You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Michael Mina, assistant professor of epidemiology. This call was recorded at 12:00 p.m. Eastern Time on Friday, October 23rd.
Transcript
MODERATOR: Dr. Mina, do you have any opening remarks?
MICHAEL MINA: No.
MODERATOR: All right. I guess we can get started. First question.
Q: Hi. Thank you for taking our questions. This is in terms of the new COVID-19 cases that we’re seeing. We’re seeing a spike in those, the likes of what we saw in the summer. So what are your reactions to that and why is this happening? And then I have a quick follow up after that.
MICHAEL MINA: Yeah. Well, we’re seeing just the beginning. So we’re seeing a spike in those that is likely to greatly exceed what we saw in the summer. This is unfortunately wholly expected. This is because the virus, whether we want to believe it or not, as a society, is a seasonal virus. And that’s based both on the biology of the virus likely, as well as human behavior and sort of social structures and temperature and having to be indoors and such. So none of this is surprising, I think. And that’s the frustrating part. We had an opportunity in the summer to use and leverage the decreased transmission of the virus during the summer months to prepare for the fall. We didn’t do that at all. And now we’re going to have to live with the consequences of that, or some people won’t live as a result. And so I think that this is how viruses like this work. We have failed to believe that as the federal government and we’re really not in a good position at the moment to deal with this. And I think it’s going to be extraordinarily hard to figure out how to deal with this in any reasonable way. Essentially, what has happened now, we’ve had a chance to potentially get this virus under control so that we could have a fighting chance of safely opening up. We haven’t done that. And now we are really left with impossible decisions. There is no right decision anymore. There is a decision of either remaining locked down and having political and having economic fallout come from that. Or staying open and continuing to open and having health consequences as a result. There is truly no good solution anymore. And I have said this when we first locked down in the winter and spring of 2020, which was what we had to. That was going to be our shot, that this society wasn’t going to be willing to lock down again, so we had to use it in the most beneficial and efficient way. We didn’t do it then. We’re still not doing it. And we’re kind of just going through the slow slog of things, sort of pseudo opening. And that, I think, is probably the worst way to really deal with this.
Q: I’m glad you mentioned seasonality and also sort of people not following public health measures. How can you distinguish between the two? How do you know when these surges are because of the coronavirus’ seasonality or because people are not following health measures? Does that seasonality suggest that the virus is more contagious this time of year or more dangerous?
MICHAEL MINA: Yeah. There’s a lot of complexity and what drives seasonality, some of it’s like actual molecular biology. Some of it’s how the immune system and the virus work during winter months, for example. And some of it is behavior, but behavior that we can’t really change. Like when its colder, people go indoors. Even once it hits 65, it’s no longer comfortable for many people to be outside, and so we see a greater congregation indoors. So those pieces that normally drive the seasonality of the virus are colliding at full speed with the reopening of society. And going back to K-12 school, going back to universities, opening up businesses more and more, opening up restaurants because of COVID fatigue, because, you know, all of this was essentially expected. This would be we knew months ago that this was it was going to come to this. And so what’s happened is we now have seasonality roaring up. And that was expected. We have economic opening and school openings all kind of hitting headfirst into each other. And it’s creating this perfect storm, in my opinion. A perfect storm that will cause cases to continue to climb, too. I really think we’re just seeing the beginning. We have now about to exceed the average number of cases we saw at the peak at any other time in this epidemic in this country and we’re barely into the fall.
Q: Right. Thank you.
MODERATOR: Next question.
Q: Hey, Dr. Mina, thanks for taking the time this morning. I’m actually really glad I got you, because this is a question that I think you’re well suited to answer. Just a couple of days ago, the state of Florida’s Division of Emergency Management announced that it’s going to be using the Abbott rapid tests, the Binax Now test as a default test at all of its state-run drive through testing sites. They have said that they are going to recommend a PCR for people who drive up with symptoms and test negative on a rapid test. But it seems like, you know, the PCR is going to be available upon request. But the thing that you’re going to drive up and kind of the default tests are going to use on you, is this Abbott test. They gave me a couple reasons as to why this change is happening. They say, you know, being able to get a positive result in five minutes, it draws more people in to get tested. They’ve been having a hard time getting participation and testing here in Florida. And also, the question I raised was how this might affect positivity, given that we’ve been kind of using this as a benchmark, this metric and would it skew it? And they claim, I’m not sure if it’s legitimate, they didn’t provide a lot of data to back it up, but they claim that they have a similar positivity with the antigen test, as they do with the PCR test. So I just kind of wanted to throw that out and have you unpack it. I think the main question I have is, do you think it’s a good idea to use this rapid test in this setting? Again, it’s a drive up setting as opposed to like a surveillance. And what other concerns you might have about the other aspects of this that I mentioned?
