CROI Goes Digital After COVID-19 Cases Rise in Boston

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MARCH 9, 2020, BOSTON -- Every morning, Jeanne Marrazzo, MD, from the University of Alabama at Birmingham, zooms in on the number of new COVID-19 cases around the world, in the country, in the South, in Alabama, and in Birmingham.

So far, the number of cases in the United States has risen, as has the death toll. Although no cases have been reported in Alabama, they have been reported in two neighboring states: Georgia and Florida.

Marrazzo works closely with COVID-19 preparedness task forces in her state and at her university, and dons her white coat to provide updates to the state's media outlets. She knew she had to step up after learning that at least one in 10 healthcare workers were required to be in quarantine after potential exposure in the early days of the outbreak.

"I can't not be here to coordinate this," she said she remembered thinking. "I can't not be here to communicate with leadership. And I cannot not be here to work if I need to work."

Most years, Marrazzo attends the Conference on Retroviruses and Opportunistic Infections (CROI), she told Medscape Medical News, but 5 days ago, she decided not to travel to Boston.

Then 3 days ago, CROI conference organizers confirmed that she had made the right decision when they did what no other area medical conference has done so far during the outbreak: go virtual, with webcasts, Twitter conversations, and science by the bedside, on the couch, or on a laptop.

"We've dedicated our lives to the prevention and treatment of infectious diseases," Mary Kearney, MD, PhD, head of the translational research section in the HIV dynamics and replication program at the National Cancer Institute at the National Institutes for Health (NIH), said from her home in Maryland. "It's important for us to lead by example, to protect our colleagues and their families. It's people first."

The move comes amid conflicting messages from top government officials on the severity of COVID-19 and the best methods to respond to it. But public health officials have countered that the threat of community spread will require intentional action.

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On weekend news shows, Anthony Fauci, MD, director of the NIH National Institute of Allergy and Infectious Diseases, reported that the strategy needs to move beyond containment, which officials did early on by keeping travelers from Wuhan, China in quarantine for 14 days to see if they developed symptoms.

But once person-to-person spread started inside the United States, containment became less feasible. "If we continue to get cases like this, particularly at the community level, there will be what we call mitigation," Fauci said on Fox News. That includes measures such as social distancing, which is exactly what it sounds like: keeping people out of crowded places and keeping travel to a minimum.

Social Distancing

In early February, Carlos del Rio, MD, from Emory University in Atlanta, counseled the public that the vast majority of Americans shouldn't worry about acquiring COVID-19 unless they, personally, had traveled to Wuhan or were around someone who had.

But by March 7, del Rio's perspective, and the trajectory of the virus, had changed. States of emergency were declared in New York and Washington because of the rapid increase in diagnoses and deaths. Outbreaks had emerged in Italy and Iran. More than 500 people were diagnosed with COVID-19 in the United States. And officials in Italy were planning to close — and have since closed — borders in the northern part of the country to keep the outbreak there from spreading.

If there were one COVID-19 case at CROI, it would mean that every one of the 3901 people attending the meeting, from 77 countries, would need to go into quarantine, meaning they could not work, treat patients, or cover for sick team members for weeks.

"We don't want to happen here what has happened in Italy," del Rio said. "I don't think it's panic; I think it's an abundance of caution."

On March 1, Marrazzo received an email from Donna Jacobsen, executive director of the International Antiviral Society–USA, which is responsible for organizing CROI.

"I'm trying to take the temperature on people's sense about CROI," the email read. "Knowing everything we know right now, if CROI were held, would you go?"

Even on March 1, Marrazzo was a firm, "I think so."

By then, two people had been diagnosed with COVID-19 in Kirkland, Washington, and gene sequencing suggested that the virus had been spreading in the community through person-to-person contact for weeks.

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Countdown to CROI as Cases Grew

Marrazzo's calculus was that she is healthy and younger than 60 years (data indicate that older people are at higher risk for serious effects of the disease), trusts that infectious disease specialists who are sick would stay home, and — as someone who's been involved in the CROI planning process — knows the implications of canceling a massive event.

It was around then that Kearney said she'd started watching the case numbers rise and began an email exchange with a colleague, someone on the CROI organizing committee and a member of the CROI Foundation.

"Several times over the course of that week I relayed my thoughts to him," she said. "I did feel very strongly that it should be a virtual meeting rather than an in-person meeting."

