity
fairly early in an epidemic . The limitation though , is the population on board that ship is elderly ( so need to be careful
about generalizing to the entire population ). But it is the best data we have .

The reasonwhythis is so importantis decisionsre theimplementationofNPls dependupon severity ( themore

severethemoreintensethe . The soonerwehave a more accurateassessmentof severity, the better for
makingplans for NPls.

From : Carter Mecher

Sent: Monday , February 17 , 2020 10 : 39 PM
To : Caneva , Duane ; Tracey McNamara ; Dr. Eva K Lee; ail. com

. com om > ; Dodgen, Daniel(OS ASPR SPPR) ; DeBord Kristin

(OSIASPRSPPR ); Phillips
, Sally (OSASPR ) ; DavidMarcozzi
; Hepburn, Matthew J CIV USARMY(USA) ; Lisa
Koonin; Wargo Michael
; Walters, William (STATE.GOV) ; HARVEY, MELISSA; WOLFE, HERBERT
; Eastman,
Alexander EVANS, MARIEFRED Callahan. Michael
V . UTMB.EDU unc.edu; Johnson, Robert (OSASPR/ BARDA) ; Yeskey,
Kevin; Disbrow , Gary (OS ASPR/BARDA) ; Redd John (OS ASPR SPPR ); Hassell, David ( Chris)
(OSIASPR Hamel, Joseph (OS ASPR 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 Gruber
is. texas. gov ); KAUSHIK , SANGEETA ; Nathaniel Hupert
Subject : RE: Red Dawn Breaking COVID - 19 Collaborative , Feb 16 start

reallyneedhelp thinkingthru the testing piece (screeningfor COVID- 19). How do we protectthe staffin outpatient
clinics (where allthe ILI is typically seen and conservePPE by shiftingall themild illness away from clinics and
toward patients' homesusingtelephonecare/ telehealthand homehealthcareand employing homeisolationfor those
who are infectedand voluntaryhomequarantinefor otherwisewell (butexposedand potentiallyinfectedhousehold
contacts? Having all the suspectedpatients comingin to clinics to be screenedreally defeatsthe purpose. So how
Id very large numbers of outpatients get screened ? Home screening ? Drive thru screening ? Or creating a free
standing screening facility for rapid screening ? Has anyone thought this thru (how you screen for disease plus
promote adherence / compliance to home isolation and home quarantine and shift outpatient care of patients with mild
disease 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 per
day in primary care clinics across the US .

US Data
population 325,700,000
Hospital Beds , 107
ICU Beds 81,790
Hospital Admissions 36 ,353,946.00
ER Visits 145,600, 000
Family Practice/PC Visits 481
, 963, 000
TotalDeaths ,813,503
A Day in the US
HospitalAdmissions 99,600
InpatientCensus 85 % occupancy) 785 491
Census (85% occupancy) 69,522
ER Visits 398, 904
Family Practice/PC Visits 1 ,447
Deaths
Current Background of Similar to COVID -19
2019-20 Flu Season MMWR Week 5 ILIRate 6 .7 %
1. 4M hospitalizations annually forpneumonia
Medicare Average LOS Pneumonia 6 days
55 672 pneumonia & influenza deaths annually
Daily Hospital Admissions Pneumonia 3, 836
Hospital Census Pneumonia 23,014
Daily cases seen in 26,727
Daily cases seen in FP/PC clinics 88,470
Daily pneumonia & influenza deaths 153

Tuesday, February 18, 2020 11:01AM , Carter Mecher rote :

More puzzle pieces re the cruise ship outbreak .

 About 2 / 3rds of the passengers have been tested so far (2 ,404 out of 3 ,711).
61Americans opted to remain onboard and not be evacuated .

Japan has completed tests for all passengersand crew aboard the ship as ofMonday, butthe results for the
lastbatch of tests aren' t expected untilWednesday, the day that the quarantineis slated to end. So far, results
are back for 2 ,404 passengersand crew , out of the 3, 711whowere on board the ship when the quarantinebeganon
Feb. 5 .

Japanese Health Minister Katsunobu Kato said Tuesday that people who have tested negative for the virus would
start leaving on Wednesday , but that the process of releasing passengers and crew won 't be finished until Friday,
according to theWashington Post.

The remaining 61American passengers on the DP who opted not to join the evacuation will notbe allowed to return
to the US March 4 , accordingto the American embassy in Tokyo . The governments of Australia , Hong Kong and
Canada have also said they would evacuate passengers.

Elsewhere , Japan confirmed three more cases of the virus. This time, they were confirmed in Wakayama, a
prefecture in eastern Japan .

February 18, 2020 11

: 39 AM , Dr. Eva K wrote :

Wepredictedthe DiamondPrincess infection totalitybeforethey announcedit. Whatit shows-- is that intervention

( NPI
) mustbe done timely. A delayedinterventioncannotreversethe course and canbecatastrophic. They havefar
morepositive infectedcasesthan they shouldhave, have they interveneddifferentlyand swiftly. The health system
burden cannotbe overemphasized . Justthink about 1 % infection in Georgia, outofthat 20 % requiresmedical
attention. Thatis over 18, 000 people. Canwe handle theseextra peoplein the hospitals in a timelyand prolonged
manner? That is assumingnooneis goingto infect anyoneanymore. So this is themessagethe localMUST
undersatandand take action now .

So assumethose61Americanswillatleastget offthe cruiseand stay inland in Japan. And I hope Japan willnot
makethe crew stay on boardthe ship forlongerperiod of quarantine. Everyonehasto get off the ship now . The ship
now becomesthe bestclinicalforsenic evidenceto study the sufface contact, how longinfectionremainsactive and
of course, large-scaledisinfectionat the very end. ButI hope atleasttheywill collectsomeevidential
samplesfirst
beforeeverythingis destroy.

From : CarterMecher <

Sent: Tuesday, February 18, 2020 1:32 PM
Subject: RE: RedDawn Breaking, COVID - 19 Collaborative, Feb 16 start

CAUTION : This email originated from outside of DHS . DO NOT click links or open attachments unless you recognize
and / or trust the sender . Contact your component SOC with questions or concerns.

My thinkingis evolvingin termsofhealthcaresystem response. Initially I described how I would refocus the
outpatientclinics away from COVID care and leveragetheNPls of isolationand quarantineto help keep the
workplacesafe for the clinic staffand otherpatients ratherthan a strategy thatemploys PPE. I would only use the
outpatientclinic staff to help with telephone/homecare supportof those patients underhomeisolation or home
quarantine help with complianceladherence to isolationand quarantine, monitoringtheir health, and optimizingthe
care of their other chronicmedicalconditions( to keep them outof the ER and the hospital ) . Butas I thoughtmore
utthis, it occurs to methat this can be generalized beyond 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 , medical
specialty , surgical specialty , dental, mental health rehab , . ), as well as other inpatient areas (inpatient mental
health , substance abuse , nursing homes, hospice care , memory care , assisted living, etc .). Inpatient surgery ( and I
suppose labor and delivery ) is part of acute care , but for this outbreak , it probably best belongs bundled with the other
non -acute inpatient areas. I would anticipate that the tripwire for implementing NPls (community transmission ), will
also be the triggerfor healthcaresystemsto dialdownor turn off electiveadmissions(primarilysurgical
) to free up
acute care and ICU/monitoredmeds. Themosteffectiveway to protectthesenon- acute areas is by shuntingpotential
COVID patients awayfrom these areas and eitherprovidingthis type ofcare while the patientsis hospitalizedin
acute care or thru telephone care/homecare forpatientswith mild illnessreceivingcare at home
. And themost
effectiveway to shuntthese patientsawayfrom non-acute care areasis thru the implementationof early and
aggressiveNPls of isolation of the ill and homequarantineof household contacts ( andnotfit testingtheworld and
passingoutPPE thatwe don' t have).

On Tuesday, February 18, 2020 1:51PM, Caneva, Duane wrote :

Seems to me a big challenge willbe asymptomatic or mild symptoms in kids, spread through the schools , shed to
parents who both categories acute and non -acute care clinics . If there are several days of asymptomatic
shedding , 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, and it remainsthemostcritical
.
Henceeven 1 % ofinfection for us -- can balloonout of proportion and wecan' t handle. Sheddingnot only during
infectionperiod, butalso post-recovery. It' s a very long timelinethatwehave to dealwith . Then you haveall the
university siudents. Students travelledto China and cameback to school, they askedhealth service if they neededto
quarantineor take any action, theadvice - - no need. Those aremissedopportunities. Again , seasonalinfluenza
nfectedrequired hospitalization andmorality is roughly 0 . 1% . So it is easy
affects 8 - 10 % Americans .7 % of those infectedrequiredhospitalization
to " calculate" all these numbers backwards... So 20 % ofCOVID 19 infectedmayneedhospitalization,mortality is 10
30 timeshigher than seasonalflu . How much can we toleratebefore anyonewould spring into action? Keep in mind,
somebegin to infectrapidly upon contractingthe virus, the incubation is so short (and so long) and infectious too
duringthatperiod (with much beingunknown).

Carter, I think you will expectheterogeneousapproachesfrom differentcommunitiesin the overall response strategy,
since it dependson the socialsettingand the demographicsandmore importantly the localresources. We have to
optimize for sure.

On Tuesday, February 18, 2020 7 : 56 PM , Carter Mecher t> wrote:

Japan inching toward mitigation

Abe urgespeople with cold - like symptomsto avoid work , school

Today 06 :30 am JST 24 Comments

TOKYO

Prime Minister Shinzo Abe on Tuesday advised people across the country not to go to work or school if they develop
cold -like symptoms, as the country grapples with the spread of a new coronavirus originating in China .

Workplacesin the country, knownfor their longhours need to encouragepeopleto take daysoff withouthesitation if
they do notfeelwell, Abe said.

" The first thing that I want the people of Japan to keep in mind is to take time off schoolorwork and refrain from
leavingthe house if they develop cold -like symptomssuch as fever, " Abe told a meetingofa governmenttask force
on 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 more
people with no obvious link to China getting infected in Japan .
The global outbreak of the disease called COVID - 19 has prompted some event organizers in Japan to rethink their
plans for hosting mass gatherings .

The number of confirmed cases in Japan has topped 600 , including over 500 passengers and crew on the Diamond
Princess, a quarantined cruise ship docked at Yokohamanear Tokyo with more than 3 , 000 confined .

The steady risein infectionsin variousparts of Japanhasraisedpublic concern, promptingthehealthministry to ask

peoplewho develop symptomssuch as a temperatureof 37. 5 C or higherfor at leastfourdaysto consultlocalhealth
care centersand go to designatedhospitals. Theperiodis set shorterfor the elderly, thosewith underlyingconditions
and pregnantwomen.

As Tokyo and othermajor cities in the country are notorious for packed rush hourtrains, commutershave been
encouragedby a governmentpanelofmedicalexperts to go to work earlieror later than usualas the risk of infection
is increasedin crowds.

On Tuesday , Fujitsu Ltd and Hitachi Ltd said they are expanding teleworking, though Japanese companies overall
have been slow to introduce it.

From : CarterMecher
Sent
: Wednesday
, February19, 2020 4 :45 PM
Subject : RE: Red Dawn Breaking , COVID - 19 Collaborative
, Feb 16 start
Was listeningto the discussiontoday. There was a discussionabout the shortagesofPPE. There wasalso
discussionre , but m notsure thatmostfolks appreciatethat the thathavebeen arrayedas partof the
TLC strategy to reducediseasetransmissionin the community can be leveragedto create safer compartmentsor
spacesby shuntingdiseasetoward the home. By implementingthese interventions
, one could reducethe likelihood
ofdiseasein workplaces( homeisolationandhomequarantine keepingsick employeesathomeand
keeping employeeswho are wellbutpotentially infectedbecause someoneis sick in theirhousehold, at
neasuresincludingsocialdistancingatwork, helpsto reducecommunity
transmission(addsadditional
protectionto the workplace). The consequenceis shuntingdiseaseto the home- 120
M differentcompartmentsin the US, andmakingtheworkplacethe safe place. Thatis potentially very importantfor
criticalinfrastructure
. The answeris notPPE for these employees . Andwhy would we expect that employeesin
these sectorswould haveanybetterIPCwith theuse of PPE thanwe saw with staff on the DiamondPrincess?
Healthcareis a key criticalinfrastructure
. It is differentfrom the othersectorsin thatitwillbe attractingpatientswith
COVID likea magnet . It is hard to imaginehow one couldmakeshealthcare a safeworkplace
. Butit is only hardto
imaginehow onecould do thatunless you begin to look a little closeratthe differentcomponents thehealthcare
system and the roles each component mightplayduringthis pandemic.
To illustrate this, I took a stab atdevelopinga conopsorroadmapto look atthe variouspiecesofthehealthcare
system. The shuntingofdiseaseis really fractal
. Just as wecan look atshuntingdiseaseacross a communityinto
one compartment (the home ) to makeothercompartmentssafer, we can do the samewithin ourhealthcaresystem
shuntdiseaseto the acute care area where COVID patientswillbe concentrated . Whatare the strategiesto do that?
This conops is notional
. It is purposelydesignedfor a severeoutbreakwith severe diseaseand assumesthatthe
healthcaresystem must somehow continueto limp alongand continueto care for thebackgrounddiseasewe see
duringnormaltimes(strokes , fractures andtrauma, appendicitis
, otherseriousinfections
, CHF, diabetic
emergencies , psychoticepisodes, preeclampsia , complicateddeliveries
, end stagerenaldiseaseanddialysis, etc. )
aswell as sustain outpatientswith chronic conditionsthatrequiremonitoringand care to keepthem wellandoutof
the ER andoutofthehospital .

From : CarterMecher
Sent: Thursday, February 20 , 2020 6 : 39 AM
To: RichardHatchett; Dr. Eva K Lee
Cc: Tracey McNamara; Caneva, Duane; @ gmail. com ; Dodgen, Daniel(OS ASPR /SPPR ); DeBord, Kristin
( OS ASPR SPPR ); Phillips, Sally (OSIASPRSPPR) ; David Marcozzi
; Hepburn, Matthew CIV USARMY(USA) ; Lisa
Koonin; WargoMichael; Walters, William (STATE.GOV) ; HARVEY , MELISSA; WOLFE, HERBERT ; Eastman,
Alexander; EVANS, MARIEFRED; Callahan, Michael
V ., . D .; @ UTMB.EDU; @ email.unc. edu; Johnson, Robert (OS ASPR /BARDA) ; Yeskey
Kevin; Disbrow, Gary (OS ASPR/BARDA) ; Redd, Johnt(OS ASPR ) ; Hassell
, David(Chris)
(OSASPR IO ) ; Hamel Joseph (OS ASPRI Lawler, James V Kadlec, Robert
(OS ASPR ); Martin Gregory te .gov) ; Borio Luciana
; Hanfling
, Dan McDonald
, Eric; Wade
David; TARANTINO DAVID A WILKINSON THOMAS: David Gruber ; KAUSHIK
SANGEETA ; Nathaniel Hupert
Subject : RE: Red Dawn Breaking , COVID - 19 Collaborative , Feb 16 start

Keeping track of the outbreak aboard the cruise ship . The latest update is the announcement of 2 deaths (both
patients in their 80s ). An 87 -year -old man and an 84 -year-old woman , died on the 20th . Both were Japanese (the
87 -year-old man was hospitalized on Feb - 11and the 84 - year-old women on Feb - 12 ). So time to death from
recognition of infection was 8 -9 days. On Feb - 12, the total number of confirmed cases was 203 . So estimated CFR
back dating the denominator to Feb - 12 is 1 % . Assuming a denominator of621, the CFR is 0 . 3 % . deaths are
lagging by 8 - 10 days (and confirmed cases plateau ), we should have a pretty good estimate of CFR for he entire
group in another week or so . Will need to peel off the number of cases involving the crew
estimate of CFR in the elderly . These numbers are within the range we have been estimating
The 2 , 666 passengers are similar in age ( and likely in co -morbidities ) to the population we see in a nursing home or
residential care facility . The 1,045 crew are a proxy for a young healthy population . Itwill be important to look at the
outcomes separately . One of the concerns is how a ' remake of this movie ' could play out in similarly confined
populations of elderly frail Americans . Here are the numbers of long term care facilities /programs in the US that care
for the frail elderly . A large number of locations and a large number of residents /participants . I know thathealthcare
leaders were engaged yesterday , is anyone engaging this sector (long term care )? The healthcare leaders seemed
more concerned about critical supply shortages (akin to the IV fluid shortage ). Listening to them , it felt like their
concerns seemed almost divorced from the threat of COVID .

Number of Number of
Number of Number of Numberof
Facilities / Agencies/
Beds Residents Participants
Communities Centers

NursingHomes 15 ,600 1,700,000 1 300 ,000

ResidentialCare 28, 900 100 811, 500
Hospice Care 4 ,300 1 ,400, 000

|AdultDay Care 4 600 286, 300

Source: https: //www. cdc. gov/nchs/ fastats/nursing

- home
- care. htm

The outbreak on the cruise ship shouldbethe wake up call for leadersin longterm care ( and I would think healthcare
overall)

Here is a summary of the cruise ship data (as of Feb 20 )

Cumulative
Cumulative
Numberof
Date Event Numberof Notes
Confirmed
Deaths
Cases

20 - Jan Cruise ship departs from Yokohama Japan

25 - Jan year old passenger disembarks in Hong

Kong
year old passenger confirmed to have
COVID - 19

When results known, certificate of landing

1 -Feb canceled and ship under quarantine . Tests for
the virus would be administered to three
Igroups: those with symptoms, those who got
in Hong Kong, and those who had close
contact with the infected passenger.

-Feb Ship arrivesin port of YokohamaJapan

5-Feb passengers and crew confirmed +
6 -Feb more passengersand crew confirmed + 41

more passengerand crew confirmed +

8 -Feb morepassengerand crew confirmed + 170
10 -Feb morepassengerand crew confirmed + 136 439 tested
11- more passengerand crew confirmed + 492 tested
12- Feb | more passenger and crew confirmed + 203 4 in ICU
13- Feb passenger and crew confirmed + 218 713 tested
14 - Feb 67 more passenger and crew confirmed + 285 927 tested

73 asymptomatic;
15 -Feb passenger and crew confirmed + 355
1,219 tested

American evacuated from cruise

ship ( 14 of the evacuees found to be
+) 61Americans
16 - Feb
remained on
board 44
Americans remained hospitalized in Japan

1, 723
17- Feb more passenger and crew confirmed + 454 tested; 19
seriously ill
18 -Feb more passengerand crew confirmed+ , 011tested
19 -Feb 22 deaths
deaths 621

Data by country is a bit sketchy

Total Confirmed
Country Passengers Deaths
Cases Admissions

us 434

Hong Kong 330

Canada 256 32

Australia 241 46
UK

Italy
South Korea
Japan

142
Subtotal

New virus cruise ship disembarksand kills two Japanesepassengersin hospital

February 20, 2020 11

: 38

Two Japanesemen and women in their 80swho were hospitalizedand treated for the viruswere killed on the 20th in
a cruiseship passengerwhowas confirmedto be infectedwith the new coronavirus. This is the firsttime a cruise
ship passengerhas died and three people havebeen killed in the country.

As of the 19th , 621 cruise ships out of approximately 3 , 700 crew members and passengers on the cruise ship where
outbreaks 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 said
thatmen 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 Kanagawa
Prefecture on the 13th of this month .

From : CarterMecher
Sent: Thursday, February20 , 2020 7: 15 AM
To : RichardHatchett; Dr. Eva K Lee
Cc: TraceyMcNamara; Caneva, Duane; gmail.com ; Dodgen, Daniel(OSASPR SPPR) ; DeBord Kristin
(OS ASPR/ SPPR) ; Phillips, Sally (OS ASPR SPPR) ; David Marcozzi;Hepburn, Matthew J CIV USARMY(USA) ; Lisa
Koonin; Wargo Michael
; Walters, William ( STATE.GOV) ; HARVEY, MELISSA; WOLFE, HERBERT Eastman,
Alexander; EVANS
Johnson , 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; Nathaniel
Hupert
Subject
: RE: RedDawnBreaking, COVID- 19 Collaborative
, Feb 16 start

What has meworried is what happened on the cruise ship is a preview ofwhat will happen when this virus makes its
way to the US healthcare system (not to mention institutionalized high -risk populations in the US , like nursing
homes ). I 'm not sure that folks understand what is just over the horizon .
Remember the story about Mann Gulch ? We are at the equivalent of about 5 :44 . I anticipate that when we reach
5 : 45 , there is going to be chaos and panic to get anything in place . I doubt that what we would then hurriedly put in
place will be any better than what they did on that cruise ship . As a consequence , would expect much the same
results .
I listened to the discussion yesterday . After listening to James and Michael describe the conditions on and around
the cruise ship , I wondered whether anyone in healthcare leadership (outside the expertise at our biocontainment
facilities ) is thinking about infection control practices for any staff entering areas of a hospital caring for COVID
patients ( like changing clothes before entering and perhaps wearing scrubs, not bringing personal items into the area
like iphones , ipads , stethoscopes , white coats , purses , briefcases , etc . ) ? And instituting policies that require all
patients to phone for clearance to enter prior to presenting at safe acute and non -acute areas including community
based clinics we confident of the infection control practices of acute care staff (that they know the basics of how
to don and doff PPE and behavior while in PPE ? ) Would HCWs in outpatient clinics or long term care facilities be
any better prepared than the crew on board the cruise ship or the responders in Japan ? 'm no expert in infection
control and would defer to the expertise in this group . I was just a little surprised how little this seemed to be a
concern for the healthcare leaders gathered yesterday .

I think we are getting close to the point where we need to drop those things that are not criticaland focus on themost
importantthings.

We are going to have a devil of timewith lab confirmation — it is just too slow (they had a 2 day turnaround on the
cruise ship and we just don ' t have the capacity for the volume of tests we would anticipate . Charity has stressed this
pointagain and again . That means we are going to have to fly blind early on . Perhaps the best we are going to be
begin to accelerateis screenall suspectcases (prettymuchanyonewith
symptomswith a quick flu test andassumeanyonewho tests negativeis suspectedCOVID untilprovenotherwise
andtreat everyonewho tests positivewith Tamiflu. It will proveproblematicearly on, butas the epidemicbarrels
along, COVID will displaceeverything( atthatpointwe willjust assumethat anyonewith a feveror ILIhas
COVID). The problem is in thebeginning . It is going to be so hard to sort things out
. Matt, James andothers are
pushingfor more rapid screening but just aren't there yet. The consequenceis thatwewillbe placingpatients
with resp illness (thatis not flu andpresumedto be COVID) in areaswith actualCOVID patients. I hate to do that,
butnotsurehow it couldbe avoidedearlyon. Butwewould only do thatfor those who are ill enough to be
hospitalized
. The largenumberofasymptomaticandmildly illpatientswould be underhomeisolation (so no worries
aboutmixing confirmedand suspectedpatients) . The downsideis thatwewould havelargernumberofpeopleis
isolation andhome quarantinethan is really necessary(and the consequenceof increasedworkplaceabsenteeism) .