MICHAEL MINA: Yeah, I think certainly and what I’ve done a lot of research in the last number of months, and what I’ve spoken very widely about is that the real power in tests like the Abbott, Binax Now and other rapid antigen tests is going to come from frequent testing. So a drive through site is not going to be a frequent type of testing. You’re not going to be having people drive through it for three days, at least my expectation is that that’s not happening. But that said, I am not particularly concerned. I think that the Binax Now and a lot of these it’s proving to work really quite well. So if it can draw more people in, if it can serve to catch more people, that’s really all I care about, you know. For drive through sites, if it’s a public health program, the effort should be what can we do to catch and pull as many transmissible people out of the population as possible? I think that if people are more enticed, then I think they should be more enticed to go to get a test if they know that they’re going to get a result in some reasonable amount of time. A lot of people don’t want to wait three days and they’d rather just not get any tests than wait three days for a result. Even 24 hours. Humans like immediate feedback. And so in that sense, these tests can be very powerful.
The sensitivity of the tests has proven to be really very high. In particular, when used by trained professionals, I think that we can train the public to use them as well. But at the moment, when being used by trained professionals to read it, the sensitivity is up in the high 90, 95 percent of cases are detected within the first seven or so days of infection or of symptom onset. And so this is going to be used for asymptomatics, but the important piece is that the test doesn’t care if you’re asymptomatic or symptomatic. The test cares if you have a lot of virus in your nose. And that’s what we care about if we’re worried about people transmitting to other people. Yes, there’s going to be fringe cases when people maybe will not be detected. But if this can catch even 90 percent of people who are transmitting the virus at the time when they get tested, then that’s a win. Otherwise, if the test had to go to a lab to get PCR, they would those people would probably go through that, drive through and then go to work or do whatever they were going to do that day and find out 24 hours or 48 hours later that they are infected. And they wouldn’t actually even know from the PCR if it really means that they’re infectious or not. Right. It could be an old infection that’s continuing to linger with the PCR. So I think that with the right messaging, these tests can be used extremely powerfully to catch people who are infectious, let them know immediately, ask them to go home and isolate and say maybe do another test. There are concerns that these tests are going to be rolled out in places or in ways that don’t make a lot of sense. Certainly, if I had my way and I have 30 billion dollars, I would build a lot of these tests and I would get people to use them frequently at home and I would message them appropriately. And I’d get Apple and Google’s marketing teams and Coca-Cola marketing teams and whoever else needs to get on board to ensure that the public understands the role of these tests and how they’re used.
And, you know, there’s been a lot of people who are concerned with these antigen tests when it comes to reporting because they aren’t linked to any department of public health system. They’re just pieces of cardboard. I think for things like these drive through sites, I truly, really do hope that in these sorts of well-situated setups, I hope that they’re planning to report the results. There’s no reason not to report these results. And I’ve heard that some people are saying, well, we won’t report positive.
Q: They’ve been reporting all antigen results at state run testing sites. I guess the question is getting, you know, getting back to positivity, Doctor Mina. Is that something to be concerned about or do you think that that’s kind of, you know, not a significant concern or outweighed by the benefit of tests?
MICHAEL MINA: No, I mean, the sensitivity for detecting people who are positive is like 95, 97 percent. If your goal is to detect people who currently really have virus in them, if your goal is to detect people who have been infectious within the last month or so, then you want to use an RNA or even an antibody test. But this really just depends. I think these drive thru sites are really public health measures to try to catch as many people who are infectious. And I think that if the tradeoff is that we can do more of them and get results to people quicker, then I think that the math adds up to make it worthwhile.
Q: Just one last question and then I’ll let you get to the other reporters here. You know, one other concern I heard from a local public health official. She said that she was concerned kind of what you were getting at with the messaging, that perhaps this would give people a false sense of security if they test negative and are in that pre-infectious window and they might, you know, go get a rapid test negative, be in that truly infectious window and then go hang out with their grandmother or something. And that was her major concern. I mean, where do you kind of come down on that particular concern?