And then, several days before conference organizers finally announced their decision to go virtual, she developed congestion — a typical cold, not the coronavirus, she emphasized — and realized she would have to back out.

Apparently, conference organizers were listening. When the week began, there was "a diversity of opinions" about what to do, said Sharon Hillier, PhD, chair of the conference and researcher at the University of Pittsburgh. They held daily conference calls, consulted with local public-health authorities, and began, quietly, to ask speakers to record their presentations, in case "we had to go virtual," she reported.

This year would have been the tenth time Nesrine Rizk, MD, from the American University of Beirut in Lebanon, attended CROI. She had trained in infectious disease at Case Western Reserve University in Cleveland and ran an HIV clinic in New Haven, Connecticut before moving to Beirut, and had been looking forward to reconnecting with former colleagues.

But then the cases started to rise in both the United States and Europe. And there were no direct flights to Boston from Beirut, so she'd have to stop in Paris.

"The issue of travel was not very reassuring," she told Medscape Medial News. In the event of an Italian-style quarantine, "I didn't want to be stuck in Boston and not be able to come home."

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So Rizk decided to cancel.

On Wednesday, Marrazzo canceled, too. That night, close to midnight, conference organizers announced that the in-person conference would go ahead as planned.

But they were still watching the news and talking to experts. Around the same time, the Fred Hutchinson Cancer Center at the University of Washington in Seattle and the University of North Carolina at Chapel Hill asked its researchers not to travel. Others quickly followed suit.

And then on Thursday, three of about 150 Biogen employees who attended a meeting in Boston were diagnosed with COVID-19.

With just a few people affected, "there was a large impact on the healthcare system because so many healthcare workers have to be tested and quarantined," Hillier said.

By late Thursday, 1000 attendees had canceled their registrations, and more cancellations were expected, according to the CROI press office.

"What started as a few concerns turned into a torrent of concerns, and we found ourselves in a set of raging rapids," Hillier explained.

On Friday morning, Cynthia Shi, a PhD candidate in epidemiology at the Yale University School of Public Health in New Haven, was in Boston attending the 10th International Workshop on HIV & Women when she got the email: CROI was going virtual.

To Shi, this made sense, although the last-minute change meant some people would have to incur extra expenses.

A Chilean HIV doctor who'd paid out of her own pocket to fly to Boston, only to arrive and discover that the conference had gone virtual, found it cheaper to pay $1000 for a one-way ticket back home than try to change her existing reservation, del Rio reported.

And stories started to pour in over social media of people traveling from afar who landed only to find there was no conference to greet them.

Ace Robinson, director of strategic partnerships for nonprofit NMAC, was also attending the women and HIV workshop, and before he headed home to Washington, DC, he stopped in at the conference center where CROI was to take place. The registration area was a mass of boxes as staff packed up their elaborate displays.

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Amid the peach-hued banners announcing the conference, there was none of that "joy that people get from seeing each other," he reported.

"The balloon had burst," he told Medscape Medical News. "Everyone was sharing the same story of, 'I have to go back home. It's a good idea, but I invested my heart and my soul into coming to this and/or presenting'."

Robinson did manage to snag a souvenir though: a CROI backpack, a coveted part of the welcome package that attendees receive.

When the opening session finally happened on Sunday evening, it was unclear how it would go and what the conference would look like.

"There's no question we're charting new waters at CROI," Hillier said during her opening remarks. "It's really quite unprecedented."

Bob Cook, MD, director of the Southern HIV Alcohol Research Consortium (SHARC) Center at the University of Florida in Gainesville, tweeted his concern that the virtual nature of the meeting would rob attendees of their ability to connect in person.

But Kearney said she's been delighted with the connectivity so far. After her recorded presentation on genome-wide integration streamed, she responded to questions and comments that came to her on Twitter and in email.

She joked that when people heard her congested voice, they would be grateful for the virtual presentation. And, she added, sitting at home watching the conference on her smart TV in her pajamas actually made for a better experience.

"I was wondering how they were going to pull this off, but they did an amazing job," Kearney said after the opening session. "You don't have to scramble for a seat and end up getting one in the back of the room, so you end up watching it on the jumbotron anyway and struggling to see the data. I could see it so clearly. The sound quality is fantastic. I think it's a very effective way to communicate science."

Conference on Retroviruses and Opportunistic Infections (CROI) 2020.

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