And it is becausehomeisolation andhomequarantineare so important , healthcaresystems( and notjust public

health) haveto grab a hold ofoperationalizing those NPlswith both hands . A while back , I created some
prescriptions tonguein cheek) , just to underscorethatphysiciansdo have a role in isolation and quarantine(it is not
limited to public health ). Wemightnothavepharmaceuticalsavailable to treatCOVID, butwhy can' t we write
prescriptionsfornon-pharmaceuticals ? don' t thinkhealthcareleadersappreciatethis point. Every COVID patient
we admit or see in the ER will requireus to follow up with householdmembersto make sure they know to home
quarantine(need to do the sameanywherein our system we find a patientwho is infected). You could notimagine
the pushback have received when proposedthatwemusthave an activerole seem to think that state and
localpublic health is aloneresponsiblefor this. I would think publichealth willbe overwhelmedand taking charge of
this is ourbest strategy to keep our safe areas safe.

I would be interested to hear how other healthcare systems and public health leaders are thinking about this.

From : CarterMecher
Sent: Sunday, February 23 , 2020 7 :28 AM
To: RichardHatchett; Dr. Eva K Lee
Cc: Tracey McNamara Caneva, Duane com ; Dodgen , Daniel (OS ASPR / SPPR ); DeBord , Kristin
(OS ASPR SPPR ); Phillips, Sally (OS ASPR / SPPR ); David Marcozzi ; Hepburn , Matthew J CIV USARMY (USA ); Lisa
Koonin ; 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(OS ASPR/IO ); 'Martin, Gregory J @ state. gov) ; Borio,
Luciana; Hanfling, Dan; McDonald, Eric; Wade, David; TARANTINO, DAVID A ; WILKINSON, THOMAS; David
Gruber shs.texas. gov) ; KAUSHIK, SANGEETA; NathanielHupert
Subject
: RE: Red DawnBreaking, COVID- 19 Collaborative
, Feb 16 start

Cruise 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 went thru some ofmy old emails and tried to thin thru the conops for envisioning how to organize and realign
the healthcare system to respond to this looming threat.

Somefollow up thoughts. Protectingoutpatientcare ( and therole and function of outpatientcarewith a massiveshift

toward care deliveredthru a phone) and leveragingTLC ( especiallyhomeisolationandhomequarantine ) is relatively
straightforward
. Doingthe samefor acute care areasdedicatedfor caringfornon-COVID patientsandlongterm care
is muchmorecomplex.

A thought came to me as I reread something shared with the group earlier.

The conceptof shuntingof disease is really fractal. Justas we can apply and look at shunting disease across a
community into one compartment( the home) to make other compartments safer, we can do the same within our
healthcare system disease to the acute care area where COVID patients willbe concentrated as well as
shunt disease into the home (homeisolation and home quarantine).

We talk aboutmedical
homesfor patients, so think of the equivalentof a medical
homemodelfor inpatientcare. Just
as we think about shunting diseaseto the home( as a meansofprotectingthe entire community) , can we think of an
inpatientarea thesameway. The entire inpatientarea (the entire safe area of thehospital
) is the community and
within the community are a numberof inpatientmedicalhomes. And those medicalhomeshavethe equivalentof
households( the patient( s ) within thathomeand the HCWscaring for them ). For TLC the smallest unit is the
household. Whatis that equivalentsmallestunit in hospitalsetting

The risk of introducingCOVID into this very dynamic communitycan be thru patients or staff. The numberof
inpatientstaff is probably on the order of 5 FTE perbed (roughly 5M staff for nearly 1 M beds), andnursesaccount
for about 30 % of hospitalstaff, so about 1. 5 perbed. The totalhospitalstaffing includesnumbers of employees
whonevercomein contactwith patients (or easily could be prevented from coming into contactwith patients) .
So over the span of a day, the numberoftotalhospitalpersonnelis about5 times higherthan the numberof
inpatients, however, the staff of greatestconcern arenurses
. So let' s focuson the primary care giverwho willhave
themostcontactwith the patient nursing. Over the span of a day, the numberofnursesthatwillhave contactwith
patients is aboutthe sameasthe numberof inpatients. Nearterm turnoverofnursesis negligible Turnoverof
patients ismuch, much higher( inpatient turningover on averageevery 3 - 4 days). So the risk is much, much
greater thatCOVID will be inadvertentlyintroducedthru a patient
who wasincorrectlytriaged or slips through with
asymptomaticdisease .

So now let' s getback to the idea of an inpatientmedicalhome. Patients are transients . They will enter and stay in
the inpatienthome for their hospitalization ( 3 - 4 days ). The idea of a homeis to also dedicate inpatient staff to that
ofnosocomial transmission/outbreakwithin this acute care area, we can shuntthe disease
outbreakto individualinpatienthomesand protectthe restofthe community(entirehospital ). Ideally, one would want
dedicatedstaff (primarilynursing, butonecould also think ofother inpatientteam memberssuch as NAs, health
techs, housekeeping , hospitalist
, etc.). It is unrealisticto have single patienthomes (just not enough staff to do that).
So whatcould be the smallestunitwithin a hospital ? This doesn' t needto beperfectjustbetterthan random
distributionof patientsthroughoutthe hospitalandassignment
ofstaff to care for them . Inpatient
wards do this
alreadyby specialty ( surgical
, medical
, psychiatric, etc. ). Nursingandotherstaff tend to have a homein either
medicineor surgeryor psychiatry, butit isn' t ironcladand nursesdo getreassig
simple solution would beto have a ward = inpatient medical homebutbemuch stricterin termsofdedicatedstaffing.
Soif a staffmemberworkingthere is foundto haveCOVID, we isolatethe staffmemberand quarantinethe ward
( effectivelytaking it outof service), but sparing therestofthehospital . The sameif wefind a patientwho is found to
have COVID, we isolatethe patientand quarantinethe restof thepatientsand staff. Again, effectivelytakingitout of
servicebutsparingthe restofthehospital . Itis relatively straightforwardandwardsare physicallyisolated (so staff
andpatients can bepreventedfrom mixing). This would requiretreatingeachward as a separateentity (no patient
movementsto otherwards, exceptfor theneed for ICU care which createsmore things to think thru). Thatmay
work for largehospitalswith largenumberofwards. Itmay notwork in smallerhospitalswith few wards ormixed
medical
/surgicalpatients.

Anotherthoughtis to define thepatienthomeby the day of admission. Wedid that in the old dayswhen I was a
residentandweadmittedpatients to a team (thatincludedtwo internsand twomedicalstudents) every 3rd day. But
wehousedpatients all over the hospital(pretty muchwherevertherewasan open bed). Think ofdoingexactly the
samebutonly admittingthem to a dedicatedarea orinpatient
homewith dedicatedinpatient24 / 7 staff. Thatwould
ssion andkeep them togetherwith single team caring for them ( from
dedicatednursingacross the shift, tech, hospitalist
, etc . ). Wouldneedto think aboutwhatmakes sense theinpatient
homeopeningits doors for admissionsevery 3 - 4 days or so) . If a patentis foundto have COVID, the response
would focuson thatinpatienthome isolate the illpatientand quarantinethe restof the home patients and staff) . If a
staff is found to have COVID, the response again would focuson the inpatient home, isolate the staffmemberand
quarantinetherestof thehome(patients andstaff) . By defininginpatienthomeby dayofadmission, it also helpsus
quickly doing the equivalentofa contacttracing sincewewould know the day the suspectpatiententeredthe system
andwhohad contactwith the patient .

can 't underscoreenoughhow importantthe early implementationof TLC is in a communityto tamp down community
transmissionandreducethe probabilitythateithera staff memberof a patientpresentingto thehospital willbe
infected
. It is the singlemostimportantthingwe can do. These strategieshelp to minimizethe disruption should
infectiousindividuals(staff or patients) slip thru our defenses
.

In addition to an inpatient medicalhome, how else mightwe leverage social distancing and infection control to
minimize transmission among staff and patients within an inpatient home ?

The next thing we need to think more about is the nursing home. Should we think of compartmentalizing the nursing
home ? The risk to the nursing home is primarily from staff since turnover of nursing home residents is so low . Are
there ways to create a LTC home where we break the nursing home into smaller subunits or LTC homes with a small
number of dedicated /assigned staffing to minimize the introduction of infection from staff into the nursing home or at
least shunt it into a subunit of the nursing home? It is easier to minimize the introduction of COVID thru a patient
(would need to quarantine all new admissions in an another area for 14 days before allowing them to be introduced
into the nursing home community ). Would also need to make sure that the staff caring for the quarantined nursing
home admission do not care for any nursing home patients or mix or mingle with other nursing home staff . I cant
underscore enough the importance of early TLC in a community to tamp down community transmission and reduce
the probability that a staffmember working in a nursing home will become infected . These strategies help to minimize
the disruption should infectious individuals (primarily staff ) slip thru our defenses .
Just trying to think thru ways to apply TLCmore effectivelyto healthcareto reducetransmissionand shunt disease to
smallercompartmentsto safeguard the entire system .

On Feb 23, 2020 , at 7: AM , Dr. Eva K Lee > wrote:

A few things I want to highlight - -

1. Means of spread A study from AMA confirmedmanyof the parametersassumed in ourmodels:

and went on infecting 5 relatives. When they testedpositive
was finally isolated, buttestednegativestill, and latertestedpositive, andremain normalon chestCT with no fever,
stomachor respiratorysymptoms( cough or sore throat as late as Fen 11( time of thepapertstudy duration) .

So spreading and its wide scope is unavoidable because there exists these very healthy individuals who can spread
effectively - - 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 - 19
virus is very adaptable and mutating rapidly .

3. Longrecovery The longrecoveryperiod is troubesomeandmustbe taken seriouslyby health providersas they

preparefor hospitalization. Thereis notmuch surgecapacity in hospitals. So they mustbe innoativein the staggering
processandisolationis ofparamountimportance . Government /Localshould bereadiedfor supplementing
medical
tents outsidehospitalswhen needed (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. I
overheard many people
-- (a ) asked when CDC would tell us more on what to do .
-- (b ) wish they could pull their kids out of school but there is no such option as part of the preventive measure (not
announced by CDC ).
-- ( ) wish CDCwouldrecommendtele-work optionsso they don't have to traveland exposethemselvesand their
family to unneccessaryrisk.
-- (d) haveno clue what the government
is doingto keep the risk low asitis now . Whatexactly is beingimplemented
to keep it low.

5 . Resource - limited countries pray that it would notreach the resource

- limitedcountrieslikemany in Africa
(though it seemsunavoidable). I cannotimagine the consequence.

6 . Whatwemust do: Wemustleveragethe knowledgefrom other countriesto betterprepareourselves. Japan' s

Crusis showsthe importanceof TIMELYproperisolationandSTRATEGICoperationslogisticsin testingandin
quarantine . South Korea (contrastingwith HongKong, Singapore ) demonstratescriticalimportanceof EARLYsocial
distancingand high compliancecommunity intervention . China's latestlockdownof 1/ billionpeopletruly
signifiesthat gravity and uncharteredterrority of this virus. No countrywould take to such extreme measure .

7 . CFR Since over 90 % of influenzaisnever recorded/known, this COVID - 19 seems to fall into similar spiritnow ,
with so many cases of asymptomtic and transmissionwhile incubating. While the true CFR remainsunknown, the
CFR of tested positivecases should offer a good comparison to the CFR of tested positive flu cases. That gives us a
clearer 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.
(Dr Lee is a atGaTech.

Means of spread A study from AMA confirmed many of the parameters assumed in ourmodels :
- A 20 -year old infected with COVID -19 leftWuhan and went on infecting 5 relatives. When they tested positive, she
was finally isolated, but tested negative still, and later tested positive, and remain normal on chest CT with no fever,
stomach or respiratory symptoms (cough or sore throat as 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 spread
effectively -- 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 , RobertR .

gov, Redfield ( CDC/ OD) , Redd, John (OS ASPR/ SPPR )
, Bryan (OS ASPR/ IO ) B . gov, Lee, Scott (OS ASPR /EMMO)
, Yeskey, Kevin (OS ASPR / hhs. gov, CarterMecher
RichardHatchett 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, David Marcozzi @ som . umaryland. edu, Hepburn , Matthew
J CIV USARMY (USA) .civ @ mail.mil @ gmail
. com , Walters, William

( STATE.GOV) @ state. gov

, HARVEY, MELISSA . gov, Wolfe
. dhs , Herbert
( DHS.GOV)
@ . . gov a @ hq.dhs. gov, EVANS, MARIEFRED
@ hq
. dhs
. gov, a
@ associates.hq dhs. gov, Callahan, Michael V . @ mgh.harvard.edu,
@ UTMB.EDU edu, email. unc. edu @ email.unc. edu, Johnson , Robert

( OSIASPR BARDA) @ hhs. gov , Disbrow , Gary ( OS ASPR BARDA @ hhs. gov, Hassell
,

David ( 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, Wade David . dhs. gov ,
@ cbp. dhs. gov @ cbp. dhs. gov, WILKINSON, THOMAS

hqdhs. gov, @ dshs

. texas
. gov @ dshs. texas. gov , KAUSHIK ,
SANGEETAS hq.dhs. gov ,Nathaniel

OnMonday, February 24 , 2020 12: 07 AM , Dr. Eva K Lee > wrote :

HiBob

Yes , it is reported in JAMA:

https: // jamanetwork . com / journals / fullarticle /2762028

Clearly, there' re stilllots ofuncertainty. However, there is no reason for them to lie . Furthermore
, in thevery first
model sentaroundthe results on Jan 30 , assumeinfectiousfor patients evenduring incubation, during infection,
1 / 3 asymptomatic, 2 / 3 symptomatic. I wasmotivatedto do that after talkingto theheadof laboratoryin HongKong
on Jan 29. He saidmanycases from his findings supportthatthe viralcounts are simply too low to surfaceatthe
beginningandhencecannotbe detected.

With that assumption , themodel can explain how and why the spread is so furious in China and why China resorts to
complete lock down of Hubei, and now 1/ 2 billion people Simply , people are carrying the virus everywhere . And this
young woman is doing exactly that. She wasn 't even tested positive after she infected her 5 relatives . Only
afterwards . That's why I modeled the test and told James of the days to test and that we either must test all,
or we must sample . The Diamond cruise partially supports that priority screening on only " suspected symptomatic
individuals " are not sufficient. Please note also thatbefore the Jan 23 lock down ofHubei, approx . 5 million people
have 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 we must roll out the NPI systematically .

Best, Eva

OnMonday, February 24 , 2020 5 55 AM , Dr. Eva K Lee < > wrote:

HiBob,
In addition to the JAMA paper, there is more -
1. Infectious during incubation:
Attached is another paperthatwill appearin LancetID this week . The viralload atearly diseaseonsetin high. In this
study, there were two individuals sheddinghigh level of viralRNAbefore symptoms . The resultin this LancetID
paperwas the basis formymodelassumption
. [ [ received the initialdraft about4 weeksago .]]

2. DiamondPrincess:
If the 80 yearold who boardedthe ship on Jan 20 and disembarkedon Jan 25 and showedsymptomslater and
tested positive on Jan 31, then that s yet another asymptomatictransmission. Theway the infectionspread on the
ship, even assumingno quarantineat all, reflects asymptomaticsecondaryinfection too in order to reach such high
number. Orthatthis man is a super spreader.

3 . Early a must:
Even if there is only 1 % COVID- 19 infection, and within which 20 % requireshospitalization, this will already
overwhelm ourhealth systems . Singaporeand HongKong have demonstratedthat early NPIcan help contain and
preventdiseasespread. In HongKong, governmentandprivate sectors are practicinghome- office tele-work) ,
schools are closed, community service even churchesare doingdistanceworship, and public places are disinfected
regularly, so is personal
hygiene. Regardlessif there is any asymptomatictransmission, wemusttake these steps
early. Weneed to allow parentsmake thatchoice, workersmakethatchoice, withoutbeingpenalizedby their
teachersand employers.

4 . Screening: Wemustbe strategic in community screening. Cartermademany points. Patientswho have flu - like
symptomswill go to their primary care, pediatrician, urgentcare, or even ED . So there is a big contamination risk.
Settingup a POD ( likemass dispensing ) for screeningmightbe good. So we can ensure screening is doneproperly
and with properprotectionto the providers. Since so little is knownabout this COVID - 19, a concentratedeffortas
such allows for knowledge sharing and disseminationrapidly across. Itis invaluable for the whole process.

5 . Care for COVID -19 patients : advocate separating the COVID -19 patients from hospital ED/ ICU patients since
COVID - 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 1
month behind ). Wuhan was overwhelmed less than 2 weeks later . I would expect the same for South Korea with the
epicenter 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 city
that will likely becomes its epicenter .

I see a few hopeful signs. Singapore and Hong Kong have done a great job thus far and have implemented
very early . Both have great surveillance . They are holding the line. They are also small and islands. Japan on the
other hand is struggling and hasn't been as aggressive as Singapore and HongKong.

The other thing thatgivesmehopeis what I see in HubeiandWuhan. realize the data is a little sketchybecause
Chinahasgoneback andforth with the definition of cases, butI tried to smooth thatoverby lookingat cumulative
hospitalizationratesper 100, 000 ( likewe do for flu ) . Hubei( and Wuhan is a city within Hubei ) reportseach day the
currentnumberofpeople in thehospital( # currently in severe condition, in criticalcondition), cumulativenumberof
hospitaldischarges , cumulativedeaths, andcumulativecases. From this we can estimate cumulativehospitalizations
and then rates. 92 % ofthe caseshavebeenhospitalized(up thru Feb 2nd 100% of the casesthey reportedwere
hospitalized
) Knowingthe numberof cases in Wuhan, wehavebeen estimatingthe numberhospitalizedassuminga
similar % ofthe casesrequiringhospitalizationrate for Wuhan ( that92 % of the cases are beinghospitalized that
numberis adjustedeach day basedon currentdata ). So we really can't back outthe Wuhannumbersfrom theHubei
numbers. Thebestwe can do is compareHubeitotals ( includingWuhan) with an estimateofWuhan. This data is
goodenough to show thatthe Chinese appearto be slowing transmissionoutsideofWuhan ( Theywere late to
implementNPlsin Wuhanbutwere able to implement earlier in the epidemicoutsideofWuhanbecausethe
outbreakhadabouta 2 week head- start in Wuhan) .
< EOB38B2300CE43F09DC37BFDDDB81F3C .png>

Weneedto emulatethe blue curve. If could subtract

Wuhan
, this curve wouldbe significantlylower
.

Remember the goals ofNPls.

From : Caneva, Duane

, February 24 , 2020 12 : 28 PM
Sent: Monday
To: Subject: RedDawnBreakingBad, StartFeb 24
Importance: High

All
This is a new Red Dawn Email String. Pleaseuse this one going forward .
Best
Duane

Duane C. Caneva , MD MS
ChiefMedical Officer
Department of Homeland Security

(U ) Warning: This documentis UNCLASSIFIED// FOR OFFICIALUSE ONLY (U // FOUO). It contains information that
maybe exemptfrom publicrelease underthe Freedom of InformationAct

From : Carter Mecher

Sent : Monday , February 24 , 2020 4 : 58 : 53 PM

To .dhs . gov @ hq. dhs. gov ; Richard Hatchett
@ cepi.net> ; Caneva Duane

. dhs. > gmail.com . com > ; Dodgen, Daniel( )

@ HHS.GOV> ; DeBord Kristin ( OS ASPR ) @ hhs . gov Phillips , Sally

(OSIASPR SPPR ) @ hhs . gov > David Marcozzi @ som . umaryland. edu > ; Hepburn, Matthew
CIV USARMY( USA) n . civ @ mail
. mil ; Lisa Koonin @ gmail. com > ; 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. edu @
mail.unc. edu > ; Johnson, Robert (OS ASPR/ BARDA) < Robert. Johnson @ hhs. gov ; , Kevin
hhs. gov>; Disbrow, Gary ( ASPR/ BARDA) @ hhs . > ; Redd , John

(OSASPR SPPR) @ hhs

. ; Hassell David(Chris
) (OS ASPR ) @ hhs. gov > ; Hamel
,

Joseph ( 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 @ iqt org> ; @ 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: Red Dawn Breaking Bad, Start Feb 24

Several new countries announced first confirmed cases

Afghanistan
Bahrain
Iraq
Kuwait
Oman
From : Walters , William @ state . gov

Sent: Tuesday , February 25 , 2020 6 : 56 PM

To : @ . dhs. gov ; Richard Hatchett @ cepi.net> ; Caneva, Duane
@ hg. dhs gmail.com ; Dodgen, Daniel (OSIASPR SPPR )
@ HHS .GOV > ; DeBord Kristin (OS ASPR SPPR ) @ hhs
. gov> ; Phillips
, Sally
( OS/ ASPR/ SPPR ) @ hhs. gov > David Marcozzi i @ som . umaryland.edu > ; Hepburn , Matthew
CIV 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 ; Martin
Gregory 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 > ; Nathaniel
Hupert 005 @ med. cornell.edu> ; TraceyMcNamara
sternu.edu > ; . K Lee Lee, Scott .gov > ; Carter
Mecher
Subject: Re: Red Dawn Breaking Bad, Start Feb 24

Colleagues ,
Does anyone have a case fatality rate projection broken down by age?
William A . Walters , M . D . , MBA
Executive Director and
Managing Director for OperationalMedicine
Bureau of Medical Services
U . S . Departmentof State

From : CarterMecher
Sent: Thursday, February 27 , 2020 5 :00 AM
To : TraceyMcNamara; Richard Hatchett; Tom Bossert
Cc: Caneva Duane; Dr. Eva K Lee Martin Gregory J; Walters, William ; HAMILTON
CAMERON .com ; Dodgen, Daniel(OS ASPR /SPPR) ; DeBord Kristin (OS ASPR SPPR) ; Phillips
,
Sally (OS ASPR/SPPR) DavidMarcozziHepburn Matthew J CIV USARMY(USA) : Lisa Koonin HARVEY
MELISSA; WOLFE, HERBERT Eastman, Alexander; EVANS, MARIEFRED; Callahan Michael
V . M . D.; @ UTMB.EDU; email.unc. edu; Johnson, Robert(OSASPR BARDA) ; Yeskey
Kevin Disbrow Gary (OS ASPR / BARDA) Redd John (OS ASPR ) HassellDavid (Chris)
(OS ASPR/ IO ; Hamel
, Joseph (OS ASPR ; A @ CDPH ; Lawler James V ; Borio Luciana; Hanfling
Dan; @ sdcounty . ca . gov ; Wade , David ; TARANTINO DAVID A ; WILKINSON
THOMAS dshs . texas. gov ; KAUSHIK , SANGEETA ; Nathaniel Hupert; Lee, Scott; Padget, Larry
G ; Ryan Morhard ; Stack Steven J (CHFS DPH
Subject : RE: Red Dawn Breaking Bad , Start Feb 24
Details below on case in California . From the cruise ship data we would estimate there are 20 -50 cases for each ICY
admission (assuming ICU admissions in 2 % -5 % of cases ). That ratio was for an aged population . Suspect that ratio
might be higher for a general population . And given the time from disease onset to being on a ventilator for at least a
week (since at least Feb 19 when the patient arrived at UC Davis ), the outbreak has had a good head start. That
would suggest we already have a significant outbreak and are well behind the curve . We are now well past the
equivalent 5 : 45 moment at Mann Gulch . You can ' t outrun it. They need to be thinking locally (full TLC including
school closure ).
[ I will send something I was looking at re the cruise ship data and kids . ]

https://www . sacbee. com /news/local/article240682311

. html
Latest : Coronavirus patientatUCDavisMedicalCentersince Feb. 19wasn' t tested for days
The SolanoCounty residentwho is the nation' s first confirmedcaseof coronavirusfrom " exposure in the community
hasbeen underthe care of UC DavisMedical Center for a week, accordingto an internalmemoobtained
Wednesdaynightby The SacramentoBee.
Justbefore 10 p. m ., thehospital
published thememothatwas sentto employeesby UC Davis Healthleadersearlier
in the day andoutlinesthe timelineofthe patient' s admission and disclosedthat severalemployeeswho were
exposedto the patientself-isolateathome"outof abundanceof caution."
Thepatientwhom the U . S . CentersforDiseaseControland Preventionconfirmedhas testedpositivethe COVID- 19
strain, wasmovedto the Sacramentoteachinghospitalon Feb. 19, accordingto thememosentto staffers by David
Lubarsky , thehead of the hospital
andUC Davis Health's vice chancellorof humanhealth services
, and Brad
Simmons
, thehealth system ' s interim CEO .
 The patient was transferred to the facility from another hospital, where a medical team had already put the patient on
a ventilator .
" The individual is a resident of Solano County and is receiving medical care in Sacramento County . The individual
had no known exposure to the virus through travel or close contact with a known infected individual, California
Department 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 care
workers should wear personal protective gear when with the patient to guard against exposure to droplets , said the
memo , 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 officials
perform 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 for
coronavirus at this time," the memo says . " Since the patient did not fit the existing CDC criteria for COVID - 19, a test
was not immediately 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 Wednesday
that 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 for
possible infection .
Just as when a health care worker has a small chance of exposure to other illnesses , such as TB or pertussis , we
are following standard CDC protocols for determination of exposure and surveillance , the memo said . “So , out of an
abundance of caution , in order to assure the health and safety of our employees , we are asking a small number of
employees to stay home and monitor their temperature .
"We are handling this in the same way we manage other diseases that require airborne precautions and monitoring ,
the memo said , adding hospital officials are in constant communication with the state health department and the
CDC and Sacramento County Public Health about the optimal management of this patient and possible employee
exposures ."
UCD officials did not respond to The Bee ' s request for comment.
The memo ended : “We are dedicated to providing the best care possible for this patient and continuing to protect the
health of our employees who care for them . "