MICHAEL MINA: Well, that pre-infectious window is short. This is where we don’t have enough people taking a big step back and saying what matters here? What matters is the overall number of people we can find that are infectious. So if this means that we can scale up the number of tests tenfold, but we are missing a few people who otherwise would have been caught with a PCR test in that pre-infectious window, which it’s really rare to find people in the pre-infectious window. I think people don’t get that. If you look at the viral kinetics, it’s like a 15-hour window when your PCR positive, but not yet antigen positive. So what are the chances that somebody is going to happen to drive through, if they’re taking a test once and they’re asymptomatic and they’re taking a test once every few months through a drive through, what are the chances that it’s going to happen to be in that 15 to 24 hour window? Pretty slim. And so if you can increase testing because of the use of these tests, then all of a sudden it makes sense from a public health perspective, maybe if you’re only focusing on each individual that drives through, then sure, PCR, as always, can be better. But PCR has a delay. So in that sense, it’s not even better if you’re going out and you’re going to visit your parents. We just have to do a simple thought experiment. And I’m taking time to talk about this because I think that people are just really missing the ball here. The simple thought experiment is this. You can be in that pre-infectious window on day one or day two. Let’s say you start it on day two and you get a test here. On an antigen test, maybe you’ll miss it when you would have caught it on a PCR test. But, you know, say that person just happened to show up at that drive through one day earlier, maybe both tests would have missed it. Or you find out PCR and you don’t get a result for 48 hours, whereas if that person otherwise would have for just happenstance, you know, showed up a day later and gotten an antigen test. They would actually have gotten their results quicker than the 48-hour delay PCR. So I think it’s some people are really missing what are the tradeoffs here. And when you start to focus so much on each individual, that is absolutely the wrong thing to do for public health. Public health, you have to take a step back and say what’s the right program to catch the most people? And this issue of catching people at the pre-infectious stage, it’s just really rare that we catch people in that window. If it was a two-week period of time and we were able to catch everyone during that period of time, then sure. But that’s not how this virus works.
Q: Thank you so much, Doctor Mina, I really appreciate you taking the time. Really helpful.
MICHAEL MINA: Absolutely.
MODERATOR: Next question.
Q: Hey, thanks for doing the call. I just want to know if you can comment generally on the hospital situation. Looks like they’re filling up again in various states. Seems the good news is that treatment and clinical knowledge is probably better than it was in the spring. But the bad news is the virus is everywhere, including rural areas that might not have the same kind of capacity. So what’s kind of outlook heading into the winter in terms of being able to avoid bad outcomes? Thanks.
MICHAEL MINA: I’m really getting frustrated, not with this call, but the outlook sucks. It really sucks. The benefit, like you say, we call it a silver lining, is that we truly are seeing drops in fatality rates. I do believe very strongly that’s because we are learning how to treat these people. We’re learning what are the right vent settings, learning how to position people, we’re learning what are the right cocktails of drugs to give so that we can help abrogate inflammatory responses that get out of control. So all of that’s really important. And we’re going to see more and more people live through the hospital stay. The problem is to live through the hospital stay means that you’re still going to the hospital. And so that means we’re going to prehospital. Nothing has changed with the virus. So we’re still having these people land in the hospital. If we have too many people land in the hospital, then the hospitals get overloaded. You can’t have a functioning society, in my opinion, if we don’t have the availability of hospital beds for people. Even if everyone lives, let’s say one hundred percent of people lived through their ICU stay. If we don’t have enough ICUs to get those people in, then people aren’t going to have a chance to live through their ICU stay because they won’t make it into an ICU bed and a vent. We won’t have a place for cancer patients to safely be able to go to the hospital if there’s too many people with coronavirus in that hospital. So we’re seeing these hospitals fill up. And they’re just going to keep filling up. Nothing has changed. Just because the infection fatality rate has gone down doesn’t mean that the hospitals are going to keep filling up to get treated. You have to show up there. And I think, you know, I hope that some of the cities have are going to be doing better. But I agree. I mean, the rural areas and the heartland of the United States, middle America does not tend to have a ton of massive tertiary care hospitals. And their environments, you know, some pretty limited outbreaks can potentially cause these clinics and hospitals in much of the United States to quickly become overloaded. And this is areas of the country that are already short on physicians and medical staff. And that’s why they pay physicians so much money to go out to work in those areas because they don’t have enough physicians in general. And so I do worry that even if on a per case basis of hospitalized people, we start to see infection fatality rates decrease. The absolute numbers may continue to start to build and build and build and certainly will. And here I think we might be seeing two levels of removal. You might be having a lot of younger people getting infected like we saw in the summer, but eventually it catches up. All of those young people ultimately transmit to older individuals. We will see hospitals fill up more and more. We already are. And if that continues unabated, we are going to have a hard time functioning in our hospitals in this country.