From : Carter Mecher

Sent: Friday, February 28, 2020 5 : 20 AM
To : TraceyMcNamara; Baric, Ralph S Caneva , Duane; Richard Hatchett; Dr. Eva K Lee
Cc : Tom Bossert; Martin , Gregory ; Walters, William ; HAMILTON, ; Dodgen, Daniel
( OSIASPR SPPR ) ; DeBord Kristin (OS ASPR 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 (OS ASPR /BARDA) ; Redd, John (OSASPR/ SPPR ) ; Hassell,
David (Chris) (OS ASPR IO ) Hamel, Joseph ( OS ASPR IO ) Dean , ; Lawler James V ; Borio
Luciana; Hanfling, Dan sdcounty. ca. gov; Wade , David ; TARANTINO, DAVID A ; WILKINSON,
KAUSHIK, SANGEETA; Nathaniel
Hupert ; Lee, Scott; Padget Larry
G ; RyanMorhard; Stack, Steven J (CHFSDPH); Adams, Jerome(HHS/OASH); Fantinato, Jessica - OHS,
Washington
, DC ; Colby, Michelle - OHS, Washington, DC
Subject
: RE: RedDawnBreakingBad, StartFeb 24

Japan announced fifth death of Diamond Princess passenger (70 year old woman ). CFR for infected passengers is
now 0 .67 % ( this represents the lower limit of CFR ). Below are the latest numbers I have (had to make a correction
when I learned that the 705 total cases reported by Japan also included the 14 confirmed cases in Americans who
were evacuated but not the cases that have appeared in the remaining citizens from the US (28 ), Australia (8 ), Hong
Kong (4 ), UK ( 4 ), and Israel (2 ) after they were evacuated .

Cumulative Number of Cumulative Number of

Date Event Notes
ConfirmedCases Deaths

20 - Jan Cruise ship departs from Yokohama Japan

25 - Jan 80 year old passenger disembarks in Hong Kong

 80 year old passengerconfirmedto haveCOVID- 19

1 -Feb

When results known, certificate oflanding canceled and ship under quarantine. Tests for
the virus would be administered to three groups: those with symptoms, those who got off
Hong Kong, and those who had close contactwith the infected passenger.

3 -Feb arrives in port of Yokohama Japan

5 - Feb 10 passengers and crew confirmed +

6 - Feb more passengers and crew confirmed +

7 -Feb morepassengerand crew confirmed+

8 -Feb more passenger and crew confirmed +

10- Feb more passenger and crew confirmed + 136 439 tested

11-Feb more andcrew confirmed+ 175 492 tested

12-Feb morepassengerand crew confirmed+ 203 4 in ICU

13- Feb 15 more passenger and crew confirmed + 218 713 tested

14- Feb morepassengerand crew confirmed+ 285 927 tested

1, 219
15 - Feb more passenger and crew confirmed + 355 tested; 73
asymptomatic

329 American evacuated from cruise ship (14 ofthe evacueesfoundto be

16 - Feb 61Americans remained on 369
board 44 Americans remained hospitalized in Japan

1, 723
17 -Feb morepassengerandcrew confirmed+ 454 ested ;
seriously ill

18 -Feb more passenger and crew confirmed + 621 3 , 011tested

19-Feb 2 deaths 621

3 , 066
ested; 28
20- Feb 13morepassengerand crew confirmed + 634
seriously
ill; 322
asymptomatic

23 - Feb Death reported in Japan

24-Feb Japanupdates
totalto 691
; USreports 36 in US 691

3 , 894

Death reportedin Japan ; US reports 40 in US UK 4 Australia 7 HongKong 4 ; Israel2 ; tested; 35

25- Feb Total 744 ; plus 4 not on ship
seriously
ill; 380
asymptomatic
 JUS reports total of 42 cases in US Japan announces that45 of 813 former passengers
26 - Feb symptomsand will need to be tested new cases confirmed in the Diamond 750
Princess cruise ship , raising the total to 705 cases inside the ship

27-Feb Australia + 1) 8 cases (repatriated

)

27 -Feb Death reported in Japan

Cases Hospitalizedin CasesConfirmedupon Total Confirmed

Cou Passengers
/Crew ICU Admissions Deaths
Japan Repatriation Cases Infected

20 %

Hong 160

Kong

Canada

Australia

UK

Italy

South
Korea

Israel 2

Japan

Subtotal 1,433 262

Total 3 ,711
691 751

From : CarterMecher
Sent: Friday, February 28, 2020 5 : 37 AM
To : TraceyMcNamara; Baric Ralph S Caneva, Duane Richard Hatchett; Dr. Eva K Lee
Cc : Tom Bossert; Martin Gregory ; Walters William ; HAMILTON CAMERON; gmail. com Dodgen Daniel
(OS ASPR SPPR ) ; DeBord Kristin (OS ASPR / SPPR ); Phillips, Sally (OS ASPR SPPR Marcozzi
; Hepburn,
Matthew J CIV USARMY (USA); Lisa Koonin HARVEY, MELISSA , HERBERT Eastman,
Alexander; EVANS, MARIEFRED Callahan, MichaelV . . nson Robert
(OS ASPR / 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 ; WILKINSON
THOMAS; KAUSHIK , SANGEETA ; Nathaniel Hupert ; Lee Scott Padget, Larry
G : Ryan Morhard : Stack Steven J (CHFS DPH ) Adams (HHS/OASH ) Fantinato Jessica - OHS
Washington DC ; Colby Michelle - OHS Washington DC
Subject : RE: Red Dawn Breaking Bad, Start Feb 24

New areas impacted of spread from Italy), which tells us that the outbreak in Italy is substantial . Most
concerning development is case in Nigeria .
 Belarus traveler from Iran)
Lithuania
Netherlands traveler from Italy)
New Zealand
Nigeria (traveler from Italy)
Northern Ireland (traveler from Italy)
Wales (traveler from Italy )

FIRST CASE OF CORONA VIRUS DISEASE CONFIRMED IN NIGERIA

Friday, February 28, 2020
The FederalMinistry of Health has confirmed a coronavirus disease (COVID - 19) case in Lagos State Nigeria .
The case, which was confirmed on the 27th ofFebruary 2020 , is the first case to be reported in Nigeria since
the 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 25th
of 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, with
no serious symptoms, and is being managed at the Infectious Disease Hospital in Yaba , Lagos .
The Government ofNigeria , through the Federal Ministry of Health has been strengthening measures to
ensure an outbreak in Nigeria is controlled and contained quickly . The multi-sectoralCoronavirus
Preparedness Group led by the Nigeria Centre for Disease Control (NCDC) has immediately activated its
national Emergency Operations Centre and willwork closely with Lagos State Health authorities to respond
to this case and implement firm controlmeasures .
wish to assure all Nigerians that have we have been beefing up our preparedness capabilities since the first
confirmation of cases in China , and we will use all the resources made available by the government to
respond to this case .
We have already started working to identify all the contacts of the patient, sincehe entered Nigeria . Please
be reminded that mostpeople who become infected may experience only mild illness and recover easily , but
it can be more 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 protect
themselves and others , including their own families , following the precautions below :
1. Regularly and thoroughly wash your hands with soap and water , and use alcohol-based hand sanitiser.
2. Maintain at least 1 & halfmetres (5 feet) distance between yourself and anyone who is coughing or
sneezing.
3 . Persons with persistent cough or sneezing should stay homeor keep a social distance , butnotmix in
crowd
4 . Make sure you and people around you, follow good respiratory hygiene, meaning cover your mouth and
nose with a tissue or into your sleeve at the bent elbow or tissue when you cough or sneeze . Then dispose of
the used tissue immediately .
5 . Stay home if you feel unwell with symptoms like fever , cough and difficulty in breathing. Please call NCDC
toll free number which is available day and night, for guidance 970000 -10 . Do not engage in self
medication
6 . Stay informed on the latest developments about COVID - 19 through official channels on TV and Radio ,
including the Lagos State Ministry of Health , NCDC and Federal Ministry of Health .
Citizens must not abuse socialmedia and indulge in spreading misinformation that causes fear and panic .
The Federal Ministry of Health , through Nigeria Centre for Disease Control, will continue to provide updates
and will initiate allmeasures required to prevent the spread of any outbreak in Nigeria .

DrOsagie Ehanire
Hon. MinisterofHealth
https: / /ncdc. gov. ng/news/ 227 /first- . .med in -nigeria

From : CarterMecher
Sent: Friday, February 28 , 2020 7 : 31 AM
To: Tracey McNamara; Baric , Ralph S ; Caneva, Duane; Richard Hatchett; Dr. Eva K Lee
Cc: 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
( OS ASPR BARDA); Yeskey, Kevin; Disbrow, Gary (OS ASPR BARDA) ; Redd, John (OS ASPR ) ; Hassell ,
David ( Chris ( OS ASPR IO ) ; Hamel, Joseph ( OS ASPRI Lawler, James V ; Borio ,
Luciana; Hanfling, Dan; David; TARANTINO, DAVID A ; WILKINSON ,
THOMAS; SANGEETA; NathanielHupert; 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, DC
Subject: RE: Dawn BreakingBad, Start Feb 24

Italy has emerged as a major exporter of COVID . Above the surface , nothingmuch was happening in Italy until Feb
21 before that just a few cases reported , on Feb 20 Italy reported a cumulative total of 3 cases / deaths ). Over the
explodedand Italy has exported casesaroundthe world . Things exploded in matterof days ( or at
leastwere recognized to have exploded in a matter of days). That is what will likely happen here. Itwillbethat fast
and soon the US (becausewe are a major travelhub /destination could become an exporterof disease like
Italy. Think of thatwrt the window for implementingcommunity mitigationmeasures.

Timeline for Italy

Feb 22:

Over 50,000 people have been asked to stay at home in the areas concerned , while all public
activities such as carnival celebrations , church masses and sporting events havebeen
banned for up to a week .
Coronavirus , ordinance on compulsory quarantine and isolation for those returning from
China
VENETIAN UNIVERSITIES CLOSED . The universities of Veneto will remain closed due to the
Coronavirus emergency . This was announced by the president of Veneto , Luca Zaia
specifying that he had 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 journalists
on possible measures for events such as the Venice Carnival, Zaia said he awaits the
guidelines that will be issued by the minister ofhealth , Roberto Speranza , because the
initiatives must be uniform across the country .
Cases of the new coronavirus in Italy , the most affected country in Europe, rose on
Saturday to nearly 80 , killing two people and prompting the government to close off the
worsthit areas in the northern regions of Lombardy and Veneto . Authorities in the two
regions , where the outbreak is concentrated , have cancelled sports events and closed
schools and universities , while companies from Ray -Ban owner Luxottica to the country ' s
top bank UniCredit have told workers living in the affected areas to stay home.

Feb 23

" Prohibition of all individualsstillpresentin themunicipalityorarea from leavingthemunicipalityor the

affectedarea" ; " banon accessto themunicipalityor area concerned" ; " suspensionof eventsor initiativesof
any nature, ofevents and of any form ofmeeting in a public or private place, includingthoseofa cultural,
recreational, sportingand religiousnature, even if carried out in closed places open to the public" . Theseare
someof themeasurescontainedin the law decree approved this eveningby the Councilof Ministers to deal
with thespreadof the crown virus in the outbreakareas.

Othermeasuresalso include " the suspension ofearly childhoodeducation services and schools of all levels,
as well as the attendance of schooland higher educationactivities, exceptfor distance learning activities" ,
the " suspension of openingservicesto themuseum public " that" every educationaltrip , both on the
nationaland foreign territory " , and" the applicationof the quarantinemeasure with active surveillance
amongindividuals who havehad close contacts with confirmed cases of widespreadinfectious disease " .

in
Municipalities affected : Eleven municipalities in the Lodiarea and in the Veneto region are affected by the
coronavirus emergency and by the relevantmeasures taken by the authorities to prevent the spread ofthe
virus. Here is the complete list:

Vo ' Euganeo
Codogno
Castiglioned' Adda
Casalpusterlengo
Fombio
Maleo
Somaglia
Bertonico
Terranova deiPasserini
Castelgerundo
San Fiorano.

Carnivale in Venice suspended

Feb 25

Veneto , what is suspended and what is not. Open markets , closed cinemas . And ' private wedding
Coronavirus , what can be done and what cannot be done, after the state of emergency proclaimed in
Veneto ? What are the prohibited and allowed venues and events ? A circular from the Region explains it in
detail
1. All events that cause ' significant concentrations of people in public and private places' ARE SUSPENDED .
IN DEPTH
2. ' 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 , musical performances , 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 public
and 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 and
day centers .
7 . Marriages and funerals , civil religious , are NOT SUSPENDED , provided that participation is limited to
family members only .

Italian oil and gas contractor Saipem has confirmed thatmore than 2 , 000 staff are working from homedue to
the coronavirus .
Around 2, 196 employees , many whom are based in the firm ' s headquarters in Milan , are under what Saipem
called " working ”.

Feb 26

An Italian cruise ship, theMSCMeraviglia , was rejected by two ports in the Caribbean, Jamaicaand the
Cayman Islands , for fear of the coronavirus. A crew memberwould not be in goodhealth. The New York
the ship over 4 ,500 passengersand 1,600 crew members. Ithad arrived Tuesday morning
atthe port of Ocho Rios, Jamaica, comingfrom Miami . The landing banwas triggeredwhen the captain
communicated the flu status of oneof the people on board. Same situation at the port ofGeorgetown in the
Cayman Islands.

Feb 27

Coronavirus in Veneto , hospitals under pressure : more infections among doctors

Another cluster grows in Treviso . Zaia orders another 200 permanent hires for the emergency

From : CarterMecher
Sent: Friday, February28, 2020 8: 39 AM
To: TraceyMcNamara ; Baric, Ralph S Caneva, Duane; RichardHatchett; Dr. Eva K Lee
Cc: Tom Bossert; Martin, Gregory J; Walters, William ; HAMILTON, CAMERON; Dodgen, Daniel
(OSIASPRSPPR); DeBord, Kristin
(OS ASPR SPPR); Phillips, Sally (OSIASPRSPPR); DavidMarcozzi
; Hepburn, Matthew J CIV USARMY(USA); Lisa
Koonin; 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 ,
THOMAS
Scott; Padget, Larry G ; Ryan Morhard ; Stack, Steven J (CHFS DPH );
Adams, Jerome (HHS/OASH ); Fantinato , Jessica -
OHS , Washington , DC ; Colby , Michelle - OHS , Washington , DC
Subject : RE: Red Dawn Breaking Bad, Start Feb 24
 Updated tables

Cumulative Cumulative
Date Event Number of Numberof Notes
Confirmed Cases Deaths
20 - Jan Cruise ship departs from Yokohama Japan
25 - Jan 80 year old passenger disembarks in HongKong
year old passenger confirmed to have
COVID - 19
When results known, certificate of landing

1- Feb
canceled and ship under quarantine . Tests for
the virus would be administered to three groups:
those with symptoms, those who got off in Hong
Kong, and those who had close contact with the
infected passenger.
3 - Feb Ship arrives in port of Yokohama Japan
5 -Feb 10 passengers and crew confirmed + 10
6 - Feb 31 more passengers and crew confirmed + 41
7 - Feb 30 more passenger and crew confirmed + 61
8 - Feb 9 more passenger and crew confirmed + 70
10 -Feb 66 more passenger and crew confirmed + 136 439 tested
11- Feb more passenger and crew confirmed + 175 492 tested
12 - Feb more passengerand crew confirmed+ 203 4 in ICU
13 -Feb 15 more passengerand crew confirmed+ 218 713tested
14 -Feb 67 more passengerandcrew confirmed+ 285 927 tested
1 , 219 tested;
15 - Feb morepassengerand crew confirmed+ 355
73 asymptomatic

329American
evacuated
from cruise

ship ( 14 of theevacuees
found
to be

61Americans
16- Feb 369
remained on
board 44
Americansremainedhospitalizedin Japan
1,723tested
17 -Feb 85 more passengerand crew confirmed+ 454
19 seriouslyill
18 -Feb passenger andcrew confirmed + 621 3 , 011tested
19- Feb 2 deaths 621 2
3 , 066 tested
20 -Feb morepassengerand crew confirmed+ 634 2 28 seriously ill;
322 asymptomatic
23-Feb Deathreportedin Japan
24-Feb Japan updatestotalto 691USreports36 inUS 691

Deathreportedin Japan reports40 in US 3 , 894 tested

25 - Feb UK 4 Australia7 Kong4 Israel2 734 35 seriously ill;
744 ; plus 4 noton ship 380 asymptomatic

USreportstotal of 42 cases in US Japan

announcesthat 45 of813 formerpassengers
havesymptoms andwillneed to be tested 14
26 - Feb
new cases confirmedin the DiamondPrincess
cruise ship raisingthe totalto 705 casesinside
the ship
27 - Feb Australia( 1) 8 cases(repatriated
) 751
28- Feb 2 deathsreportedin Japan 751

Cases
Cases Total
Confirmed ICU
Country Passengers /Crew Hospitalized Confirmed Deaths
upon Admissions Infected
in Japan Cases
Repatriation
US 434 44 42 86 20 %
HongKong 364 55 59 16 %
Canada 256 47 18 %
Australia 241 8 23 %
UK 78 13%
Italy 35
South Korea 14
Israel 11 45%

Japan
Subtotal 1,433 202
Total 3 , 711 691 20 %

From : CarterMecher
Sent: Friday, February 28 , 2020 9 : 14 AM
To: Tracey McNamara; Baric, Ralph S ; Caneva, Duane; RichardHatchett; Dr. Eva K Lee
Cc: 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); Lisa
Koonin ; 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 , DC
Subject: RE: Red Dawn Breaking Bad, Start Feb 24
This might be of interest. A comparison I ran of the distribution of the US population by age group compared to the
passengers and crew aboard the
Diamond Princess ( surprised nobody ever did this ). Except for kids, the cruise ship data tells a lot about adults (really
shifted toward the 60 -80 year
old group )

Cruise Ship
USPopulation
AGE % Distribution Passengers & % Distribution
2017
Crew

0-9 years 40,243,098 12 % 0%

10- 19 years 41,910 ,114 13% 23 1%
20-29 years 45 ,489, 095 14% 347 9%
30-39 years 43,204,209 13% 428 12 %

40-49 years 40 ,617,231 12 % 334 9 %

50-59 years 43, 409,050 13% 398 11%

60-69 years 36 , 824,083 11% 923 25 %

70-79 years 21, 588 , 326 7% 1,015 27 %
> years 12, 433, 972 4 % 227 6 %
Total population 325 719, 178 100% ,711 100 %

Here is how the distributions compare when I only look at age essentially

Cruise Ship
US Population
AGE % Distribution Passengers & % Distribution
2017 Crew
20-29 years 45 ,489,095 19% 347 9%
30-39 years 43,204, 209 18 % 428 12 %
40-49 years 40,617,231 17% 334 9%

50-59 years 43,409,050 18 % 11%

60-69 years 36 ,824 , 083 15 % 923 25 %
70-79 years 21588, 326 9% 1,015 27 %
> years 12, 433, 972 5% 227 6

Total population 243,565, 966 % 672 100 %

Friday , February 28 , 2020 12:21PM , Dr. Eva K Lee

Three things:
1. biosurvelliance

Carter, yes, a month ago you talked aboutwanting to screen everyonewho comes into ED and ICU. And I wanted to
sample tests even those who don 't come into ED ICU , and we wanted to include primary care also .
At themoment
, weindeed havenot yet gone forward with any of these. The" unknownorigin" case in California
showsttatwemissed a wholeweek before shewas tested. And shemay very well notbepatientzero becauseshe
could have gotten it from someonewith no symptomsatall. And yes, wenow havemultiplesources (clearly) and it is
unclearhow far itwill / can go . Weare like Europe
, each state is connectedto each other through air and ground
transit.

It is notunexpected about the widespread from Italy. I know it sounds a bit silly , when I lived in Lausanne Switzerland
we would drive to Annecy France to have dinner (students do go everywhere ). So spread in Europe is unavoidable .

The unusalcase is thatthis Californiacase sheis youngbut she is very sick.

This site has details on mortality vs age groups.

https: / /multimedia scmp com / infographics

/news
/ china/article/ 3047038
/wuhan-virus/ index. html

2. Drive Through Screening

I just got back from discussion with the head nurse in Mississippi. I went through the drive -through setup and
screening and she is very pleased . She told me although they have been planning for pandemic since 2006 , many
people still do notknow what their roles are and what they are supposed to do during pandemic flu crisis . Now
COVID - 19 causes more confusion . I wll finish the final layout and the information and send it around for comments .
Some states already have my earlier version . I want to give more detail so they can prepare .

3 . Homelesspopulation

Any big or urban cities are going to face the challenges in containment and homeless popiulation needs to be taken
care 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 check
out how the homeless population is preparing for these and what we are providing on the medical fronts .

Eva

On Friday, February28 , 2020 8: 16 AM , CarterMecher wrote :

My concern is that a possiblescenario is thatwe becomeItaly part 2 (the sequel

).

Italy had to have had ongoing community transmission well before Feb 21st when things appeared to take off for the
reak to take off this quickly including 17 deaths) and to have the amountof spread across the globe in such a
short period of time. I suspect that prevalence is much higher than anyone realized. Watching how aggressively they
implemented NPls includingcordon sanitaire (within just a couple of days of the first deaths and the acceleration in
the number of confirmed/ suspected cases) and the continued explosive growth suggests to methat diseasemust
have been much more prevalent.

The lesson is that although things might have looked under control on Feb 20 (3 cases / deaths), things obviously
weren 't fine . They couldn 't see how large the iceberg was below the water line. They were blind to the extent of
disease and the extent of ongoing transmission .

Wehave also beenflying blind. Wesee thatpart of icebergabove the surface ( 60 cases in the US) . But
becauseof little to no surveillance(other than ourfocus on travelers from China), wehavelittle awarenessofwhatis
below the surface. Thecase in CA confirmsthatwhatis below the surfaceislargerthan whatis above ( given what
we learned from the cruise ship wrt the % of cases that endup in the ICU and the delay in recognizingthis case) . The
CA patientwas in an ICU and on a ventilator formore than 1 week beforewe even hadconfirmation .

So the scenario am concerned about is the Italy scenario . We have unrecognized smoldering community
transmission . We don 't recognize the large numbers of asymptomatics (maybe half of the cases) , we miss the mildly
ill (maybe another 38 % or so ), and the remaining 12 % get lost in the busy flu season .

Italy actually acted pretty quickly once they realized whatwas happening ( things explode on Feb 21 and they
implementNPls pretty aggressively on Feb 22) . ' m not sure we willbe able to act thatquickly.
A few weeks ago we talked about our priorities surveillance and early implementation of NPls. We still don ' t have
surveillance , and because of thatwe will likely be late to implement like Italy.

From : CarterMecher
Sent: Friday, February 28, 2020 9:26 AM
To: Tracey McNamara; Baric, Ralph S; Caneva, Duane; RichardHatchett ; Dr. Eva K Lee
Cc: Tom Bossert; Martin, Gregory J; Walters, William ; HAMILTON, CAMERON ; Dodgen
, Daniel
(OSASPR ); DeBord, Kristin
(OS/ ASPR/ 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. , M . D . ; UTMB
. EDU; Johnson, Robert
( OS ASPR/ BARDA); , Kevin; ,
(OS ASPR BARDA ) ; Redd, John (OS ASPR/ SPPR); Hassell, David( Chris) (OS ASPR/ ; Hamel, Joseph
(OS ASPR IO ); Lawler, James V ;
Borio, Luciana; Hanfling, Dan;
david
KAUSHIK , 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, DC
Subject
: RE: Red DawnBreakingBad, StartFeb 24

I think this data is close enough to convince people that this is going to bebad and we will need to pull the full array
ofNis ( TLC) . All that is left is 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 individual
outbreaks .

In St. Louis , were put in place 1 week after the first cases at Jefferson Barracks, 5 days after the first death , and
3 days after the first civilian cases in St. Louis . In Philadelphia , were put in place 3 weeks after the first cases at
the Navy Yard , 16 days after the first civilian cases in

Philadelphia, 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 measures
China implemented to slow transmission happened about two later in the course of the outbreak in Wuhan compared
to the rest of Hubei Province . That comparison looks a lot like Philadelphia and St. Louis .

So we have a relatively narrow window and we are flying blind.

Looks like Italy missed it.

From : Tom Bossert

Sent: Friday, February 28 , 2020 8 : 06 : 19 PM
To : Carter Mecher
Cc: Tracey McNamara @ westernu
. edu>; Baric, Ralph email. unc. edu> ; Caneva, Duane
@ . gov > ; Richard Hatchett @ cepi
. net> ; Dr. Eva Lee

Martin, GregoryJ @ state. gov ; Walters

, tate.

HAMILTON
, CAMERON @ hg. dhs
. . com @ gmail. com > ; Dodgen,
Daniel(OS ASPR SPPR) @ hhs. gov ; DeBord Kristin (OS ASPR )
. gov > ; Phillips, Sally (OS/ASPR SPPR @ hhs. gov> DavidMarcozzi
som . umaryland
. edu> ; Hepburn, Matthew J CIV USARMY(USA) @ mail.mil> ;

Lisa Koonin @ gmail. com > ; HARVEY, @ . gov ; WOLFE, HERBERT

@ hg. dhs. gov > ; Eastman, Alexander @ hg. dhs. gov > ; EVANS, MARIEFRED
 @ associates. . . gov ; Callahan, MichaelV . , M . D .
@ mgh .harvard. edu> ; @ UTMB.EDU @ utmb. edu> ; Johnson, Robert

OS ASPR/ BARDA) hhs. gov ; Yeskey, Kevin < k @ hhs. gov > ; Disbrow, Gary
( OS @ hhs. gov ; Redd, John ( OS ASPR SPPR ) @ hhs. gov > ; Hassell
,

David ( Chris) ( OS/ ASPR/ ) @ hhs

. gov> Hamel
, Joseph ( OS/ ASPRO hhs. gov > ;

Dean, Charity A @ CDPH < @ cdph. ca . gov> ; Lawler

, James mc.edu > ; Borio, Luciana
arg> ; Hanfling, Dan
org > @ sdcounty.ca . gov d @ sdcounty . ca . gov ; Wade, David
@ . dhs. gov ; TARANTINO , DAVID A @ cbp. dhs , THOMAS
. gov> ; WILKINSON
@ hq . gov> ; r @ dshs
.texas
. gov @ dshs. texas. gov > ; KAUSHIK ,

SANGEETA < hq . Nathaniel Hupert 5 @ med. cornell . edu > ; Lee , Scott

hhs. gov > ; Padget, Larry G state . gov > ; Ryan Morhard rd @ weforum . org > ;

Stack , Steven ( CHFS DPH) k @ ky. gov ; Adams, Jerome ( HHS/ OASH ) < s @ hhs.gov ;
Fantinato , Jessica - OHS, Washington, DC @ usda. gov> ; Colby, Michelle - OHS, Washington , DC
y @ usda. gov
Subject: Re: Red Dawn Breaking Bad, Start Feb 24

On Friday, February 28, 2020 8 : 28 PM , Caneva, Duane . dhs. gov > wrote :

Criticalsectors likeHealthcareneedto be empoweredby Governmentto establish ReliabilityOrganizations

unencumberedby Federalbureaucracy . The sector should be expected to identify risk, prepare and respondto
predictablehazards. Less than a yearafter CrimsonContagion, andhow much of the Sectorwas informed and
improvedby the "lessonslearned ' s even heard of it ?

On Friday, February28 , 2020 10 : 39 PM , Dr. Eva K Lee @ pm .me> wrote:

I don' t know much aboutthe Crimson Contagion. But clearly planning itselfdoes not includeenough uncertaintiesfor
people to really think aboutwhatcould go wrong. For example, itassumesevery place is going to acceptthepatient
being sentto them is that true, I do notknow ) . The Alabamacase where they refusedto house someAmerican
passengerswith coronavirusin Anniston, Ala . after these individualswere evacuatedfrom the Diamond Princess
cruise ship was a good example - - can we plan that a judge or the president
, or senators would intervenein such
situation ?

James accepts the 14 patients readily in Nebraska. The unknowniswhat wehave been planningfor allthese years.
So if not doing it now , when ? Everyone has to step up now .

I do believe if we can summon all the capabilities around the country (private and government sectors ), we can put up
a very good and successful fight. And being decisive in making the calls of action is of paramount importance .

From : CarterMecher
Sent: Friday, February 28 , 2020 9: 26 AM
To: TraceyMcNamara; Baric, Ralph S Caneva, Duane; RichardHatchett; Dr. Eva K Lee
Cc: Tom Bossert; Martin, Gregory J ; Walters, William ; HAMILTON, . com ; Dodgen, Daniel
(OSIASPR/ SPPR ) DeBord, Kristin (OS ASPR / SPPR) ; Phillips, Sally (OS ASPR / SPPR ) ; DavidMarcozzi ; Hepburn ,
Matthew J CIV USARMY (USA); Lisa Koonin HARVEY, MELISSA; WOLFE, HERBERT
; Eastman,
Alexander; EVANS, MARIEFRED Callahan, Michael V . @ 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 WILKINSON
THOMAS; . texas. gov; KAUSHIK, SANGEETA NathanielHupert; Lee, Scott; Padget, Larry
G ; Ryan Morhard; Stack, Steven J (CHFS DPH ) ; Adams, Jerome (HHSOASH) ; Fantinato, Jessica - OHS,
Washington, DC Colby Michelle - OHS, Washington, DC
Subject: RE: Red Dawn BreakingBad, Start Feb 24

I think this data is close enough to convince people that this is going to bebad and we will need to pull the full array
of Nis (TLC ). All that is left is when (timing ).
I wentback to our comparisonof Philadelphiaand St . Louis in 1918. The differencebetweenPhiladelphiaand St.
Louis in termswhen they pulled the trigger on NPlswas abouttwo weeksduring the courseof their individual
outbreaks .

In St. Louis , NPls were put in place 1 week after the first cases at Jefferson Barracks , 5 days after the first death , and
3 days after the first civilian cases in St. Louis. In Philadelphia , put in place 3 weeks after the first cases at
the Navy Yard , 16 days after the first civilian cases in Philadelphia , 2 weeks after the first death . In the cases of
, timing matters .

Wewould estimate that the outbreak in Wuhan had about a 2week headstarton the rest of Hubei. So themeasures
China implemented to slow transmissionhappened abouttwo later in the course of the outbreak in Wuh
to the restofHubeiProvince. That comparisonlooks a lotlike Philadelphia and St. Louis.

we have a relatively narrow window and we are flying blind.

From CarterMecher
Sent: Friday, February 28, 2020 11
:52 AM
To: TraceyMcNamara; Baric , Ralph S ; Caneva, Duane Richard Hatchett; Dr. Eva K Lee
Cc : Tom Bossert Martin Gregory ; Walters, William HAMILTON, CAMERON; Dodgen, Daniel
( OS ASPR/SPPR ); DeBord, Kristin (OSASPR SPPR ) Phillips, Sally ( OS/ ASPR/SPPR ); David Marcozzi
; Hepburn,
Matthew J CIV USARMY(USA) LisaKoonin HARVEY, MELISSA: WOLFE HERBERT: Eastman
Alexander EVANS, MARIEFRED; Callahan MichaelV . Johnson, Robert
(OS/ASPR /BARDA) Yeskey, Kevin Disbrow Gary (OS/ASPR /BARDA) ; Redd John (OS ASPR/ SPPR ) Hassell
David (Chris) (OS ASPR IO ); Hamel Joseph (OS ASPR IO ) ; Dean, Charity A @ CDPH Lawler, James V Borio,
Luciana; Hanfling, Dan; Wade , David ; TARANTINO , DAVID A ; WILKINSON
THOMAS; @ dshs. texas. gov KAUSHIK, SANGEETA Nathaniel Hupert Scott PadgetLarry
G : Ryan Morhard: Stack Steven J (CHFS DPH ) Adams Jerome(HHS/OASH) Fantinato Jessica- OHS
Washington, DC Colby, Michelle - OHS, Washington, DC
Subject: RE: Red Dawn BreakingBad, StartFeb 24

Estimatesofthe impactof COVID on VA

In FY2019, VA cared for 6, 271, 019 unique veterans and had 9, 237 ,638 veteran enrollees

The DiamondPrincesscruise ship outbreakcan provide invaluableinsightsinto the potentialimpactto VA .

Below is a comparisonoftheUS population
, the adultpopulationaboardthe cruise ship , and the Veteranpopulation
.

20- years 45,489,095 347 932,473 5%

30 -39 years , ,209 18 % 428 12 % ,045 10 %
40 - years ,231 17 % 334 9% 2 194,505
50 -59 years ,050 18 % 11% 3, 169,787 17 %
-69 years 36 ,824,083 15 % 923 25 % 3,735, 399 19 %
70-79 years ,326 19% 1,015 27 % 4, ,551
> 80 years 12,433,972 5% 227 ,943 14%
Total population , 565 , 966 100 3, 672 100 % 19,209,704 100 %

The Veteranpopulationis similar to the cruisepopulation. If anything, theveteran population is even older( at
even higherrisk). There were 3 ,711passengersand crew aboardthe crew ship ( 1, 045 crew and 2 ,666
passengers) . As of February 28 , 2020, therehavebeen 751confirmedcases of COVID (attack rate of20 % ). There
havebeen 6 deathsthusfar (lower limitof a casefatality rate of 0.80 % ) A timelineofthe outbreakisprovidedatthe
bottom ofthis message
. 380 of the confirmedcaseswere asymptomatic(50.6 % ). Itis estimatedthatapproximately
12 - 15% of the 751 passengersand crew with confirmeddiseaserequiredacute care with 36 hospitalizedpatients
reportedto be in seriouscondition ( 5 % ) .

Given the similaritiesof the demographics ofthe cruise ship and veterans, we could project the potential impacton
veterans

All Veterans 19, 209,704 3,841, 941 1, 944,022 461,033 192,097 30 ,736
Veteran Enrollees ,237,638 ,528 ,849 703 , 376 14,780
Veteran Uniques ,271,019 1254, 204 1634 627 150,504 710 10 034
Need to place these numbers into perspective .

Acute Inpatient Care VHA Total

OperatingBeds Hospital 15,744

OperatingBedsMedicine/Surgery 9 ,817

Operating Beds ICU 1,692

ADC Hospital ,805

ADCMedicine
/ Surgery 6, 225

ADC ICU 1, 101

ADC On a Ventilator 40
DailyHospital
Admissions 1641
Daily Admissions Medicine/ Surgery 1,226
Daily Admissions/Transfers in ICU 389

EmergencyDepartment Care
DailyER Visits 6 . 874

Outpatient
Care (non- ER )

Clinic Visits 209 336

Annually, VA has:
450, 000 acute (medical
/ surgical
) admissions
140.000 ICU admissions
2 . 5M R/ UrgentCare visits

Ifwe assumethatthis outbreak will lastapproximately3 months

, we can then overlay the projecteddemandupon the
usualbackgroundutilizationover 3 months.

Even if we simply focus on the veteran uniques (veterans who use VA services), we can assume that there mightbe
3 ER visits for each admission-- so roughly 450 ,000 ER visits, 150,000 hospitalizations, and 63, 000 ICU admissions.

Over an average 3 month period, VA wouldhave , 000 ER /Urgentcare visits, 112,000 acute care admissions,
and 35 , 000 ICU admissions.

Now you understandthe 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 for
people to really think aboutwhat could go wrong . For example , it assumes every place is going to accept the patient
being sent to them is that true, I do notknow ). The Alabama case where they refused to house some American
passengers with coronavirus in Anniston, Ala ., after these individuals were evacuated from the Diamond Princess
cruise ship was a good example - - can weplan that a judge or the president, or senators would intervene in such
situation ?

James accepts tthe 14 patients readily in Nebraska . The unknown is what we have been planning for all these years .
So if notdoing itnow , when ? Everyone has to step up now .

I do believe if we can summon all the capabilities around the country (private and government sectors ), we can put up
a very good and successful fight. And being decisive in making the calls of action is of paramount importance .

From : CarterMecher er net

Sent: Saturday, February29 2020 2: 09 PM
To: Dr. Eva K Lee me>

Cc: Lawler, James V . edu ; Tracey McNamara @ westernu. edu > ; Baric, Ralph S
c. edu ; Caneva, Duane . dhs . gov > ; Richard

Hatchett @ 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

(OS ASPR SPPR) hhs

. gov> ; DavidMarcozzi @ som .umaryland
.edu> ; Hepburn, Matthew
CIV USARMY(USA) mail.mil> ; Lisa
@ gmail. com > ; HARVEY
, MELISSA < @ hq.dhs. gov> ; WOLFE, HERBERT
< F @ hq.dhs. gov >; Eastman, Alexander @ hq.dhs . gov> ; EVANS
MARIEFRED associates
.hqdhs.gov> Callahan, MichaelV ., M .D .
@mgh. harvard. edu> ; LeDuc, James W . TMB. EDU > ; Johnson, Robert
(OS ASPR/BARDA)
@ hhs. ; Yeskey, Kevin @ hhs. gov > ; Disbrow , Gary (OS ASPR BARDA )
@ . gov> ; Redd, John (OS/ASPR SPPR ) @ hhs
. gov ; Hassell
, David

( Chris) (OS ASPR IO ) hhs

. gov> ; Hamel
, Joseph(OSASPR/ @ hhs. gov ; Dean,
Cha . ca. gov> ; Borio, Luciana iqt
. org > ;

Hanfling, Dan @ iqt org > ; @ sdcounty . ca . gov; Wade, David @ hq. dhs. gov
TARANTINO, DAVID .dhs. gov> ; WILKINSON, THOMAS
@ hq.dhs. gov> ; dshs. texas. gov; KAUSHIK , SANGEETA
hq. dhs. gov > ; Lee , Scott . gov> ; Padget
, LarryG < PadgetLG@ state. gov> ;

RyanMorhard < @ weforum. org> ; Stack, Steven J (CHFS DPH) ; Adams,

Jerome (HHS OASH ) s @ hhs. gov > ; Fantinato, Jessica - OHS Washington, DC

gov > ; Colby, Michelle - OHS, Washington, DC @ usda. gov

Subject
: RE: Red DawnBreakingBad StartFeb 24
WARNING : This emailoriginatedfrom outsideof UTMB ' s email system . Do notclick links or open attachmentsunless
you recognizethe senderandknow the contentis safe.

I am also concerned about Seattle (Kings County ). Charity , do you have contacts there ? Orcould someone reach out
to Jeff Duchin from CDC or HHS?
https://www .kingcounty .gov /depts/health /communicable -diseases /disease
control/ /media / depts/health /communicable diseases /documents / influenza/ 2020 /week -08 .ashx
This is week 8 data (so recentdata ). Compare the 3 graphs. Seeing a mismatch between pathogens
down) and syndromic surveillance (flat). Also looking at ED visits and seeing an
upward trend in school age kids (ages 5- 17) and 45 -64 year olds. Something doesn't sit rightwith me.
 PublicHealth - Seattle & County
Summary of Influenza Syndromic and Laboratory Surveillance
Influenzaandother respiratorypathogens,PCR testingonly (NREVSS)

2059
/ /
9
2019
/

23
/ / / /
/ / /
/

34
/ /

23
201921
/ /
2020
/
/
2020
/

25 22
9
2
1
6
25 27
/
/
/
3
/
4 / /
5
6
/ /
7
/
7
/
8
/
9 /
/ 11 11
/ /
1 2
/
2

King County syndromic surveillance

ED Weekly ED Visits for
Group
2014 206 -

-
209
Percent
Legend 7
30 - 64 - 65

34 38 40 42 44 46 1 3 9 11 23 31

- - - - -
02 05
06
07
/ 80 0809 02
04 06
/ / /
Allages 17 14092812
08 /
Note - 9 .
Last , 22 20192019 132019 2019 20192019 01042020 2020
Base M
A wook period 2 for 2
Week Ending
the ' of for
ALLHOSPITALS 2020

From : James W .
Sent: Saturday, February29, 2020 3: 08 PM
To: CarterMecher
Cc: JeffDuchin(Jeff.Duchin @ METROKC.GOV) < OKC.GOV>
Subject: RE: RedDawnBreakingBad, StartFeb 24
ContactingJeff Duchin.
Jim
James W . LeDuc, Ph. D .
Director
GalvestonNationalLaboratory
UniversityofTexasMedicalBranch
Galveston, TX 77555-0610

From : CarterMecher
Sent: Saturday, February29 2020 2 :58 PM
To : Dr Eva K Lee
Cc: Lawler, James V ; TraceyMcNamara
; Baric, Ralph S ; Caneva, Duane; RichardHatchett
; Tom Bossert; Martin,
Gregory J; Walters, William ; HAMILTON
, CAMERON ; Dodgen, Daniel
(OS ASPR 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, MichaelV . M . D . .EDU; Johnson, Robert
(OS ASPR BARDA) ; Yeskey, Kevin Disbrow, Gary ( BARDA) ; Redd, John (OS ASPR/ SPPR) ;
Hassell, David (Chris) (OSASPR/ IO) ; Hamel , Joseph (OSASPR/ ; , Luciana;
Hanfling, Dan; . ca . gov; Wade, David; TARANTINO, DAVID A ;
WILKINSON, THOMAS @ dshs. texas . gov ; KAUSHIK , SANGEETA ; 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 , DC
Subject: RE : Red Dawn Breaking Bad, Start Feb 24

Charity, 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 have
COVID upon their returnto Japan .
https: // bigislandnow. com / 2020/02/ 17/53-self-monitor- for- coronavirus- in -hawaii-after- visiting-japanese-couple-tests
positivel
Myunderstandingis thatHawaiidid notperform testingon anyone ( monitored some contacts from symptoms ).
I went to Hawaii's flu surveillance (their latestdata is from week 7). My concern is the continued rise in despite a
drop off in influenzain the lab.
https:/ /health.hawaii.gov/ docd/files/ 2018/03/ FLU_ Influenza_ Surveillance.pd

-From : Dr. Eva K Lee

Sent : Saturday
, February 29 , 2020 1: 15 PM
To CarterMecher
Cc: Lawler, James V TraceyMcNamara ; Baric, Ralph S Caneva, ; Richard Hatchett; Tom Bossert; Martin,
Gregory J; Walters, William ; HAMILTON, CAMERON; @ gmail. com ; Dodgen, Daniel
(OS ASPR SPPR) ; DeBord Kristin (OSIASPR 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 ., M . D . ; UTMB. EDU; Johnson, Robert
( OS ASPR BARDA) ; Yeskey, Kevin; Disbrow , Gary (OS ASPR/ BARDA); Redd, John ( OS ASPR SPPR) ;
Hassell, David (Chris) (OS ASPR/ IO ) ; Hamel, Joseph (OS ASPR 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 ; Ryan
Morhard ; Stack , Steven J (CHFS DPH ) Adams , Jerome (HHS / OASH ); Fantinato , Jessica - OHS ,
Washington , DC; Colby , Michelle - OHS , Washington , DC

Subject : Re: Red Dawn BreakingBad, Start Feb 24

Oops. I mixed up the order. It shouldbe -

From travelers: Washington, Illinois, California, Arizona, MA Wisconsin, Oregon

Unknownorigin: California, Oregon, Washington

I did a quick analysis on strategic screening , if wehave enoughtesting power, I would suggestcommunitytesting
strategicallyin California, Chicago/ Illinois, Oregon, Washington, Boston, Atlanta, New
York. It would be great if wecan covermore. Wehaveto go beyondcontacttracing. Itis also good to coversome
universities.

From : Duchin , Jeff @ kingcounty . gov >

Sent: Sunday, March 1, 2020 10: 16 AM
To: 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: exposures in hospitals

Weare having a very serious challengerelated to hospitalexposuresandimpacton the

healthcare system . Would be great to have a call to discuss.Willbemeetingwith your team
here thismorningand then maybewe can chat after that.
_ Jeffrey S . Duchin ,MD
Health Officer and Chief, CommunicableDiseaseEpidemiology& Immunization Section
Public Health - Seattle and KingCounty
Professorin Medicine, Division of InfectiousDiseases, University ofWashington
Adjunct Professor, Schoolof Public Health
4015th Ave , Suite 1250 , Seattle , WA 98104

From : Armstrong, Gregory (CDC/DDID/NCEZID/OD)

To: Duchin, Jeff
Subject: RE: exposuresin hospitals
Date: Sunday, March 1, 2020 7 :45: 23 AM
[EXTERNALEmailNotice! ] Externalcommunication is importantto us. Be cautious of phishing
attempts. Donot
click 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 the POC

On Sunday, March 1, 2020 11

:42 AM , CarterMecher wrote :

Shouldhave pulled all the triggers for NPls by now they are already later than they realize. I fear we
are about to see a replay of Italy. Other cities need to learn from Seattle.