Q: Thank you.
MODERATOR: Next question.
Q: Hey, Michael, thanks for doing this. It’s always appreciated. So I want to ask you about a more sort of local question in our neck of the woods. Boston officials told us recently that they’re going to start urging residents to get tested, whether or not they have symptoms. Probably as frequently as they can. Maybe every couple of weeks or so at city opera testing sites. I assume they’re not expecting everyone in the city to do this. But my question is, would having more surveillance testing data, more than what they already have, empower health officials to do anything specific or make any specific intervention?
MICHAEL MINA: So it’s a great question. This issue, I think we have to always remain cognizant of what the role of testing is and what our goals are. And you just said it very well, which is we have testing for clinical reasons. We have testing for surveillance. We have testing for screening for entry, you know, to help make schools safe and things. And then we have testing for a screening for public health to suppress outbreaks. A lot of what I’ve talked about is all the way over here, screening for public health to suppress outbreaks at a much larger level. So what you just suggested is surveillance. And that’s exactly what it is. It’s to survey the community, to empower public health officials to be able to act. And if that is your goal, I do think that more surveillance testing is useful. It’s not going to be any sort of silver bullet that will cause cases to dramatically be reduced. This sort of every once in a while, drive through testing, like the first question was about and this one, isn’t going to necessarily really cut down on cases in any appreciable way, but it will continue to inform public health officials so that they can better understand. Do we need to make new rules? Can we lift regulations, or do we have to put more regulations in place and more lockdowns and things like that? And just to keep a pulse. So I think in that sense, this kind of more frequent testing, or the drive through testing and sort of opening it up to large numbers of people can be very useful. But I worry that sometimes these messages are getting mixed up, that people actually think that sort of infrequent drive through testing is a control strategy. But it’s not. It’s an information strategy to keep public health officials in the know. But it’s not really going to ever pull enough people out of the community to really make a dent. And that’s where I think we’ve really lost track in many ways when it comes to contact tracing and what our real goals are. And it’s why I’ve pushed so hard for frequent testing of large fractions of the population. That’s until you’re testing large fractions of population pretty frequently, say every week, you’re going to barely find the people who you need to find when they’re infectious. And so you’ve maybe put a small dent, but they’re really not changing the course of things. So I think if the goal, like your question asked, is to inform policy decisions, then, yes, more testing of these drive through sites, even if infrequent per person, is very reasonable. I would say that you could get similar effects by monitoring sewage and wastewater.
So if our goal is just to inform policy makers, then maybe there should be more of a focus on those types of like doing that very frequently in the sewers. Just to keep a pulse on what’s happening at the community, and then really continue to offer drive through sites for asymptomatic people or people who believe that they’ve been exposed so that we give people some access to testing. And then over on the other end, you know, eventually maybe we’ll see enough rapid tests to become available that people can actually frequently test on a regular basis and find themselves as positive before they have symptoms, before they have a chance to infect others.
Q: Now, I want to ask you, I think a very large proportion of the Massachusetts population hasn’t ever gotten the COVID-19 tests, or coronavirus test. How do you actually get people to use these sites, even if they’re already free and available for appointments or walk ins.