Eva , I did some back of the envelope estimates of hat a 1 % threshold means and when I would pull
the trigger.

I made some estimatesusingthe cruise ship data butthen made someadjustments assuming that if
we could do serology, the extentof the outbreak is likely twice as large as whatwe are estimating from
swabs and pc (James Lawler' s argument). So here is mysecondtry with themath adjusting for true
prevalencebeing doublewhatwe think it is on the cruise ship .

So assumptionsare 80% asymptomatic, 6 % hospitalized, 1% critical, 0 .4 % CFR. Part ofthis

assumptionis thattrueprevalenceusing serologywillproveto be significantly greater than prevalence
based on currentdiagnostics (swabs) and asymptomatic/mild diseasein the age groups under
represented on the cruise ship (kids and young adults) will dilute thenumberswe are estimatingfrom
the cruise ship. [So this is a bitof SWAG. ]

We usually think of the window for implementing NPls as before 1% prevalence . But this disease
would be predicted to have more than 80 % asymptomatics , so the threshold is really 0 . 2 % prevalence
of any symptoms (including very mild symptoms ). But CDC criteria for testing is severe disease . Let' s
say 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 the
span of 2 weeks plus the lag time for testing, the outbreak could have had at least 3 doublings (so an
8 - fold increase ). Thatmay be conservative . So we are really talking about a threshold of close to
0 . 01% 8 = 0. 00125 % . For a city of M that is 12 serious cases, 250 symptomatic , 1, 250 infected . In
2 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 onset
to death , the number of deaths would be based on a denominator of 3 weeks ago , so divide 1, 250
infected by roughly 3 (assume cases triple in a week ), to get 400 . Assume a CFR of 0 . 4 % , so about 1
death . More than 1 death per million population is probably too late .

We can work backwards from the first critically ill case involving local transmission and no linkage to a
known case . If our threshold is 15 cases of seriously ill individuals (really ICU cases ), and cases
increase by a factor of 8 over a period of about 2 weeks , the far end of the window is about 2 weeks
from when you identify 2 critically ill cases . To give you a cushion , I would be ready to pull the trigger
no later than 2 weeks of the first critically ill patient. If we look at the in CA , that patient had been
critically ill for at least a week . Thatmeans they had about a week from recognition until the windows
starts to close . I would be pulling the trigger in Fairfield / Sacramento .
 So think of time to act.
1 Bythe timeyou identify thefirstdeath per millionpopulation in someonewith local
transmission (no linkage to a known case) , you needto pullthetrigger on . Lookingat
Seattle ( population of city of Seattle of740K and populationofmetro Seattle of 3. 5M ) , I would
pullthe trigger very soon thewindow is very close to closing.
2. No later than 2 weeks from the confirmation of the first critically illpatientper million
population. The window is very close to closingforFairfield/SacramentoCA.

From : Dr. Eva Lee lee64 @ gmail . com >

Sent: Monday , March 2 , 2020 7 : 45 : 51AM

To : 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 ;

@ state . gov > ; William @ state . gov > ; CAMERON

Gregory
@ . dhs @ gmail
. com @ gmail. com ; Daniel(OS/ ASPR )
@ hhs. ; Kristin (OSIASPR SPPR) @ hhs. gov ; Sally (OS ASPR SPPR )
@ hhs. gov > ; Matthew CIV USARMY (USA) iv @ mail
. mil
>; Lisa Koonin
@ gmail
. com > ; MELISSA @ . dhs. HERBERT @ hq . gov ;
Alexander < @ . gov > ; MARIEFRED
@ associates.hg. dhs. gov > ; @ utmb. edu @ utmb. edu> ; Robert(OS ASPR / BARDA)
@ hhs. gov > ; Kevin @ . gov> ; Gary ( OS ASPR BARDA) < G @ hhs . gov ;

John ( OS/ ASPR / SPPR . gov > ; David ( Chris) ( OS ASPR / IO ) hhs . gov Joseph
(OS ASPR / el @ hhs . gov > ; Luciana @ igt.org Dan @ igt. org > Eric ( San Diego

County ) @ sdcounty . ca . gov ; David < e @ . gov > DAVID A

@ .dhs .gov @ dshs. texas er dshs.texas. gov> SANGEETA
ushik @ hg. dhs.gov> ; Lee hhs.gov ; Larry G < @ state . gov > ; RyanMorhard
d @ weforum . > ; Steven Jt( ) @ ky. gov ; tJerome (HHS/OASH )
ms @ hhs. gov >; DC . gov >
usda .gov ; @ usuhs. edu usuhs. edu > ; Danny Shiau

cghe org > @ hhs. gov @ hhs.gov > ; Eva Lee

Carter Mecher
Subject: RE: Red Dawn Rising Start Feb 29

Weneed 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 Tracey McNamara westernu. edu > wrote :

S . Korea drive through COVID19 testing. Weneed this now

Tracey
Get Outlook for Android

On Mon,Mar 2 , 2020 at 11:58 AM Dr. Eva Lee wrote:

Yes, they are processing 10,000 screeningper day. I believewehave to put in NPIactionsnow across the affected
communities- - - those sensiblesteps of schoolclosure, tele-work , call- in advisoryhot- lines forself-reportingor
advice) , avoid crowds, businesscontinuityplans
, exercisecautionson travel
, practicepersonalhygiene, etc . These
won't requiretoomuch government resources( . . funds ) . Thebiggestpartis screening
. Screeningrequiresfinancial
support and requirestimeandactualhumanand lab resources . Sowemustengage private laboratoriesto provide
the screeningsurge capacitiesthatwe need. I willwork to makesure Kaiserlabswillbe on board.

From : CarterMecher
Sent: Monday, March 02, 2020 11:45 AM
To : Dr. Eva Lee 1; TraceyMcNamara
Cc: THOMAS @ . gov> ; M . D . @ mgh. harvard .edu > ; James V
@ unmc. edu > ; Duane @ . > David m .umaryland. edu > ; Tom
Bossert @ me
. com > ; Charity
A @ 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 ; MARIEFRED
ates.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 Diego
County ) 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 > ; DC
usda. gov ; DC < m by @ usda. gov @ usuhs.edu; DannyShiau
< @ cghe.org > . Eva K Lee <
Subject: RE: Red Dawn RisingStart Feb 29

6 deaths in Seattle
Seattlemissed thewindow . . It is too late for NPls

From : Dr. Eva Lee

Sent: Monday, March 2 2020 12: 12 PM
To: TraceyMcNamara
Cc: THOMAS; M . D . James V; Duane; David; Tom Bossert CDPH; Ralph S ; RichardHatchett; Gregory
J; William ; CAMERON; Daniel (OS ASPR /SPPR ) Kristin (OS ASPR / SPPR ); Sally
(OS ASPR / SPPR ) CIV USARMY (USA ) Lisa
Koonin : 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 ; DAVID
A 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 Lee
Subject : Re: Red Dawn Rising Start Feb 29

Lastnightitwas 62 countries as I was writing an email. Now it's 74 countries . And we' re in the 30 's a week ago. We
have a ton to catch up. I understand it is always difficult decisions for policy makers . But hopefully the contrasts of
Hong Kong/ Singapore vs Italy / Korea/ Japan provide a good concept ofwhat needs to be putin place
immediately. We need multiple measures in place to slow down the spread that clearly is happening around the
country .

From : Tracey McNamara

Sent: Monday, March 2 , 2020 9:57 PM
To : CarterMecher
; Dr. Eva Lee
Cc: THOMAS M . D . James V ; Duane; David; Tom Bossert; CDPH; Ralph S; Richard Hatchett; Gregory
J ; William ; CAMERON gmail.com Daniel OS ASPR /SPPR ) Kristin O
( S/ASPR/ SPPR ) Sally
(OSASPR SPPR) J CIV USARMY (USA ) Lisa
Koonin MELISSA; HERBERT
; Alexander MARIEFRED edu; Robert
(OSASPR BARDA) Kevin ; Gary (OS ASPR BARDA) John (OS ASPR/ SPPR ) ; David ( Chris ) (OS ASPR IO ) ; Joseph
(OSASPR IO ) ; Luciana; Dan; Eric (San Diego County) ; David; DAVID
A s. texas
. gov; SANGEETA
; Scott
; LarryG ; RyanMorhard Steven Jt ) ; tJerome
(HHSOASH); DC; DC; @ usuhs
. edu; DannyShiau gov Dr. Eva K Lee
Subject: RE: Red Dawn Rising Start Feb 29

Courtesy of unsw .edu. au

I think one of the problems is the poor sensitivity ofthe throat swab . Several studies have shown that serial throat
swabs can be falsely negative . A nasalswab is more sensitive . There should be guidelines stipulating that a sputum
is the gold standard , and if that is notpossible for a "recovered " patient, serialnasal swabs should be done . I think
this is also telling us the duration viral shedding is quite long. 5 - 9 days from symptom onset to seeking medical
care; + 2- 3 weeks in hospital+ shedding in the convalescentphase adds up, Mostof themodellingstudiesassume
7 days of viralshedding, which is clearly wrong. See:

importantpaper showing:
1 viralload in asymptomaticsameas symptomatic
2. Viralloadhighestearlyin the illness, when symptomsmild or absent
3. Nasal /NP swab more sensitive than throatswab

And in 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 everyone
focused on vaccines

Regards
Raina

ProfessorRainaMacIntyre
Head Biosecurity Research Program Kirby Institute Medicine
ProfessorofGlobalBiosecurity & NHMRC PrincipalResearch Fellow

-From : Carter

Sent: Tuesday, March 03, 2020 2 : 27 AM

To: Richard Hatchett < i . net > ; Tracey McNamara < du > ; Dr. Eva Lee
om
Cc: THOMAS . dhs. gov ; M . D . gh .harvard. edu > ; James V
@ unmc. edu > ; Duane < hq. dhs. gov> ; David @ som . umaryland
. edu> ; Tom

Bossert @ me
. com > ; Charity A @ CDPH cdph .ca . gov > ; Ralph S
c @ email.unc. edu > ; Gregory @ state . gov ; William state. gov> ; CAMERON
n @ . dhs. gov ; @ gmail. com ; Daniel(OSIASPRSPPR) < D @ hhs. gov ;

Kristin ( OS/ ASPR/ SPPR) . gov Sally SPPRE @ hhs.gov> ; Matthew J

CIV 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 ( OS ASPR BARDA)
hs. gov ; John (OS ASPR SPPR) dd @ hhs. gov > ; David ( Chris) ( IO )
. gov> ; Joseph (OS ASPR/IO ) mel@ hhs. Luciana @ iqtorg> ; Dan
org> ; Eric ( San Diego County) < @ sdcounty . ca . gov > ; David
de @ hq.dhs. gov ; DAVID A < no @ cbp . dhs . gov er @ dshs. texas. gov; SANGEETA
shik @ hq. dhs. gov > ; Scotti @ hhs. gov ; Larry G @ state. gov> ; RyanMorhard
orhard @ weforum . org> ; Steven Jt ky. gov tJerome( HHS/ OASH)
< ams @ hhs. gov > DC @ usda. gov ; DC
@ usda. gov > ; uhs. edu; Danny Shiau @ cghe. org @ hhs. gov; Dr.
Eva K Lee < h @ pm .me>
Subject: RE Red Dawn Rising Start Feb 29

The documents Richard sentare excellent. I went thru and pulled out excerpts that really struck me. To get to the
bottom line, I pasted the recommendation for us.

For countries with imported cases and/or outbreaks of COVID - 19

1 Immediately activate the highest level of nationalResponse Managementprotocols to ensure the all-of
government and all -of-society approach needed to contain COVID - 19with non -pharmaceuticalpublic health
measures;
2. Prioritize active , exhaustive case finding and immediate testing and isolation, painstaking contact tracing and
rigorous quarantine ofclose contacts ;
3. Fully educate the general public on the seriousness of COVID - 19 and their role in preventing its spread;
4. Immediately expand surveillance to detect COVID - 19 transmission chains, by testing all patients with atypical
pneumonias, conducting screening in some patients with upper respiratory illnesses and/or recent COVID - 19
exposure , and addingtesting for the COVID - 19 virus to existing surveillance systems( e g. systems for influenza -like
illness and SARI);
 Conductmulti-sector scenario planningand simulationsfor the deploymentof even more stringentmeasuresto
interrupttransmission chainsas needed( e. g. thesuspensionof large-scale gatheringsand the closure of schools
and workplaces
)

On Tuesday, March 3, 2020 1: 56 PM , Marcozzi, David < DMarcozzi@ som umaryland. edu> wrote:

Act. Now .

Respectfully,

David Marcozzi, MD, MHS- CL, FACEP

Associate Professor
Director of Population Health
Department of Emergency Medicine
University ofMaryland School ofMedicine

Dr. Eva K Lee pm .me>

Sent: Tuesday , March 3 , 2020 3 :53 PM
To : Marcozzi, David umaryland
. edu

Cc: Carter Mecher rter. net> ; TraceyMcNamara a @ westernu. edu > ; Richard Hatchett
@ cepi.net> ; . Eva Lee 64 gmail. com > ; WILKINSON, THOMAS
Inson @ 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 , HERBERT
dhs. 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, SANGEETA
aushik @ 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. gov
Subject: Re: RedDawn RisingStart Feb 29

Yes, weought to actnow . Ok, I know have been urging this for a longtime. I wantto cover a few itemsdiscussed
here

1. Socialdistancing
, NPIcan deterthe spread
Singaporeand HongKongprove thatwithoutany definitivetreatment, and absenceof anyprophylacticMCM
protection, closingschools
, home-officebusinesscanmakea huge difference
. I ran a fewmodels for schoolclosure
andbusinesstele-work for Santa Clara, KingCountyand I wantto sharesomegraphshere.
Santa Clara: Onepositive case on Jan 31
. I look at closing schoolas of today, and tele-work by 0. 5 million workers.
Wecan see the rapid decrease ofspreading . I also contrastthe results ifwe close a week from now , or twoweeks
from now.

Please note , the parameters need notbe perfect. The idea is to contrast how NPI can work very effectively and we
MUST act now and make it a success .

Santa Clara: Strategies for Containment

Total Inectionsvs Intervention, 90 days Total infectedcaseswith intervention

25000

12000
Confirmed
positive close on 3 /3

intervention 20000 Schoolsclose on 3 / 10

10000
close on 3 / 3
Schoolsclose on 3/ 17

infect d
of
-
Schoolsclose on 3 / 10

Schools close on 3 / 17
15000 School+business 3 /3
School+business 3 / 10

Number 4000
School business3 3
.. . .. School+business 3/ 10
- + business 3 / 17
10000

5000
- school+ business 3 / 17

2000

3 / 31/2020 4 / 30 /2020 5 / 31/ 2020 6 / 29 /2020

/ /12/7 2 /2020 /2020/2020/6/2020/13

/202014
/ 2/212/28 3
20202020 /10/2020/17/2020/24/20205/1/2020
/202020
/ / 3/27/ 4/3/2020
640 9 ,724 139,774 911,204
13 3 3 4 4 4 Total infection without intervention

EK Lee, Copyrightmaterials2020

2 . Quarantinea city ?
I believethere's a contingencyplan (I did recallworkingwith National Guard on it) wherewewill quarantineeveryone
insidea city if there' s a severe diseasespread. It is like whatChina did for Wuhan. WithMCM, we can give citizens
MCM beforethey leave. There is no MCM now .

While one can a federalquarantineandtotal lock downof a city ismore effective, I think Lu's commentis on
point. We cannotexpect perfectparticipation. Everyoneis goingto make a decision. Ifwecan contain 80 % of the
people' s movement(as in HongKong and Singapore, or in the Santa Clara model above), you can see thatweare
stopping the spread. Clearly, those who getout ofthe city mightvery wellbe infected and sow a seed to otherplaces.
Yes, we probablyneed to think harderwhatto do. The closing schools and tele-work in a sense is volunteering
quarantine. It can work beautifully and very effectively. Note thatHongKonghas only limited transportationban. The
citizensand the healthcareworkers protestto close theborder, buttheborderwasn't closed. So the effortis
volunteering quarantineof their own residentsand then quarantinefor everyonewho enters the
city. Together, itputs a brakeon the spread. It is rightto do it now .

3 . KingCounty Seattle
Trueto the form ofthe COVID-19and themortalityof elderly, which is 1. 3 % , 3. 6 % , and 14. 8 % from 50 years
owards, for every 10 year agebracket
. So we see the very high mortalityof thenursinghome
. AlthoughI know next
to nothingaboutwhat's goingon in China, thesefigures seem to be a good guidingpointfor us.

Whattroublesmeaboutthe spread is that it is almost likeby- the- book . We got schoolteacher get infected, nursing
home, a very sick patientin ICU ( healthcareworkers got quarantine) you see wherewe are heading, every
vulnerable population is hit.

4 . Limited TransportationBan
So lastweek, wrote thatweneed to includeNew York and Atlanta in the screening. Badenough thisweek wehave
casesin these cities. I do thinkweneedto step up in reducingthe South Korean flights into the US. HongKonguses
brand-new public estates to quarantinethe incomingtravelers from high- risk regions. It is a luxury thatwe do not
have. Here, wemust figure outan effective quarantinefor these enteringvisitors or returningcitizens. Maybeit is time
to stop visitors Korea and Italy. Itis just temporary . So we can focus on handling citizens coming back . We
need to let them in . Cannotleave them outside their own country .

On Tuesday, March 3, 2020 4 : 22 PM , Caneva, Duane @ hq dhs. gov > wrote :

Looking at a projectto develop triggers for communitymitigationbasedon proxy data such as ICU cases, deaths,
surveillance diagnostics, and gap between ILIpresentationswith ILI+ panels. Wehave good data from other cities
aroundthe world on whattheir data showed andwhen they implementedmitigation efforts. Wecan measure that
data in near-realtimeand use itas objectivemeasure to pull the trigger.

Thoughts?

From : CarterMecher
Sent: Tuesday, March 3, 2020 5 :59 PM
To : Dr. Eva K Lee: Eastman. Alexander
Cc: Caneva, Duane;Marcozzi , David; TraceyMcNamara; RichardHatchett ; Dr. 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 CIV
USARMY (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)
(OS ASPR IO ) ; Joseph (OS ASPR/ IO ) ; Luciana; Dan; Eric ( San Diego County) ; Wade, David; TARANTINO, DAVID
A ; . 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 29

I don' t getthe sensethat Seattle will considerclosing schools ( exceptperhapsreactiveschool closure due to high
absenteeism) .

Has Seattlemodeled the potentialimpactto their healthcaredelivery system ofan unmitigatedoutbreak? The high %
of asymptomatic/mild disease is a bitmisleading
. Itmightbe eye openingfor Seattle to simply overlaythe cruise ship
data atop their populationage > 60 and assumeeveryoneunder60 hasmild diseaseand even use an attack rate of
20 % . Easy enough to do for them .

King County health officials : No reason yet to close schools for COVID - 19
Localhealth departments recommended Monday schools stay open as more announcements of cases of the novel
coronavirus were made , but several districts closed schools on Monday anyway , mostly as students were tested
There were no blanket closures , or a scene of district -wide shutdowns , but different schools had different reasons for
closingMonday . As of Monday , no schools in Washington state had confirmed cases of COVID - 19
The schools that have closed so far have done so for deep cleanings after students were either being tested for
COVID - 19 or had come into close contact with someone who had the virus
Another school district is closing Tuesday for staff training on how teachers can continue their lesson plans remotely
should the schools need to shut down as the virus spreads
Dr. Jeff Duchin , health officer for King County Public Health , said during a press conference Monday if there are
confirmed 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 hygiene
recommendations ," he said , mentioning that ill students and staff should stay home from school
The Centers for Disease Control and Prevention recommends school districts take steps that prioritize the
community ' s health while causing the least amount of disturbance to students
" Schools should continue to collaborate , share information , and review plans with localhealth officials to help protect
the whole school community , including those with special health needs, the CDC said on its website . School plans
should be designed to minimize disruption to teaching and learning and protect students and staff from social stigma
and discrimination . "
From : CarterMecher
Date: Tue, Mar 3 2020 at8 :55 PM
Subject
: RE: Red Dawn Rising StartFeb 29

To: Dr. Eva K me> , Eastman, Alexander

Cc: Caneva d . edu> , Tracey

. dhs
. gov> , Marcozzi
, David <

McNamara nu. edu> , RichardHatchett rich @ cepi.net> , Dr. EvaLee

m > , WILKINSON, THOMAS M .
harvard. edu> , James c . edu , Tom Bossert @ me. com > ,
Charity A @ CDPH . ca . gov Ralph .unc.edu> , Gregory J
@ state. gov William state . gov HAMILTON , CAMERON
n @ . 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 Koonin
gmail. co
WOLFE @ .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 ) (OS ASPR / ) @ 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 state. gov> , Ryan

hs
. gov Larry
G

Morhard weforum. org> , Steven Jt( tCHFSDPH) . gov> , tJerome(HHS/OASH)

. gov> , DC @ . gov> , DC y usda. gov

@ usuhs. edu < . gov > , Jolly, Brantley
@ hhs. gov @
OS ASPR/ EMMO) ( CTR ) < Cordts, Jerome ( CTR)
. hq. dhs.gov Mansoura, Monique K . @ mitre.org >

I was curious what is meant by mild disease . Somebody can double check mymath .

Attachedis a back-of-the-envelopeestimateof the impactof COVID on a notionalcity of 3. 3M [ The currentUS

populationis ~ 330M, a notionalcity of3. 3M is assumedto be 1 % of theUS population, with 1 % ofhealthcare
assets (hospitalbeds/ICU beds), 1% ofhealthcare utilization(hospitaladmissions /hospitalBDOCs / BDOCs / ER
visits/outpatientvisits), and 1 % of annualall- causedeaths— a notionalaverageUS city representing1% ofthe US
population. I 3 . 3. M becausethis makesthemath simp

Methodologyto estimate the impactof COVID on this notionalcity:

Forthe population age > 60weassumedan attack rate of 30 % and appliedthe cruise ship outbreak data ( 50 %
asymptomatic; 12% acutely ill; 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 % ) and
roughly 50 % asymptomatic and 50 % mild /moderate disease and occasional serious disease requiring them to touch
our healthcare system (100 % requiring outpatient care / 10 % ER care) . [ very conservative estimates]

Really interesting what havoc mild disease might cause on this notional city . In this scenario , roughly 89 % of those
who are infected are asymptomatic or mild disease . I assumed the event would stretch over 90 days — the
acceleration in acute care demand in Wuhan was concentrated over a period of 5 -6 weeks . So the estimates of
demand relative to capacity superimposed over a shorter time period and adjusting for peak demand are much worse
than what the numbers convey .

This is why Eva is so concerned about not delaying the implementation of mitigation measures. She understands
what is going to happen .

Metro Seattle has a populationof . 5M ( close enough to this notionalcity) .

From : CarterMecher

: Wednesday , March 4 , 2020 6 :09 AM

Subject : RE: Red Dawn Rising Start Feb 29
It is how high the prevalence must be in Italy to have the amount of spread we are seeing associated with
travelers from Italy . What is equally amazing is how it was hidden until it exploded . I suspect what happened in Italy
is really the movie ' for the rest of the world , including the US. Itwould be really useful to have better intel on what is
happening to the healthcare delivery system in Italy ( Italy also has the 2nd oldest population with 23 % age 65 + while
Japan 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 hospitals
in anticipation of the development of Coronavirus spread"
Does anyone have better data ?