MICHAEL MINA: You know, this is a massive problem. I don’t think you can easily. I mean, I’ve never been tested officially through one of these sites, I have access to rapid tests myself. And the real reason for me is because I never leave this chair, apparently. But, you know, it’s inconvenient. It’s very inconvenient. You can’t expect huge portions of the population to be going through these rapid testing sites. And talk about creating disparities. There are clear disparities in terms of you can’t expect low income individuals who are already working huge hours or taking public transit to be able to go to a drive thru. If you don’t have a car, you don’t go to a drive through, you know, these types of things. So I think I am not particularly fond of the drive thru setup and how it’s set up right now. I think it’s needed, to a certain extent better than walking into a physician’s office. So it’s needed for symptomatic and potentially exposed people to have that option. How do you get the average daily person to go? I really don’t think that we’ll ever be able to scale it up unless you really get these things. You have to be putting them on corners. Help people just be sitting out on corners and in different areas. And, you know, with booths, things they got, you could potentially do that. You could actually set up booths, or if we as a country wanted to actually take this virus seriously, we could start producing tens of millions of rapid tests and get them into people’s homes. Work with county officials, state officials and the federal government to get these tests directly to people so they can use them every few days. You can have families help pull their samples together, for example. So that two tests would give us 10 tests worth of information in a week. So we can do this in different ways. I think the drive through is a stopgap. But let’s be real. The drive through testing is for wealthy people or people with means to at least be able to do it. And with the wherewithal to figure out where to go, it’s not that easy to figure out where are these testing sites? We should be plastering it all over all the messaging, you know, everything about this epidemic could really use a good dose of marketing expertise. It’s just traditionally, public health has been sort of separate from industry. And heck, we’re going to use the Defense Productions Act to buy Abbott Binax Now, we could use the Defense Productions Act to get the funding to hire Coca Cola’s marketing team. I’ve said it a bunch, but I’m not saying it in jest. We really need the best of the best to figure out how to get messages across about how to work in a pandemic together, how to find sites that can test people. Some that don’t need cars, some that do, all of this needs to be coordinated. And the real problem here is that there’s no coordination. It’s hard for the average person to figure out just how to get a test. And that should not be the case at this point.
Q: All right. Thanks so much.
MODERATOR: Next question.
Q: Hi. Actually, it’s a good Segway I wanted to pick up on that because at the beginning of the call you said there are no good choices facing us right now. And I don’t know if you saw it, but during last night’s debate, they asked both candidates their plans for combating the coronavirus in 2021. And if you watched, I am curious for your take on what you saw, but also, if you were in the White House, what would you like the president to do in 2021? Is it about marketing? Do we have the resources to send tests home or what? Or do we have no good choices and we should all just put our heads down for a year.
MICHAEL MINA: We have very good choices. We have to make those. Things aren’t just going to materialize for this pandemic, for us to get life back to normal. We have good choices if we chose to act now. We could have acted a few months ago and had good choices in our hands now. We could act now and have good choices come January or December, maybe. And we don’t have a vaccine and we can’t necessarily rely on a vaccine. And I think that the hope and the expectation for a vaccine has effectively paralyzed effective control of this virus. It has been the piece that a lot of people have chosen to rest on their laurels with and say, we’re doing all we can, we’re trying to get a vaccine. That’s not all we can. Closures aren’t all we can do. In the current state of things, we don’t have a lot of good choices. But we could. We know how to build. I truly believe that frequent testing and giving enough people in the community access to know their status can stop the spread of this virus. It can actually bring the R value down below 1, and get outbreaks to become suppressed, to stop growing turnaround and get down towards zero. That is a good outcome. And it’s based on the exact same principle that we’re hoping for with vaccines, but we don’t know if vaccines will create, which is herd effects. We’re all hoping that the vaccines will create herd immunity. But there’s a few problems with that.