OnWednesday, March 4 , 2020 7 : 44 AM , Carter Mecher harter.net> wrote

HongKong( 101case/ 2 deaths) and Singapore( 110 cases/ deaths) continueto hold the line. Singaporehaslinear
growth (keepingRo close to 1) ; HongKongalso has linear growth. This is reallybestpracticefor a city. Mightbe
worthwhile forUS citiesto take a close look at how SingaporeandHongKonghave respondedthroughout this crisis.
When this allbegan, HongKong andSingaporewere seeded early and very early on they had the largestnumberof
cases followingmainlandChina. Since then havewatched other countriescome outofnowhere and racefar ahead
ofHongKongand Singapore( linear growth vs. exponentialgrowth ). South Korea ( 5 ,621
/ 28 deaths); Italy ( 2 ,502/79) ;
(293/6 ) France (212 4 ) (203/ 0 ) Spain ( 165 / 1) 127 / 9 ). Seattle alone will
overtake Hong Kong and Singaporeby the endofthe week . Organizations and governments and scientists
like to talk about learning from best practices. Well here they are . When show the slide ofPhiladelphia-St.
Louis in 1918 often ask audiences which city they would have preferred to be living in during the 1918
pandemic. When we look back at this pandemic, we will have new contrasting city pairs and contrasting
country pairs and can pose a similar question .

From : Dr. Eva K Lee

Sent: Wednesday
, March 4 , 2020 1: 54 PM
To: CarterMecher

Cc: TraceyMcNamara; RichardHatchett; Dr. Eva Lee; THOMAS; M . D .; James V; Duane; David; Tom
Bossert; Ralph S ; Gregory J; William ; CAMERON om ; Daniel
(OS ASPR SPPR ): Kristin (OS ASPR /SPPR ) : Sally (OS ) : Matthew J CIV USARMY (USA ) :
Koonin ; 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; DAVID
A ; xas. gov; SANGEETA ; Scott; Larry G Ryan Morhard; Steven Jt( ); tJerome
(HHS OASH ); DC DC Shiau t @ hhs. gov
Subject : RE: Red Dawn Rising Start Feb 29
Carter , please review the information I sent regarding the NPI intervention model I sent for Santa Clara yesterday . I
ran 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 time we are seeing the citizens ' symptoms and complaints , we are a few
weeks late already . The " unknown " cases are out there already . Those with no/mild symptoms , or doesn 't really
matter 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 the
model -- one case is one case too many already , because it's already growing . Because itmeans there' re others we
don 't know .
For example for the Seattle nursing home -- they get infected and they have respiratory distressed . But they don 't get
registered onto public / hospital records. And then university students , they get sick all the time, not that they will see
the doctor or anyone . So we won 't register them either. Then ICU/ED patients . Ok , that we can screen and should
screen . Also , the flu may be masked by COVID -19 , as in Japan where COVID - 19 basically halted the flu season . So
there may be no spike at all in the surveillance data , since it is the usual pattern , but instead of the usual flu / cold etc ,
it is replaced by COVID - 19 . It is really quite difficult to use disease surveillance as a guide , beca
late at least by 2 weeks . ifnot more weeks . The moment the first case appears , we're late already by 2 weeks .
From : CarterMecher
Sent: Wednesday, March 4 , 2020 2 : 19 PM
To: Dr. Eva K Lee
Cc : TraceyMcNamara; RichardHatchett; Dr. Eva Lee; THOMAS; M . D . James V ; Duane
; David; Tom
Bossert
; S ; Gregory J William ; Daniel
( OS ASPR SPPR) ; Kristin ( OSASPR SPPR) Sally (OSASPR SPPR) ; Matthew J CIV USARMY(USA); Lisa
Koonin; MELISSA; HERBERT Alexander; Robert
(OS ASPR/BARDA) Kevin Gary (OSIASPR/ BARDA) ; John (OSIASPR/SPPR) ; David ( Chris ) (OS ASPR/ IO ) ; Joseph
(OS ASPR/IO ) ; Luciana; Dan; Eric ( San Diego County) ; David; DAVID
A ; s. texas. gov; SANGEETA; ; Larry G ; RyanMorhard; Steven Jt( ) ; tJerome
(HHS/OASH) ; DC hs.edu; Danny Shiau; r
Subject: RE: Red Dawn Rising Start Feb 29

Eva, I agreewith you. Politicalleadersandpublichealth leadersneedto be convincedof theutility of these

interventionsand the courageto act. Iftheymiss thewindow to act, they don' t get a do-over. Can't take a Mulligan
with . There is no resetbuttonto play the gameagain. You only get one shot. I fear that Seattlemayhave
missed their opportunity. OutofdesperationI predicttheymay eventuallyimplementand endureall the downsidesof
with marginalto little upside
. This is exactly whathappenedin 1918. A whileback shared some slides on the
lessonslearned from 1918. Unfortunately,wehaveto learn some lessonsagain andagain.

From : CarterMecher
Sent: Wednesday, March 4 , 2020 2 : 36 PM

To: Dr. Eva K Lee

Cc: TraceyMcNamara ; Richard Hatchett; Dr. Eva Lee; THOMAS; M . D .; James V ; Duane; David; Tom

Bossert; Charit Ralph S Gregory ; William ; CAMERON; .com ; Daniel

( / ASPR / SPPR ); Kristin (OS/ ASPR / SPPR ); Sally (OS/ ASPR / SPPR );Matthew J CIV USARMY (USA ); Lisa
Koonin ; 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.gov

The US is now up to 11deaths ( 10 in Washington and 1 in California ).

I think there is disconnect among very smart people . They hear the high % of patients who are asymptomatic or have
mild illness and equate this to a mild outbreak . Hard for me to understand how they come to this conclusion .
 2019NovelCoronavirus(COVID- 19) in Washington

Positive(confirmed
)

Deaths

Snohomish County - 8 including 1 death

- 31 including 9 deaths

contact the local health department for information

Number of People UnderPublic Health Supervision

Number
ofpeopleunderpublichealthsupervision

number of people under public health supervision includes those

at risk ofhaving been exposed to novel coronavirus who are
monitoring their health under the supervision of public health officials
This number includes peoplewho have returned from China in the past
14 days and are included in federal quarantine guidance

On 4 Mar 2020, at 20 :31

, Carter Mecher @ charter.net> wrote :

Rhetoricalquestion , what is he evaluating daily ?

SEATTLE -- Washington state on Wednesdayreported a 10th death from coronavirusGov. Jay Insleesaid hewas
evaluatingdaily whetherto orderwidespreadclosures and cancellationsdue to theoutbreak.

The state Department of Health released updated figures showing that nine people had died in King
County, the state ' smost populous, and one in Snohomish County. The state hasnow reported 39
COVID -19 cases, allin the greater Seattle are

OnWednesday, March 4 , 2020 3: 37 PM , Richard Hatchett < @ cepi. net > wrote:

It is remarkable that leaders are reluctant to implement interventions that they will
have to implement anyway when they lose control. Do they think the virus is
magically going to behave differently when it gets to their community ? Why can' t
they look at the 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 March

Duane C . Caneva , MD , MS
Chief MedicalOfficer
Department of Homeland Security
Executive Assistant : Nichole

Brian Benson @ icloud . com >

Sent: Thursday , March 5 , 2020 12:08 AM
To : Caneva , Duane < @ hq . gov

Cc: CarterMecher < t > ; Mecher

, Carter outlook . com
er @ va. gov ; TraceyMcNamara < t , Richard ( OS ASPR EMMO
westernu. edu> ; Hunt
@ 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 )
< D @ 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, MARIEFRED
s @ 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 (OS ASPR /SPPR) < dd @ hhs.gov> ; Hassell, David (Chris)
( OS ASPR l l hhs. gov Hamel
, Joseph (OS R/ Joseph . gov ; Luciana
io org> ; @ .org > ; nald sdcounty . ca . gov ; Wade , David
< d @ hq. dhs
. gov ; TARANTINO, DAVID A
no dshs gov : KAUSHIK
< da

shik @ hqdhs.gov> ; Lee, Scott (OS/ ASPR/ EMMO) @ hhs. gov Larry G
tate . gov > ; Ryan Morhard @ weforum . org > ; Steven )
V
@ ky gov ; Adams, Jerome (HHS/OASH) @ hhs. gov ; Mansoura, MoniqueK .
ra @ mitre. org > ; Fantinato, Jessica (USDA.GOV [ . safelinks.protection.outlook. com
nato usda . gov ; DC < m sda . gov da @ usuhs. edu; Cordts, Jerome
rdts @ associates.hq. dhs. gov ; Schnitzer
, Jay @ mitreorg> ; Ignacio, Joselito
io @ .dhs.gov
Subject: Re: Red Dawn Raging Start March 4

Duane, thanks forincludingme in the conversation.

I 've been readingwhat I can on PubMedand in thenews, butcan' t find manyanswers, thus I' ll asks this group. First,
being thatsomeviruses are capable ofinsertingtheir DNA into hosts genome, is there any evidencethatthis RNA
virus can do that? Thavenothingto support this , but ask to anticipateany late term effects, i. e. Cancer,
other post viral syndromes . Secondly , are there any restriction
sites in this strain that are not present in others of the same family , suggesting this is engineered ? Lastly , what 's
gong on in North Korea ?

Folks, those of you thatknow meunderstand 'm glad to help in any can. Please letmeknow

From : " Baric, Ralph S"

To: " Brian Benson ", Duane "
Cc: "Carter Mecher ", 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 J
CIV USARMY (USA) " , " Lisa Koonin , MELISSA" , HERBERT" , Alexander" , MARIEFRED" , @ utmb. edu" ,
Robert(OSIASPR/BARDA) " , Kevin " , Gary ( OSIASPR/BARDA) " , John (OS ASPR/ 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 ", "Ryan Morhard" , " Steven
Jt( ) , Jerome( HHS OASH) ", MoniqueK . ", Jessica (USDA.GOV
[ safelinks. protection.outlook. ] , usuhs. edu", Jerome ( CTR )", Jay J" , Joselito "
Sent: Thursday March 5 2020 7: 52:21AM
Subject: RE : Red Dawn Raging Start March 4
HiBrian,
No coronavirusRNA viruses don' t incorporatetheir genomesinto thehostDNA
Yes, potentialhit and run diseaseis pulmonaryfibrosis, which can occuras a resultof acute lunginjurymonthsto
yearslater
No, thereis absolutelyno evidencethatthis virusis bioengineered
.
Ralph

To: 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 . " , " James V " , " David" , " Tom
Bossert
" , " 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 (OS ASPR SPPR)",
David (Chris (OS ASPR/ 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.GOV
safelinks.protection. outlook. coml
) " "DC" , . edu ", Jerome (CTR )", Jay J" , Joselito "
Sent: Thursday March 5 2020 8:55 : 31AM
Subject : RE: Red Dawn Raging Start March 4
Impact assessment pulled together and shared with my leaders . I utilized the attack rate of 20 % that was
experienced on the Diamond Princess so that could begin to help people get their head around what is perceived to
be a mild outbreak means . I purposely used an actual event(and actual attack rate ) for comparison so as not to be
perceived as fear mongering . I sense confusion among very smart people (politicians , physicians , public health
leaders hear that more than 80 % of those who are infected have mild disease and that overall case fatality rates
are on the order of 0 . 5 % . And they then equate these stats to a mild outbreak . They really don ' t consider attack
rates 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 can
look at these projections and envision what will happen to our healthcare system if we don ' t take aggressive actions
to 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 this
disease . We know whatworks just need the will to do it. We should be treating this like we treat stroke and acute
coronary syndromes where time = tissue . In this case time = transmission .

From : ter. net .net

Sent: Thursday, March 05, 2020 10 : 53 AM
To : et
Cc: ' . Eva Lee' ; Caneva, Duane a @ . ; ' Tom Bossert
@ me. com > ; Baric , Ralph S @ email. unc
> ; Tracey McNamara
l 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. coml
state . gov HAMILTON, CAMERON g .dhs. gov ; r @ gmail.com
mail. com > ; ' Dodgen, Daniel (OS ASPR / SPPR ) en @ hhs. gov Bord, Kristin
(OS ASPR/ SPPR hhs. gov > ; ' Phillips
, Sally (OS ASPR SPPR)
ps @ hhs. gov ;
Matthew J CIV USARMY (USA .civ @ mail.mil> ; Lisa Koonin @ gmail
. com > ;

HARVEY, MELISSA . dhs. gov ; WOLFE, HERBERT H @ .gov

' Eastman, Alexander' .dhs. gov EVANS, MARIEFRED
ociates.hg. dhs.gov . edu' utmb. edu> ; Johnson, Robert

(OS ASPR BARDA) hhs. gov ; ' Yeskey, @ hhs. gov ; Disbrow , Gary
(OSIASPR BARDA . gov > ; 'Redd, John (OS ASPR d @ hhs. gov> ; Hassell
,

David ( Chris) (OSASPR/ )' < D @ hhs. gov Hamel Joseph (OS ASPR/ IO ) ' @ hhs.gov
Luciana' < @ 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 ; ' Ryan Morhard' < d @ weforum . org> ; ' Steven )
tack @ ky. gov>; ' Adams, Jerome( ) dams@ hhs. gov > ; Mansoura, Monique K .
@ mitre. org > ; Fantinato, Jessica . safelinks.protection .outlook. com
ato @ usda . gov DC' < y @ usda . gov u @ usuhs.edu '
hiau @ usuhs. edu > ; ' Cordts, Jerome ( CTR ) associates
. hq. dhs. gov> ; ' Schnitzer
, Jay J

mitre. org> ; ' , Joselito

' acio fema
. dhs. gov> ; WillGaskins
' @ efiia .com > ;
CHRISTOPHER ALLEN @ msn . com > ; ' Kevin Montgomery ' < collaborate . org >
Subject : Re: Red Dawn Raging Start March 4

Listeningto CDC. Anita Patelhasjust summarizedCDC guidancere communitymitigation measures. They are not
recommendingclosingschools- - talking aboutreactive school closure ( e. g. , a studentbecomesill and they close the
schoolto disinfect).
Very unfortunate

From : " Dr. Eva Lee"

To: Duane"
Cc: " Tom Bossert" , , Ralph S" , "Brian Benson", Carter (VA. GOV
[ safelinks. protection outlook. com " TraceyMcNamara" , Richard (OSASPR EMMO" , " Richard Hatchett",
THOMAS" " M . D ." " James " David" @ CDPH" , " Gregory J" William ( STATE GOV
. safelinks.protection outlook. com CAMERON " . " com Daniel(OSIASPR/SPPR )", Kristin
(OSIASPR SPPR ) ", Sally ( OS ASPR/ 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) ( ) , Joseph (OSIASPRIO )", " Luciana",
"Dan"
"Larry G " , "Ryan Morhard", "Steven Jt( ) , Jerome( HHS/OASH) ", MoniqueK ." ,
Jessica(USDA.GOV [ .safelinks.protection.outlook. com ] )" , " usuhs .edu" , Jerome (CTR )" ,
Jay J" Joselito " , "Will Gaskins" "CHRISTOPHER ALLEN " "Kevin Montgomery
Sent: Thursday March 5 2020 1:05 :54PM
Subject: Re: Red Dawn Raging Start March 4
Yes, 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. We like to use the binary trees, since it explodes
fast enough already . I think a tree with the contact rate would be great to show the policy makers so they know how
many 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 in
older age groups, but thehospitalstays are 2 - 3 times longer, resourceintense, and affectaccess and availability for
everyonein the community.

@ charter.net
To: "Dr. Eva Lee"
Cc: Duane", " Tom Bossert" Ralph S ", " Brian Benson" , Carter (VA.GOV[ gcc01
. safelinks . protectionoutlook. com ,
" TraceyMcNamara", Richard (OSIASPR/EMM )", "RichardHatchett " , THOMAS", " M . D . ", " James V ", "David" ,
" CharityA @ CDPH" " Gregory , William (STATE.GOV[ . safelinks.protection
. outlook. com CAMERON",
. com ", Daniel(OSIASPR )" , Kristin (OSASPR SPPR)" , Sally (OS ASPR/ SPPR)" "Matthew J
CIV USARMY(USA)" , "LisaKoonin" , MELISSA ", HERBERT " , Alexander " , MARIEFRED ", utmb. edu",
Robert(OS ASPR/BARDA) ", Kevin", Gary (OS BARDA ) ", John (OSIASPRSPPR)", David (Chris
(OSASPR ) , Joseph (OSIASPR , "Luciana", " Dan", " @ sdcounty.ca .gov" , David" , DAVID A
dshs. texas. gov" , SANGEETA", Scott (OS ASPR/EMMO)", "Larry G " , " Ryan Morhard" , " Steven
Jt( )", Jerome(HHSOASH) ", Monique K . ", Jessica (USDA.GOV
[ . safelinks. protection. outlook. com ] ) ", " DC" , @ usuhs. edu ", Jerome (CTR " , Jay J" , Joselito " , "Will
Gaskins" , "CHRISTOPHER ALLEN ", "Kevin Montgomery "
Sent: Thursday March 5 2020 1:50 :09PM
Subject: Re: Red Dawn Raging Start March 4
CDC is going to hold a meeting today on telehealth . Just some background as we prepare to gear up for
implementing teleheath ,
Annually , primary care clinics see 482M patients (actually patient visits in the US (the total number of outpatient
visits is about 900K ). Over a 3 month period primary care providers see about 120M patient visits . So hold onto that
number for a moment,
Let' s assume this outbreak has an attack rate of 30 % ( so about 100M infected that50 % of those infected are
asymptomatic (50M ) . Let' s assume the other 50 % (those 50M who are symptomatic ) are the ones seeking care. How
many telehealth visits per patient do we think will be required ? There will be the initial presentation, then most of
e patients (35 % -38 % of those who were infected 35M - 38M ) will be prescribed home isolation for 14
days ). The remainder will require hospitalization butprobably notbefore additional teleheath visits as their conditions
worsens . How many follow up telehealth visits will be necessary to monitor the health of these patients in home
isolation ? Let s say we want to touch base with the patients twice per week , so that is another 4 visit per patient that
would equate to 140M - 152M visits . Now add in the other 50M visits for initial presentation and we are up to about
200M 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 speak
with their physician or primary care provider and chronically ill and elderly patier
checks . This also does not include the background demand we see each day (for the management of chronic
conditions etc . ) where we would also like to use telehealth .
We have never done this on this scale before . We have people from large healthcare systems on this email, how are
you planning to scale up to meet the demand for COVID andmeet the needs ofnon -COVID patients with chronic
conditions ?

@ charter.net
To : " TraceyMcNamara
Cc: "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
(OS ASPR / 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 ) " , Monique K . " ,
Jessica (USDA.GOV [ . safelinks.protection outlook. com ] )" , " DC" , @ usuhs. edu", Jerome(CTR)" ,
Jay J", Joselito", "WillGaskins
", " CHRISTOPHERALLEN", "KevinMontgomery
"
Sent: ThursdayMarch 5 2020 3 :46: 37PM
Subject : RE: Red DawnRagingStartMarch4
Historydoesn't repeatitself, butoften does rhyme
.
In 1918, the pandemicstartedon the east coastand sweptacross the country from east to west. The initialcitiesthat
werehitwere understandablya little slow to react. Initially, publichealth leadersminimizedthe threat. Itwas
fascinatingknowinghow the outbreakwould unfold to readnewspaperaccountsandthe quotesand responsesby
politiciansandhealth departments(who early on tried to reassureand calm the publicby communicatingthatthey
thought worsthadpassedwhen the outbreakwas justbeginningto accelerate). These cities on the eastcoast
first to face this threat. Other cities like St. Louis were lucky in that they had the
chance to see whatwas happening to the east and act more quickly andmore aggressively .Influenza never traveled
faster than modern transportation . In 1918 , travel was by ship or train .
In 2020 , this pandemic seems to be starting on the opposite coast. Seattle has the misfortune of being the first major
US city to be impacted . We are seeing some of the same reassurances from political and public health leaders to
calm the public and minimize the threat. We have heard that Americans are at low risk . We also have heard it is a
mild disease where more than 80 % of those infected have either no symptoms or very mild disease, and only the
very elderly or those with underlying medical conditions are at risk . Only 0 . 5 % of those who become infecte
again the vast majority are very old with chronic conditions ). That description sounds even milder than flu because flu
also hits the very young and anyone who had the flu would not likely remember it as a mild disease. And we hear
that this disease is not impacting children so really no need to close the schools . I suspect there will be other cities in
California and Oregon up and down the west coast that will be impacted and leaders will also need to make a
decision re the public health interventions . Like 1918 we willl have a natural experiment to assess the effectiveness of
the public health interventions (both the measures and timing). The question is how quickly will this outbreak
emerge since a number of areas across the US have already been seeded and influenza can now travel at the speed
of air travel. Ifwe are lucky the outbreaks will be asynchronous and some cities will have enough time to be able to
learn from the first cities like Seattle and judge the wisdom of the decisions beingmade now . But this isn 't 1918 and
I 'm not sure there will be enough time for that to happen . What is unfortunate is that they don 't need to wait for
results from the Seattle experiment , they can learn from China 's experience , Hong Kong' s experience , and
Singapore ' s experience . They can also go back to the body of work that has been done on community mitigation .
Has CDC modeled the interventions they are proposing ? How effectively do these interventions reduce community
transmission ? In short, where is the science to support these recommendations in the face of what we are learning
from the experiences of China, Hong Kong and Singapore ? When history judges our response , the comparison will
be to thebestpractices . Unlike 1918, wewere actually blessedto know aboutthosebestpracticesbefore COVID
arrived. Seemslike a sin notto take fulladvantageof thatknowledge.

From : " TraceyMcNamara

"
To
Cc: "Dr. EvaLee", Duane", " Tom Bossert ", Ralph S ", "Brian Benson", Carter (VA. GOV
[ . safelinks. protectionoutlook. com ]) " , Richard(OS ASPR ", THOMAS" , " M . D ." ,
", " RichardHatchett
" James V", "David", " Charity A @ CDPH", "GregoryJ", William (STATE.GOV
. protection.outlook. com ] )" , CAMERON
. safelinks ", @ 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 " , " Ryan Morhard" , " Steven Jt , Jerome ( HHSIOASH) " , Monique K ." ,
Jessica (USDA.GOV . safelinks.protection . com " ", " usuhs
. edu", Jerome(CTR )" ,
Jay J", Joselito", "WillGaskins
" , "CHRISTOPHERALLEN" , "KevinMontgomery
"
Sent: ThursdayMarch 5 2020 2 :02: 25PM

Subject: RE: Red DawnRagingStartMarch4

Unbelievableand unfortunate.