First, it’s impossible for the vaccine to create herd immunity until we get enough of them out. We know that we’re not going to have enough vaccines out to the whole population, at least until late spring or early summer of 2021. We just know that regardless of how well they work, they’re just not going to become widely available yet. And so we can’t bank on herd immunity coming about any time really soon. But we could drive herd effects which would have the same effect to start immunity through frequent rapid testing. And the nice thing is we have to, again, message them appropriately. We have to do everything appropriate, but we can actually cause herd effects, so we can get R to drop below 1, and the same way that we have vaccines. But we just have to build them. And so this thus far, with this pandemic, we have seen the federal government just kind of sit by and wait for one company after another to come up with a new test and then the feds just buy it. But there hasn’t been ingenuity to actually develop it ourselves. And I just I can’t stop thinking about the analogy of if this was a war and it was missiles that are causing two hundred and thirty thousand Americans or more to die, the idea of going just for herd immunity through natural herd immunity would be like us sitting in our homes while bombs are dropping on us and saying, well, it’s OK. Eventually they’re going to run out of bombs, you know. But let’s just let them keep hitting us right now because eventually they’ll run out. That’s what herd immunity is. And our decision to just wait for companies to come up and not to actually create our own defenses or offenses is akin to us all just kind of going underground and saying, well, let them bomb our houses, let them bomb everything, you know, we’ll just wait it out and wait until maybe we come up with some avenue for defense. We would never do either of those. If this was any sort of actual war that was killing two hundred thousand people, we would as a country be building bombers. We’d be building missiles. We would be doing things that cost a hundred times more than these rapid tests would. And rapid tests would be just extraordinarily cheap. Twenty billion dollars. And we could have almost enough rapid tests to cover a large fraction of the United States and actually stop these epidemics. Everyone can test themselves on a daily basis if they want. That’s what we should be doing. And I don’t remember what the question was anymore, but I’m just so frustrated that we’re not acting. You know, we just keep asking the question, is it too late? Are there any good choices? There continues to be a good choice in front of us. Testing is one thing we know can stop outbreaks. It’s why we’ve put focus on it. We’ve just put the wrong focus on the wrong type of test. The only way we can really achieve herd effects through testing and suppress outbreaks is not through the drive through tests where some people get tested once every few months. It’s getting people tested on a frequent basis and stopping people from spreading to others. Simple, simple math. And we have it within our grasp to build these. They’re not difficult to build. They’re just not. And we have the technology. It’s proven now that it works. We have to get messaging onboard. We have to you know, there’s little things that we have to deal with along the way. It can be done, but we haven’t seen anyone really take any action to do it.
Q: What do you see this in the next few months or 12 months look like if we go the other way like Florida is doing right now with not quite herd immunity, but this idea of we protect the most vulnerable as best we can, seniors, what have you. And just let everybody else go about their business. Obviously, that’s something that’s been talked about in the White House. I think we are seeing it in Florida, even if they’re not calling it that, which is obviously a big state. What happens, in your opinion?
MICHAEL MINA: Well, I think we can decide as a country to go that direction, but we have to be OK with another two hundred thousand people dying or more. And so if we’re OK with coming out of 2021 saying that epidemic wasn’t so bad, we’re all immune. We had half a million people die or more. You know, I think half a million would be the lower limit, would be absolutely the lower limit of deaths if we were to just kind of let this thing spread. I mean, I don’t know exactly the number. But if we’re okay with looking at ourselves and saying, you know, my mom had another 20 years left of life, but, you know, she passed away because of COVID, but, you know, she was older. So whatever, you know. If we’re okay saying that to five hundred thousand people or more than OK, let’s do that. Let’s go that direction. Let’s open everything back up. Pull the Band-Aid off quick. I think that we have other options at our disposal. But the longer we let it go without grappling with what those other options are, I’m bringing them to the table, the more and more likely it is that we’re going to just eventually throw up our hands and say, OK, the economic costs are becoming much worse than the viral costs. The mental health problems associated with shutting down are becoming much worse than the deaths associated with the virus. So we’re concerned the longer we go with inaction, the tradeoffs just become worse and worse and worse, and eventually we are going to get to a place where we say, you know what? Let’s just go with herd immunity because, for a number of reasons. But it doesn’t have to go that way. We are certainly painting ourselves into that corner. And I think, you know, I have still not seen any evidence that we can really keep this virus in any serious way out of senior living facilities, out of people’s homes. I mean, we keep saying older people, but, you know, 70 years old is not that old. I mean, it’s not young, but it’s not old. Many people who are 70 have two decades or more left of life. And I don’t know, how do we just tell everyone who is 65 and above and everyone with diabetes and everyone who is overweight to just not go outside during those periods of time? I don’t buy it. I just don’t see it as a viable solution.
Q: Thank you.
MODERATOR: Dr. Mina, we have about 5, 10 minutes left. And we have three questions. So just to give you a heads up. Next question.
Q: Hi, thanks for taking the time to hold this. I want to ask you first just about using PCR or other tests to effectively test out of needing to be quarantined or isolated. How should we be thinking about that? There are some government efforts ongoing to study that.