From :

To: t" : " TraceyMcNamara", "Dr

. Eva Lee" , Duane", " Tom Bossert", Ralp , " Brian
Benson", Carter (VA .GOV . safelinks. protection outlook. com ]) " Richard (OS ASPR EMMO) " , "Richard
Hatchett", THOMAS", " M . D . ", " James V ", "David" , " Charity A @ CDPH", "Gregory J" William ( STATE.GOV
safelinks.protection outlook.coml
) " , CAMERON" " Daniel (OS ASPR 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 (OS ASPR / )" , " Luciana" ,
" Dan " , sdcounty . ca . gov " , David" , DAVID A" , er @ dshs. texas. gov", SANGEETA" , Scott
(OS ASPR )" " Larry G ", " Ryan Morhard" , " Steven Jt( )", Jerome (HHS OASH )", Monique K ." ,
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 :23PM
Subject
: RE: Red DawnRagingStartMarch 4
I like to ask myself
, knowingwhat I know now , whatdo I wish I would havedone2 weeks ago.
Attachedis a slidethat show side by side the rankingof countriesby the numberofcasesanddeathsreportedfor
Feb 20 andMar5 .
Imaginewhat this is going to look like in 2 more weeks. Whatwillwehave wishedwehad done today?

From : meche
To: "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" , "Charity
A @ CDPH", "Gregory J", William ( STATE. GOV) ", CAMERON ", r gmail.com " , Daniel(OS ASPR/ SPPR) ",
Kristin (OS/ASPR/ SPPR) ", Sally (OSIASPR SPPR) ", "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 : 25AM
Subject : Re: Red Dawn Raging Start March 4
The outbreak in the US is looking more like Italy butwithout the aggressive actions [including cordon sanitaire of
50, 000 people , closing schools and universites , and canceling mass gatherings taken by Italy as soon as they
identified their first death . I pulled the numbers of cases and deaths reported by the media at the end of each (
data for today is preliminary /morning data ).

Interestingto comparethe two countriesand align the outbreaks(4th slideby the date offirstreporteddeath). The
US cases includethe PrincessDiamondcases of repatriatedpassengersaswellas Americansevacuatedfrom
Wuhan. I was unable to estimate the numberoftests performedby Italy comparedto the US. The US case count
semsto be laggingwhatItaly observed
. The USappearsto be abouta 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 (OS ASPR EMMO) ", "RichardHatchett", THOMAS " , " M . D ." , "David" , "Charity
A @ CDPH", "Gregory J" , William (STATE.GOV) ", CAMERON" gmail.com " , Daniel( OSIASPR )" ,
Kristin (OS ASPR SPPR)", Sally (OS ASPR ) ", "Matthew J CIV USARMY(USA)" , " Lisa Koonin", MELISSA",
HERBERT ", Alexander", MARIEFRED"," du", Robert(OS ASPR 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 " , " Ryan Morhard" , " Steven Jt( tCHFSDPH , Jerome(HHS/OASH) " , K . ",
Jessica (USDA. GOV) " , " DC" , " u", Jerome(CTR)", Jay J", ", "WillGaskins
",
" CHRISTOPHERALLEN" , "KevinMontgomery
" , Gerald W " , LindaL " , "LLogandakar
"
Sent: SaturdayMarch7 2020 7 : 24: 25AM
Subject : Re: RedDawnRagingStartMarch 4
The outbreakin theUS is lookingmorelike Italybutwithouttheaggressiveactions[ includingcordon sanitaireof
50. 000 people closingschools anduniversites, and cancelingma
identifiedtheir firstdeath. I pulledthe numbersofcases anddeathsreportedby themedia at the end of each (
data for today is preliminary /morningdata)
Interestingto comparethe two countriesand align the outbreaks(4th slidebythe date offirstreporteddeath ). The
US cases includethe PrincessDiamondcasesofrepatriatedpassengers aswellas Americansevacuatedfrom
Wuhan. I was unable to estimate thenumberoftestsperformed by Italy comparedto the US. TheUS case count
sems to belaggingwhatItaly observed. The USappearsto be abouta week behindItaly. Timewilltell.

OnMar7, 2020, at 5 : 42 PM Dr. Eva Lee 54 @ gmail. com > wrote :

How are ourtestingkits? Dowe have thetestkits and thethroughputpowernow ? This is yetanothermiss
opportunity - about a covid - 19 case in Georgia it true thattests are only conductedon patientswhich satisfy the
CDC criteria The symptomsare so diverse thatwe can t be fixed to a set of guidelines . Weneed broader
screening
, thatis a must.

" The third case involved a 46 -year-old female went who went to a hospitalin Rome Georgia ) complaining of flu - like
symptoms. Hospitalofficials said she didn' t meetthe Centers for Disease Controland Prevention (CDC ) and
GDPH criteria for COVID - 19 testing, so she was treated and released. After shebegan to feel worse, the woman
was eventually tested . The test has now confirmed that she has 9. Officials say she hasbeen hospitalized. "

On Sat, Mar 7, 2020 at 9: 30 PM McDonald, Eric @ sdcounty. ca . gov> wrote:

The longpole in the tentis testing capacity .withoutgoinginto why it could possiblytake so longto field tests in this
countrywhen others seem to be able to do it, at the operational level, if you only have limited access to testing, triage
needsto occur. So hindsightcriticism of providersusingthe criteria they had/have on patientswho did notmeetthese
criteria and then were foundto be positiveis notusefulin myview . Agree the opportunitywas missed, but they are
beingmissednow andwillbemisseduntilthepromisedmillion plus tests are actually fielded and results obtainedin
an actionabletimeframe
.

Whateveris goingon/wenton between cdc and fda and laboratory communitythat created this delaywillbe
dissectedby someonein the future, butit still is not fixed for us to be able to do whatothers countrieshave done or
formeas a localpublic health officialto get vitaldata on what is really goingon.

Frustrating doesn ' t capture it. You know what I am saying.

Eric
From : Gruber,David (DSHS)
Sent: Tuesday, March 10 , 2020 9 :58 AM
To : Dr. Eva Lee; McDonald, Eric
Cc: CarterMecher; Borio , Luciana; Brian Benson Lawler, James V ; Tracey McNamara; Duane Caneva; Dr. Eva K
Lee; Tom Bossert; Baric, Ralph S ; Mecher, Carter (VA.GOV) ; Hunt, Richard (OS ASPR EMMO) ; Richard
Hatchett; 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 HARVEY
MELISSA ; WOLFE , HERBERT Eastman , Alexander: EVANS. MARIEFRED : b . edu ; Johnson, Robert
(OSIASPRBARDA) ; Yeskey, Kevin ; Disbrow , Gary ( BARDA) ; Redd, John (OSIASPR ); Hassell
,
David (Chris) (OS ASPR ; Hamel , Joseph (OS ASPR IO ) ; Hanfling, Dan; Wade, David; TARANTINO, DAVID
A ; 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; Will
Gaskins
; CHRISTOPHERALLEN; Kevin Montgomery; Parker Jr, Gerald W ; Logan , Linda L ; LLogandakar
Subject: RE: Red DawnRagingStartMarch 4

As a state public health official who is in agreement that must be strongly enacted early ; ' m looking for help
from this group to find tools thatmake the case for . The target audience is those outside of health .

I' m attachingan exampleslide (admittedlyandintentionallyrudimentary

) thatmightbe usedto supportthis argument
and explainthe totalityofNPls. Do otherssee this as somethingthatmightaid in influencing
and, if so, are there
data sourcesthatI mighttap into showingthe impactsof directlyon epicurvesandhow these would
impactother communityfoundations?

Thanks
Dave

From : CarterMecher
Sent: Tuesday, March 10 , 2020 10 : 30 AM
To: Gruber DSHS); Dr. Eva Lee; McDonald, Eric
Cc: Borio, Luciana; BrianBenson; Lawler , James V ; TraceyMcNamara ; DuaneCaneva; Dr. Eva K Lee; Tom
Bossert; Baric, Ralph S ; Mecher
, Carter (VA.GOV) ; Hunt, Richard(OSIASPREMMO) ; Richard
Hatchett; 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; HARVEY
MELISSA WOLFE, HERBERT Eastman, Alexander
: EVANS. @ utmb. edu; Johnson, Robert
( OS ASPR BARDA) ; Yeskey, Kevin; Disbrow, Gary (OS ASPR /BARDA) ; Redd, John (OSASPR / SPPR ) ; Hassell,
David (Chris) (OSASPR Hamel Joseph ( OS ASPR ; Hanfling, Dan; Wade, David; TARANTINO, DAVID
A ; KAUSHIK, SANGEETA; Lee, Scott (OS ASPR EMMO) ; Larry G ; RyanMorhard; Steven Jt( ) ; Adams,
Jerome (HHS/OASH) ; Mansoura, M
usuhs.edu; Cordts, Jerome(CTR ; Schnitzer, Jay J; Ignacio, Joselito; Will
Gaskins; CHRISTOPHERALLEN; Kevin Montgomery; Parker Jr , Gerald W ; Logan, Linda L ; LLogandakar
Subject: RE: Red Dawn RagingStartMarch 4

Backin 2007, there wasmodelingfor estimatingthe economic impactofa pandemic(unmitigatedwith no and

a mitigatedpandemicplusthe costs of . I can see if can dig that up . The bottom lineis thatwhen you add in
the cost associatedwith lives lostin an unmitigatedpandemic, additional healthcare costs due to greaternumbersof
those who are illandhospitalized
, economiccosts due to lostproductivitydue to increasedillness, the costs pale
in comparison. I will see whatadditionalinfo I can find to help you.

'm listening to the arguments for not closing schools : (1) kids may not be important in disease transmission and
when kids do become infected their illness is mild; 2 ) closing schools is too disruptive , it will require parents to stay
home from work to mind their children (and this absenteeism could adversely impact critical sectors such as
healthcare ); (3 ) large number of kids depend upon school meals and the closure of schools could have serious
consequences ; (4 ) by keeping kids home, they have more time to be around older adults in the household and
potentially transmit disease to more vulnerable groups the thinking is that itwould be safer to keep them at school for
at least 8 hrs of the day to decrease contact time with older adults in the household ); and (5 ) kids will just mix again
the community ( that kids will out at malls ).

Just somethingto think about.

Schoolsare closingnow for 1 week for springbreak (manythis week and somein thenextweek or two). This is
happeningat a criticalpointof the accelerationof this outbreakin the US. In the nextcouple ofweeks ourhealthcare
system is likely to be stressed. A goodnumberof parents take timeoffover springbreakto be with theirkids (many
timesboth parentsfor twoparenthouseholds ). Below is a graphof annualleaveusagerates in VA. Itis very
consistentfrom year to year (looks a lotlike an EKG tracing. You see a spikeat Thanksgiving , anotherhuge spike
round Christmas /New Years, anothersmallbumpin the spring (springbreak), and anotherbroadbump(thatlooks
like a T waveon an EKG ) in the summermonthswhen families tend to take vacations(becausekids are outof
school.
Given the argument ofthose opposedto closingschools, shouldwe cancelspringbreak and keep the schools open
so thatparents don 't have to stay hometo mind theirkidsat this p
system is aboutto behammered? Shouldwe alsokeep the schools open so thatkidsare keptawayfrom older
adults in the householdformuch of the day duringthis periodofacceleration? Thatis prettymuch the extensionof
illogicallogic

We close schools for 1 week for spring break and the world does not fall apart. The nutrition of children does not
suffer. Do we think if schools closed for two weeks , that the world would come crashing down ? Why not close for
two weeks and then reassess least it gives us time). We can never get that time back .

Last thing. Many ofyou have kids, do any of them hangout atmalls ? In myneighborhood I don't even see kids
outside — they are all inside texting, on Instagram , playing games with their friends online orwhatever they do these
days. Hardly see them riding their bikes around. I understand that going to themall is code for kids re
congregating outside of school. Even ifthey do they are in a less socially dense environment and in much smaller
groups. The whole schooldoesn 't all go together anywhere, except to school.

From : Dr. EvaK Lee

Sent: Tuesday , March 10, 2020 1: 46 PM
To: CarterMecher
Cc: Gruber, David (DSHS); Dr. Eva Lee; McDonald, Eric ; Borio, Luciana; Brian Benson; Lawler, James V ; Tracey
McNamara; DuaneCaneva; Tom Bossert; Baric, Ralph S ; Mecher, Carter (VA.GOV); Hunt, Richard
(OS ASPR EMMO); RichardHatchett; WILKINSON, THOMAS; M . D . ; David; ; Gregory J ; Walters,
William (STATE.GOV) ; HAMILTON, CAMERON; @ gmail
. com ; Dodgen, Daniel(OS ASPR /SPPR ); DeBord
Kristin (OSIASPR ) Phillips, Sally (OS ASPR SPPR) ; Matthew J CIV USARMY(USA) ; Lisa Koonin HARVEY
MELISSA , HERBERT ; Eastman, Alexander; EVANS, MARIEFRED; .edu; Johnson , Robert
(OS ASPR / BARDA ) Yeskey Kevin Disbrow Gary (OS ASPR /BARDA ) Redd John (OS ASPR / SPPR ) .
David (Chris ) (OS ASPR IO ); Hamel, Joseph (OS ASPR IO ; Hanfling, Dan ; Wade, David ; TARANTINO , DAVID
A ; KAUSHIK , SANGEETA ; Lee , Scott (OS ASPR EMMO ) ; Larry G ; Ryan Morhard ; Steven ); Adams ,
Jerome (HHS /OASH ); Mansoura Monique K ; Fantinato , Jessica
( USDA. GOV ; DC @ usuhs.edu; Cordts, Jerome CTR ); Schnitzer , Jay J; Ignacio, Joselito; Will
Gaskins ; CHRISTOPHERALLEN; Kevin Montgomery; Parker Jr, Gerald W ; Logan, Linda L ; LLogandakar
Subject: RE: Red Dawn RagingStartMarch 4

Europegivesme an extraordinarygood example. Germanyheld outreallywell when itwas infectedfrom the one
Chinese subject. But the few cases and verymild natureallowed healthcareto contain them in no time.

With Italy so well-connected to all its neighbours, it viral spread triggers a radial cascading effect that is another text
book example . We are just like Europe in terms of connectivity by air (and less by trains). Wemay be a little slower
because ofournormal distance from each other. But if you go to any university or any school, you will notice
everyonepacks together and intertwines so tightly .

Churches , synagogues ,mosques , temples , we need to encourage the worshippers to do all these onlines . These
sites have high percentage of volunerable populations , we need to spread the words . I think the religious leaders can
take the lead .

From : CarterMecher
Sent: Tuesday, March 10 , 2020 12:52:56 PM
To: Dr. Eva K Lee
Cc: Gruber,David DSHS
) <D @ dshs. texas. gov> ; Dr. Eva Lee
McDonald, Eric county .ca . > ; Borio , Luciana Benson
> ; Brian Benson
 @ 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 > ; David
som umaryland .edu > ; Charity A @ CDPH < @ cdph . ca. gov> ; Gregory J
Walters . William STATE GOV @ state . gov HAMILTON , CAMERON
@ hg. dhs.gov > ; ; Dodgen, Daniel(OS ASPR SPPR)
@ hhs. gov ; Kristin (OS ASPR hhs. gov > ; Phillips, Sally
(OS ASPR 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 ; Hamel

, Joseph ( OS ASPR hhs. gov ;

Hanfling
, Dan @ igt
. org> ; Wade, David @ . dhs. gov ; TARANTINO, DAVID A
o @ cbp. dhs. gov> ; KAUSHIK SANGEETA @ . dhs. gov ; Lee, Scott

( OS ASPR ) . gov> ; Larry G @ state. gov> ; Ryan Morhard

@ weforum. org> ; Steven Jt ) @ ky. gov > ; Adams, Jerome(HHS/OASH )
@ hhs. gov> ; Mansoura, MoniqueK . mitre . org > ; Fantinato , Jessica (USDA. GOV )
o usda. gov > ; DC

y @ 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 ALLEN
10 . com > ; Kevin Montgomery @ collaborate.org > ; Parker Jr Gerald W
r @ tamu
. edu > ; Logan Linda @ cvm . tamu.edu> ; LLogandakar mail.com >
Subject
: RE: Red DawnRaging StartMarch4

I see that NJjust announced its first death (man in his 60s). Don ' t know the details butif this is not a travel related
case , 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 cases
announced today ). The superintendent does not agree .
https :/ /www .msn . com / en -us/news /us/cuomo -says -new -rochelle -schools -may-close - superintendent
disagrees ar BB10X67F

From : GruberDavid ( DSHS)

Sent : Tuesday, March 10 2020 2 :03 PM
To : CarterMecher; Dr. Eva K Lee
Cc: Dr. Eva Lee McDonald, Eric , Luciana; Brian Benson; Lawler
, James V ; TraceyMcNamara
; Duane
Caneva; Tom Bossert
; Baric, Ralph S ; Mecher
, Carter(VA. GOV) ;
Hatchett;WILKINSON THOMAS M . D .; David CDPH ; Gregory J ; Walters William
(STATE .GOV ); HAMILTON , CAMERON ; m ; Dodgen, Daniel(OS ASPR/SPPR ); DeBord, Kristin
(OS ASPR SPPR ) Phillips, Sally (OSASPR SPPR ) : Matthew J CIV USARMY (USA ) HARVEY
MELISSA WOLFE HERBERT Alexander , MARIEFRED utmb. edu ; Johnson Robert
(OS ASPR/BARDA); Yeskey, Kevin Disbrow, Gary (OS ASPR/BARDA) Redd (OSASPR/ SPPR) Hassell
David (Chris (OS ASPR ; Hamel
, Joseph (OS ASPR ; Hanfling
, Dan; Wade, David; TARANTINO, DAVID
A 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 ; Will
Gaskins CHRISTOPHER ALLEN ; Kevin Montgomery ; Parker Jr Gerald W Logan , Linda L ; LLogandakar
Subject: Re: Red Dawn Raging Start March 4

Another strategic approachto looking at the situation .

Applying the, Adano Principles" to manage an adversity such as COVID 19

1. Recognitionand acknowledgement of the existenceor potentialof an adversity

2. Identifyingthe specific characteristicsof the adverse environment
3. Applyinga network centric/ systemsapproach to counteringthe adversity to includedevelopment
ofprocessand
associatedmetrics thatdefine successpoints and end- state
4 . Incorporating continuous analysis and quality improvement to maintain progress and preventreversion from
success
5 . Recognition of when the adversity is neutralized or eliminated to allow for return to baseline operations

From : Carter Mecher

Sent: Tuesday, March 10 2020 3:01PM
To: Gruber DSHS) ; Dr. Eva K Lee
Cc: Dr. Eva Lee McDonald Eric Luciana; BrianBenson Lawler James V Tracey McNamara; Duane
Caneva; Tom Bossert; Baric, Ralph S Mecher, Carter (VA .GOV ; Hunt, Richard OS ASPR EMMO); Richard
Hatchett; WILKINSON THOMAS M . D . ; @ CDPH ; Gregory ; Walters William
(STATE .GOV HAMILTON , CAMERON com ; Dodgen Daniel(OS ASPR SPPR) ; DeBord, Kristin
(OS ASPR SPPR ); Phillips, Sally (OS ASPR SPPR ) Matthew J CIV USARMY (USA); Lisa Koonin HARVEY,
MELISSA; WOLFE, HERBERT Eastman, Alexander: EVANS. MARIEFRED: @ utmb. edu; Johnson, Robert
(OS ASPR/BARDA); Yeskey Kevin Disbrow Gary ( BARDA); Redd John (OS ASPR ) Hassell,
David (Chris) (OSASPR/ IO ; Hamel
, Joseph (OS ASPR IO ); Hanfling
, Dan; Wade, David; TARANTINO, DAVID
A ; 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; Will
Gaskins; CHRISTOPHERALLEN; Kevin Montgomery
; Parker Jr, Gerald W ; Logan, LindaL ; LLogandakar
Subject: RE: Red DawnRagingStartMarch 4

Italy is aboutwhere Hubei was on Feb 2. Feb 2 was day 62 on the graph below . Imagine that. The question is
whether Italy retraces HubeiorWuhan ? That means we are at about day 50 or so .

< B5B96EDAA5B54CFAAAD14BD37A08490C
. png>

From : @ charter.net>
Date: Wed, Mar 11, 2020 at 12 : 15 PM
Subject: Re: Red DawnRaging StartMarch 4
To: .net>

Cc: Richard Hatchett @ cepi

. net> , Gruber David ( DSHS) r @ dshs. texas. gov Dr. Eva

h @ pm .me> , Dr
. Eva Lee .lee64 @ gmail. com > , McDonald, Eric
d @ sdcounty . ca.gov Borio, Luciana < @ . org> , Brian Benson n icloud. com > ,

Lawler, James @ unmc

. edu > , Tracey McNamara < @ westernu. edu > , Duane Caneva
va @ . . 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 .gov
WILKINSON , THOMAS < @ hq. dhs. gov M . D . @ .harvard . edu > , David
zi@ 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 .mil

Lisa Koonin 1 @ gmail. com > , HARVEY , MELISSA < m vey @ . gov WOLFE, HERBERT
FE @ . dhs. gov Eastman, Alexander @ . dhs . gov EVANS , MARIEFRED

@ associates . hg. dhs . gov utmb . edu uc @ utmb . edu > , Johnson , Robert
(OS ASPR BARDA ) < n @ hhs. gov Yeskey , Kevin < ke @ hhs. gov , Disbrow , Gary
(OS ASPR / BARDA) < . gov Redd
, John (OSASPR/ SPPR) < @ hhs
. gov> , Hassell
,

David ( Chris) ( OSIASPR @ hhs

. gov> , Hamel
, Joseph (OS ASPR/ el hhs. gov

Hanfling
, 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 Morhard
rd @ 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 ALLEN
10 @ msn . com > , Kevin Montgomery < collaborate .org > , Parker Jr, Gerald W

@ . tamu. edu > , Logan , Linda . tamu. edu> , LLogandakar r @ gmail. com >
I notice a lotof HHS emailaddresseson this emailand group and you allhavebeen quietfor mostof the discussion
over the paste several weeks . I would urgeyou to readthe article I just sentout and upriefyourboss. This is thekey
message that they need to hearand theyhave little timeleft to act.
derstand what happened in China and what has happened in Hong Kong and
Singapore . COVID doesn ' t fade away on its own . The reason is reMore data for forecasting
report : https: // www .who . int/docs /default -source / coronaviruse /who-china -joint -mission -on -covid - 19-final-report.pdf
2 . South Korea has done an extraordinary effort to test its ciizens (more than 222 ,000 tested to date ). South Korea
has a population of51M . An equivalent effort in the US would equal . 4 M tested . How many have we tested in the
US to date ?
3 . Italy is really struggling right now and time will tell if their extraordinary efforts they now are employing will mitigate
the 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 experiences
of China , Hong Kong, Singapore , South Korea and Italy . Ifwe fail to learn from them , we do so at our peril. History
will long remember what we do and what we don 't do at this criticalmoment. It is the time to act , and it is past the
time to remain silent. This outbreak isn' t going to magically disappear on its own . If that is the conclusion some are
taking , they are misinformed and dead wrong .

From : Tom Bossert @ me

. com >

Sent: Wednesday, March 11

, 2020 23: 05

To: CarterMecher

Cc: Dr. Eva K Lee; RichardHatchett; GruberDavid (DSHS); Dr. EvaLee; McDonald, Eric; Borio, Luciana; Brian
Benson; 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(OSASPR SPPR); DeBord,Kristin
(OSASPR SPPR); Phillips, Sally (OSIASPR ); Matthew J CIV USARMY(USA); Lisa Koonin; HARVEY,
MELISSA; WOLFE, HERBERT ; Eastman, Alexander; EVANS, @ utmb.edu; Johnson , Robert
(OS ASPR BARDA); Yeskey, Kevin; Disbrow, Gary (OS ASPR/ BARDA); Redd, John (OS ASPR/ SPPR); Hassell,
David (Chris) (OS ASPR IO ); Hamel
, 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; CHRISTOPHER ALLEN ; KevinMontgomery;
Parker Jr, Gerald W ; Logan, Linda L; LLogandakar

Subject: Re: Red Dawn Raging StartMarch 4

Can anyone justify the Europeantravelrestriction, scientifically? Seriously, is there anybenefit? I don't see it, but 'm
hopingthere is somethingI don' t know .

From : Parker Jr, GeraldWI . tamu. edu

Sent: Wednesday, March 11, 2020 23: 15

I do not see it. No use now . I saw it for China. Butnotnow . We should focus on targeted, layered community
mitigationmeasures. Maybe we could use a hurricaneanalogy thatmany understand. COVID19 is like a storm
comingto our communities, butrather than evacuation or shelterin place orders, the analogousmove is community
mitigation. Atthis stage they mustbe aggressivebecause we do nothave the time luxury of a hurricanein the
Atlantic .
On Thursday, March 12, 2020 12: 09 AM , Lawler, James @ unmc.edu> wrote:

Fuck no. This is the absolute wrong move.

JamesLawler, MD, MPH, FIDSA

Director, InternationalPrograms& Innovation
GlobalCenterfor Health Security, and
AssociateProfessorofMedicine
Divisionof InfectiousDiseases
University ofNebraskaMedicalCenter

From : Parker Jr, Gerald W

Sent: Thursday , March 12, 2020 12 16 AM

Notto worry .. . is a large group of friends cleared to car pool confidentiallevel.

On Thursday, March 12, 2020 12: 20 AM , Richard Hatchett @ cepi.net> wrote :

No justification that can see, unlesswe to put up similar geographic cordons in the US - there is plenty of
disease already in the US to cause spread domestically .

On Thursday, March 12 2020 12: 26 AM , RichardHatchett @ cepi

.net> wrote:

Gerry - I thoughtyesterday about the incominghurricaneanalogy as well andthink it is a good one. This is a Cat5
threatto safety thatis coming too Jr. communities and fast, and we can either prepare and do the epidemic
equivalentof evacuate to safer ground(i. ., TLC/ CMG) or takeour chances. It's a lotharder to evacuatewhen the
windsare above 100miles an houron their way up to 190 at the eyeball.

On Thursday , March 12, 2020 12: 28 AM , Dr. Eva K Lee > wrote:

I washopinghewould mention about schools, governmentand private sector tele-work, community gatherings,
things thatreally need everyoneto actively engage in And also extra resources for healthcare providers. Wereally
need to protectproviderswho care for covid- 19 patients. Wemust protectthem because they are invaluable
resources and we don't have enough. They are notlike equipmentthatthe Presidentcould ask a manufacturerto
producemore.

Herein Georgai
, students are partitioningthe universitiesto do lecturesonline, butuniversitiesare notagreeingso
far. I am sure theywould llisten to the President
. Butnow they willwaituntila teacherhascovid- 19. Springbreak is a
dangeroustime, aswe can see from Italy.

I wonder, closing allflights from Europewould mean thatmany Americanswill bestuck in Europe. Or allthose who
wantto comehomewillrace and get a ticket to fly back on Fridaybefore closing. And they will be quarantinefor 14
days.

On Thursday, March 12, 2020 12: 38 AM Carter Mecher wrote:

There is no value to these travelrestrictions. A waste of timeand energy. The lesson from Mann Gulch was to drop
those things that are notessential. Thatlesson wasnotheeded. I wouldn't waste a momentof timeon travel
restrictionsor travelscreening.Wehavenearly as much disease here in the US as the countries in Europe.

Wrt communitymitigation, I think weran out of timefor Seattle. Butthere are other cities and communitieswhere we
still can makea difference. I don' t understandwhy California andNYC are notactingmore aggressively. Time to
focus on other parts of the country where mitigationmeasuresmightstillwork and where governors,mayors and
public health officials aremore receptiveto doingwhatworks. It feels like a replay of 1918. Somestate and local
leaderswillmakepoor decisionsand unfortunately theAmericanswho live in those communitiesare goingto pay
dearly for the choicesbeingmadeby their leaders. Itis a shamethose lessonswere notlearned.

On Thursday, March 12, 2020 12: 56 AM , Dr. Eva K Lee > wrote:

Yes, aggrssive communitymitigation will work in some states, and somewe are losing thebattleground. Tam still
very confused by testing ability. Whatexactly is our levelof throughputnow ? 10,000 a day? Or 100, 000 a day ? When
I talked to localtoday, they had no idea and their requestsfor test are stilldelayed. Who is in charge of testing
resourceand statistics? Maybe there's a leaderwho is in charge of all the vendors, andhe/ she can tellus the
throughputstatistics Now , we can strategizetesting, or perhapsitis too widespread across the US and we justhave
to test a lot, like S . Korea . Somestates are stillbetter than others.

I know always talk about 1 case" or " 1% infection". In mathematics

, we always look for the smallest things that are
ofgreatsignificance. And then welook for largestthings thatwe can solve. I think " 1" is a very good numberyeta
very dangerousnumberthatrequireshard decisionswhen it comes to infectiousdisease. I understandhaving 1 as a
triggerfor actionis a very hard decision. Butin infectious disease, 1= 1+manyunknowns, henceit is ratherbig
already. I really learn a lotfrom allofyou. I found thatyou are all very mathematical: ). Now I will go back to my
equationsagain to see which cities are stillin good shapeto contain successfully
.

On Thursday , March 12, 2020 7 : 08 AM , Tom Bossert me. com > wrote :

We are making great progress. Mymessage today on US TV will be as follows:

•Thebiggestmisunderstandingabout# coronavirus interventionsis they are an à la carte menu of options to be

selectively implemented. This is dead wrong. They ALL must be implementedto achieve a layered effect. Removing
any 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 restrictions
and screening are less useful.Wehave nearly asmuch disease here in the US as the countries Europe. We
MUST focus on layered community mitigation measures-Now !

Tom

On 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 ourpublic
health infrastructure we need to implement all in affected communities

JamesLawler, MD, MPH, FIDSA

Director, International
Programs& Innovation
GlobalCenterfor Health Security, and
AssociateProfessorofMedicine
Division of InfectiousDiseases
UniversityofNebraska
Medical
Center

On Thu, Mar 12, 2020 at 1: 14 PM Hunt, Richard (OS/ ASPR/EMMO) @ . gov> wrote :

Reflectingon this from Tom , They ALL must be implemented to achieve a layered effect."

Asmy 24 y / o told me, " the nation needsto go to war against this virus.

Rick

On 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 sufficient
because the brake has to be very big!! ! We are too late , wehaveno choice but to roll them all out.

From : "Lawler, James V "

Date : Thursday ,March 12, 2020 at 1:28 PM
To: Carter Mecher Dr. Eva K

We are making every misstep leaders initially made in table -tops at the outset of pandemic planning in 2006 . Wehad
systematically addressed all of these and had a plan that would work - and has worked in Hong Kong/Singapore . We
have 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 what their instruments
are telling them
And we continue to push the stick forward ...

James Lawler, MD , MPH, FIDSA

From : Eva Lee < om >

Thursday , March 12, 2020 1:28 PM
To: Lawler , James V u>

Yes, very very sad -- it' s all theplanning and wemustexecute and we can' t execute!

From : Carter Mecher

Thursday, March 12 , 2020 1:28 PM
To: 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! If we can only make the president, or some ofthese leaders, to say somethingatnewsconferences -- so that
every infected State could respond in a timely manner, thatwould truly work. Weare all connected, so weneed to
synchronize, thatway, there' s no room for the virus to wriggle.
From : CarterMecher <
Date: Thursday, March 12, 2020 at 8:08 PM
To : "Dr. Eva K Lee"
Cc: "Lawler, James V " Tom Bossert.. .

This coming Saturday willmark two weeks since the first death in the US. On Saturday (likely by then we willhave
500 cases and 75 deaths given the current trajectory) , ask yourself, what do you wish we would have done 2
weeks earlier on Feb 29 ? don ' t think shutting down travel with Europewould have made the list. If you can answer
that question truthfully now , then whatare we waiting for ?
-- - - ---

On Mar 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 Bossert
Sent: Friday,March 13, 2020 6 :07:00 PM

That article snippet seemsmisleading. I wonder it the CDC guidance it's based on is equally unclear.
- - - - - --

From charter.net

To: " 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 " , " Duane
Caneva ", 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 (OS ASPR SPPR)", David (Chris) (OS ASPR )", Joseph (OSIASPRIO )" , Dan", David",
DAVID A" , SANGEETA, Scott(OS ASPR EMMO)" , "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: 26AM

Subject: Re: Red Dawn Raging StartMarch 4

This is whatleadership looks like.

"Wewhole-heartedly endorsethe bold and decisivedecisionsofourGovernorheretoday. This is not abouta

healthcaresystem ; this is about of us. Wecan all fightback againstthis virus, andin fact, weneed to . The health
care system can treatthose who are ill; and across all of Maryland
, we' re readyingourselves in case weneed to
However , byputtingaggressivesteps in place that theGovernorjustoutlinedwith regard to socialdistancing
closuresofschools, teleworking are stepswe can all adopt.. . the earlierwe do this, themore layersweputin
place, the less this virus can be transmitted
. That's thekey. Marcozzi , at a press conferencehostedby Governor
Larry Hoganannouncingmajorsteps in the state ofMaryland 's COVID - 19 response . Those stepsincluded

Maryland EmergencyManagement Agency increase activation to highestlevel

Activate national guard

 state governmentis raisedto elevated level 2 - allnon- essentialemployeeswho can telework required to do so

Public access to state buildings restricted

o No gatheringsofmore than 250+ people including sports andreligious gatherings)
seniorcenters closed

All state and local governmentbuildings with more than 250 + peoplemust follow socialdistancing

cruise ship terminalin Baltimore

of expiration dates on permits including drivers licenses , license plates , professional licenses , until 30
days after end of state of emergency

Allhospitals adopt new visitor policies to stop spread of COVID -19

prisonswillsuspend visits

non-essentialfunctionsof governmentare now managed by LtGov Rutherford so Gov Hogan can focus solely
on COVID - 19

Monday, March 16 through Friday, March 27 - all public schools closed

Measurestaken to providechild care for essentialworkers/firstresponders

On 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 like
ignoring the smoke detector and waiting untilyour entire house is on fire to call the fire dept. Plus, how are you
supposed to know when you have community transmission when they haven' t been able to provide a diagnostic
assay that can beused widely and athigh volume?
- - - - - -- - - - -- - - - - -- -- - - - - - - - -

From : CarterMecher

Sent: Friday , March 13, 2020 7: 13: 19 PM

To : 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; Brian
Benson; Tracey McNamara; Baric, Ralph S ; Mecher, Carter (VA.GOV) ; Hunt, Richard
(OSASPR/EMMO) ; WILKINSON, THOMAS ; M . D. ; David; Charity A @ CDPH; Gregory
J Walters, William (STATE.GOV ; HAMILTON CAMERON:
DodgentDanielt(OS ); DeBord,Kristin ( OS ) ; Phillips, Sally
(OS ASPRISPPR) Matthew J CIV USARMY(USA) Lisa Koonin HARVEY MELISSA
.edu;
Johnson, Robert OS/ ASPR/ BARDA ) ; Yeskey, Kevin , Gary
( OS ASPR BARDA) ; Redd, John (OS ASPR SPPR ); Hassell, David (Chris)
( OS ASPR IO ) ; Hamel
, Joseph (OS ASPR 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.com

Subject: RE: Red DawnRaging Start March 4

I don' t think theintentis to close schools for only 2 weeks. Longerterm schoolclosure
willbe necessary.

What CDC is not accounting for is thatwe 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 severalweeks ago (and we stated so at the time over email and on
conference calls ), but nobody could prove itbecause CDC would only perform
confirmatory testing on cases meeting the PUIdefinition . And the PUI criteria by
definition excluded any potential case of community transmission . Itwas very circular .
CDC placed state and localpublic health in a bit of a Catch 22 .

So after a longdelay we finallyhavethe ability to testmore broadly. If you recall

, CDC
only expandedthe PUIincrementallyat firstto includeseverelyillpatientswith no
travelhx or link to a knowncase. It was only laterthattestingwas openedup more
broadly. Can a modelincorporatethat amountof confusioninto theinitialconditions
?

Oncetestingbegan in earnest
, thenumbersofcasesexploded. Itwas like popcorn
(also aswe predicted) . Caseswere appearingeverywhere . I wouldchallengeanyone
to providean accurateestimateofprevalencein theUS. I' d be interestedin how
certain theywould be of that estimate + / - ?

The differencebetweenmodels and reallife is thatwith modelswe can setthe

parameters. How would theymodelwhat happenedin Italy ?

The differencebetweenmodels and reallife is thatwith modelswe can setthe

parametersas ifthey are known. In reallife , these parametersare as clear as mud.

To check the accuracyof themodelforpredictingreallife, I would ask thatthey run

Italy for us to show us how wellhandwashing
and isolationwould work. Howwould
theymodelwhathappenedin Italy? On Feb 20, Italyhad 3 casesandno deaths. On
thatday themodelersand the guidanceCDC just releasedwould notadviseto take
anyaggressiveaction. On Feb 21, they had 1 death and 20 caseswith 6 patients in
the ICU. This is a country of51M . Whatwould CDC guidancehave advised Italy to do
on Feb 21? On Feb 22, Italy had a cumulativetotalof 2 deaths, 63 caseswith 7
patients in the ICU. How would CDC describedwhatwas goingon in Italy?
Would thismeettheir definitionof widespreadcommunitytransmission? doubtit.
CDC and theCDCmodelerwould have recommendedsitting tight. Italy responded
extremelyaggressively
. This is whathappened since. I think thepublichealthofficials
and political
leadersin Italyactedvery quickly and very aggressively more
quickly and aggressivelythan whatwe did when the outbreakbegan in Seattle two
weeksago. I would ask themodelerandCDC when theywould havepulledthe trigger
in Italy. Wehave the actualdata. Themodelercan runhis modelsandcan pointout
whathe/ she would do andwhen it should be done. I suspectearly on in Italywewould
have heardexactlywhatweare hearingnow .

I don' t pretendto have perfectknowledge of the extent of disease in the US. There is a
lot ofuncertainty. But given this uncertainty, isn ' t the safest approach to close the
tilwe knowmore ? We can alwaysreopenthe schools. Ifwedelayour
responseand the outbreaktakes off like Italy, we willhavemadea terrible gamblewith
the livesof Americans
, overwhat, an extendspring break? Which side of thebet
would you takeifyou were the responsibleofficial(mayor, governor, publichealth
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 out to 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. edu
Date: Saturday, March 14, 2020 at 1: 16 AM

CDC schoolclosure guidance

https://www. cdc. gov/ coronavirus/ 2019-ncov/downloads/considerations-for-school-closure.pdf

From : CarterMecher
Sent: Saturday, March14, 2020 7:58 AM
To: Parker Jr, Gerald W ; Dr. Eva K Lee; gmail.com
Cc: Lawler, James V ; Caneva, Duane; Tom Bossert; Hanfling, Dan; Gruber David
(DSHS); Dr. Eva Lee CHRISTOPHERALLEN; @ gmail. com ; Richard
Hatchett; 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 (OS ASPR ) ; 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 ASPR BARDA); Redd, John (OS ASPR/ SPPR); Hassell,
David (Chris) (OS ASPR IO ); Hamel
, Joseph (OS ASPR/IO ); 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 ; du; Cordts,
Jerome(CTR); Schnitzer, Jay J; Ignacio, Joselito; Will Gaskins; Kevin Montgomery;
Logan Linda L ; LLogandakar; akeda.com

Subject: RE: RedDawnRaging StartMarch 4

Most of you have been involved in table top exercises of an outbreak . In those
exercises they commonly show a map of the US with the number of cases noted and
extent of spread . At various points in the scenario , a facilitator will ask the participants
what actions should be taken . I took the graphic of the US map from the NYTimes and
created a PowerPointmovie from Mar 4 (the first day that the NYTimes presented that
map ) through today.

In this scenario, the facilitatorpausesnow on March 14. Atthis pointthe virushas

already spreadto more than 120 countries. The virusis highlytransmissiblewith an Ro
of about2 .5 andhas a CFR of 0 .5 % - 1.0 % . The elderly and those with chronicmedical
conditionsare at greatestrisk. The responsehasbeen hinderedby seriousdelays in
the ability to confirm diseasewith diagnostictesting. This testingcapacity is limited.
Case ascertainmentis limiteddue to the testing constraints. Itis believedthatoverthe
nexttwo weeks capacity for testing should improve. However, the demand for testingis
se exponentially over the next 2 weeks. A few areas in the US
have been particularly hard hit Washington and California . The currentUS case
count is 2 ,654 with 49 deaths. What actions would you take on March 14 ?

- - - - - - - -- - - - - Saturday, March 14, 2020

12: 43 PM , . Eva K Lee
This is so very sad, yes, everythingwe talked aboutand everythingwehave anticipated. Yes, you can
see from the curvesin the graphswhen they have the first confirmeddeath, they're at least2 weeks
behind. I don't understandthe screening at the airport, noteven a little adviceon self-quarantine
comingin from any countries. Yes, children will die too if they haveno support in thehospitals. There
aremanywith co - existing conditions. Beds are critical. Thatis all I am counting(when wehaveone
bed, we need everythingthat goes with it in the ). Healthcareworkersand anyonein service
to assistthis covid- 19 operationsmuststay healthy. Butof course we know they willbe quarantined at
ay think school closure is over-reacting. It isn not if you think about the
inter-dependencies . You can imagine a million different scenarios. Just a simply one -- a litle
child got infected from school. He came home and infected his mother who was a nurse. The nurse
went to work without any noticeable symptoms, and she infected the ICU patients that she cared for
Ok , this is one case -- and again -- one case is ALL we need to worry about. The cascading effect --
we don't want to even think about.

But as a country , wemust fight for everyone and every state . I truly believe and in my calculations ,
those states that took the pre-emptive steps -- they are going to have the resources to contain their
own infection and at some point, can help those states in needs. Here we go about sending patients
around -- not 7 - - butmany -- when we must 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 know
if anyone has extra resources. It is really resource - intense . Can you imagine --India, and the African
countries start to pick up ? It frightens me. Hence pre - emptive is a must.

From : Carter Mecher

Sent: Saturday, March 14 , 2020 4: 32: 54 PM
To : Parker , Gerald W > ; Dr. Eva K Lee
e gmail.com >
Cc: Lawler, James V r @ unmc. edu> ; Caneva, Duane
@ hq.dhs. gov ; Tom Bossert @ me. com > ; Hanfling, Dan
org> ; 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 Benson
icloud. com > ; TraceyMcNamara westernu. edu > ; Baric,
Ralph c @ email. unc. edu > ; Mecher, Carter (VA .GOV) @ va . gov
Hunt, Richard ( OS ASPREMMO) hhs. gov> ; WILKINSON, THOMAS
N @ hq. dhs. gov > ; M . D . @ mgh.harvard. edu> ;
David m umaryland. edu > ; Charity A @ CDPH
n @ 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 (OS ASPR SPPR )
. gov > ; Matthew J CIV USARMY (USA )
mail.mil> ; Lisa Koonin il. com > ; HARVEY ,
MELISSA @ hq. dhs. gov ; WOLFE, HERBERT
V Eastman Alexander
< v > ; EVANS, MARIEFRED
associates. hq. dhs @ utmb.edu @ utmb . edu> ;
Johnson , Robert (OSIASPR BARDA ) @ hhs. gov > ; Yeskey,
hhs gov> Disbrow, Gary ( OS / BARDA)
@ hhs. gov > ; Redd, John (OS ASPR ) < @ hhs. gov > ;
Hassell David (Chris ) (OS ASPR IO ) . gov> ; Hamel
, Joseph
( OS ASPR IO ) hhs. gov> ; , David < @ hq.dhs. gov> ;
 TARANTINO, DAVID A < @ cbp .dhs. gov > ; KAUSHIK , SANGEETA
hq. dhs . gov > ; Lee , Scott (OS ASPR /EMMO )
. gov > ; Larry G ; Ryan Morhard
weforum . org > ; Steven ( ) @ gov
Adams, Jerome (HHS/OASH ) . gov > ; Mansoura
, MoniqueK .
< @ mitre. org> ; Fantinato
,
usda .gov
usuhs. edu < . Cordts, Jerome ( CTR )
< jerome
@ fema. dhs. gov > ; WillGaskins
@ efiia.
cvm . tamu
. edu> ; LLogandakar
takeda .com >
Subject: RE: Red Dawn Raging March 4
Non -UNMC email

Is anyone atCDCmonitoringILI?

Here is the latest flu surveillance for Hong Kong, South Korea , US; the states of CA,
OR , WA, TX ; and the cities of Seattle , NYC , and Chicago (LA hasn ' t reported week 10
yet).

Whydid the US ILIcurvedeflectup this week, while influenzapositivetests are tracing

down? Seeingthe samewrt increasing
in WA, OR , Seattle, Chicago, andNYC.
this influenzaA , COVID, or both ? ChicagoandNYC are concerning becausetheir
influenzavirusdetectionis goingdownand is goingup.

From : Dr. Eva

Sent: Tuesday, March 17, 2020 7:03:58 AM
To : CarterMecher
a @ gmail. com .com >, "Caneva, Duane" @ hq.dhs. gov

" McDonald
, Eric" . ca. gov Richard Tubb @ gmail. com >, " Rob Darling,

MD patronusmedical
. com > , William Lang @ worldclinic
. com >, "Mecher
, Carter"

r @ . gov Tom Bossert @me. com >, RichardHatchett< @ cepi.net

" Lawler, James V " < r unmc. edu>, "Parker Gerald W @ cvm . tamu. edu , "Hanfling, Dan"
@ iqt.org>, " Gruber,David(DSHS)" @ dshs. texas. gov CHRISTOPHER ALLEN
@ 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 > , "Matthew

J CIV USARMY( 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 G
v>, 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>, DC
by @ usda.gov > , " d @ usuhs.edu" < danny.shiau @ usuhs. edu >, " Cordts, Jerome (CTR) "
ts @ associates.hq. dhs.gov @ mitre. org>, " Ignacio, Joselito"
cio @ fema.dhs.gov
Subject: Re: Red DawnResponding, Start 16 March

Carter, this truly frightensme

. one case is one toomany, I hope politicalleaderscan act and act quickly. We
mustdo so or else we can' t help these other cities that are escalatedso rapidly. And globally, every countryhas to
tighten, becausewe are running outofresourcesto do proper quarantine. We are already runningout ofhealthcare
resources, NYP has already canceledall electiveproceduresMarch 16 . Andmany otherhospitalswho needcare for
covid- 19 are facingthe sameissue. Themedicaltents appendicesare neededandmustbe planned. I don' t know
whatmedicalreservewe have andwe havemultiple fires burningsimultaneously!

On Tue , Mar 17 , 2020 at 9 :53 AM Carter Mecher

Bossert said on GMA this morning like 1918, this willbe a tale of manycities. What happens in the cities
impacted the earliest in the US includingSeattle, 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, publichealth leaders, and the publicwas theneed to
take action before the storm arrived and when the sun was shining.

Interestingto look atthe regionalvariationin Italy.

It is lookingjust likewhatwe observed in Hubei(includingWuhan) vs. Wuhan

It 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 .