MICHAEL MINA: Yeah, it’s a really good question, and I’ve had quite a few discussions with the CDC on this issue and with the question of testing out of quarantine becomes, maybe most important for places like the institutions where people live in dorms like universities and other areas where people have very limited space. So quarantining for 14 days isn’t the end of the world if you have a nice big house and yard and things like that. But when you live in a dorm, quarantining can be terrible. I mean, 14 days inside of a little white box, you know, it’s really terrible. So I’ve been working to try to figure out, can we safely get people out of quarantine earlier? Do we have to wait for 14 days? Well, what we’re trying to figure out is how many people who are in quarantine, A, actually do become infected. What fraction of people become infected, which helps us better understand the tradeoffs, and then when do they become positive if we’re testing people during quarantine? Do most of them become positive in the first three or four days? And it’s like an exceedingly small number of people who become positive after day 10. My guess is it’s going to be very, very limited number of people who become positive after day 10 and likely still a very small fraction who become positive after day 7 or 8. So I think that if we could create the testing infrastructure so that people who do go into quarantine could get tested at, say, day 6 and their negative, and then maybe you can actually say to people, you can leave quarantine after a day 6 if you have a negative result, if you adhere extremely well to social distancing and masks. And of course, quarantining is kind of just an extreme version of social distancing. So you still want to keep people wearing masks, social distancing as absolutely much as possible, recognizing that they might become positive. And also adding on top of that, especially now that we are seeing antigen tests become available, how these people may be using antigen test potentially every single day for the next week after they come out of quarantine. You know, something like that would, I think, start to air on a pretty safe way to get people out of quarantine earlier and have an appropriate balance.
Otherwise, I think we’ll just end up seeing people start to leave quarantine just because they don’t want to sit there anymore, especially people who might be in their second quarantine in high risk areas, in communities where multiple people in somebody’s social circle get infected. Some people might have to go into quarantine for two or three times. So that’s a month and a half of sitting in quarantine for people who have to go through your time. So the quicker we can get people out, the better. I think there are ways to do it. And in particular, university campuses where the quarantining is particularly detrimental to student’s mental health. These are also places which have the means usually or the resources to figure out how to test people, to get them out of quarantine more readily. So we’re trying to collect the data to verify that that’s an okay approach.
MODERATOR: Do you have a follow up?
Q: Yeah. And I assume you mean the test at day 6, that would be a PCR test, right?
MICHAEL MINA: Ideally. But it could be either. I think especially, if you’re going to assure that somebody can take a test at day 6, 7, 8, 9, 10, 11, 12, for example. You know, I think that if it’s what you have access to, I think the antigen tests are really doing very, very well. And so I think that those can be used as well.
Q: Right. One more question here. On this sort of related subject, using antigen tests to screen asymptomatic people has become kind of a contentious subject. Is that a bad idea? And if so, why? You know, I think we’ve seen them be talked about in as most useful in a setting where you’re really screening people. So as we see them getting rolled out more widely, you know, how should we be thinking about this issue?
MICHAEL MINA: You know, the positive predictive value goes down if you have no reason to believe somebody is infected. And these will have false positives. So you have to always associate a rapid antigen test with a confirmatory rapid test. You want to be able to confirm them right then and there. If somebody is positive on this and negative on that, then you want to be able to say, hey, false positive. Don’t worry about it. Or we think this might be a false positive, test again tomorrow to ensure that it is. But maybe today isolate anyway. So there’s approaches there. These tests, I think, are most useful for asymptomatic screening. It’s used frequently, again, because they can actually create further effects. Short of that, if we can scale them up to 100 times the number of tests we’re currently doing in the country, then sure., use them for asymptomatic screening. There’s no problem with that. Even if not being used by the same individual over and over and over twice a week, I think that they do a good job, a very good job at detecting people when they have enough virus to transmit. And so if it’s not or no test, then use the test and a lot of people say people are going to interpret it poorly and use it as a ticket to go and party. We just have to create the messaging to make sure people understand what a negative means and what a positive means. But this is the same with all of these tests. A negative never assures that it’s a negativr. But a positive, especially on an antigen test, can almost assure that you definitely should isolate. And they are currently infectious. And so I think we just need to really understand what role these tests have. And I want them to be used primarily if you’re using them for an entry screening where people are using it to say, go to school or go to a restaurant. They should be mostly used as an indicator of who not to let in, but not as an indicator of who to let in, if that makes sense.
Q: Thank you.
MODERATOR: Next question.
Q: So therapies reduce deaths. You say that doesn’t matter because they still need to be hospitalized. But in fact, the Remdesivir shortens hospitals days to 10 days from 15, that’s New England Journal of Medicine, to primary endpoints for the vaccines or reduction of symptoms. But sixty percent. Who knows if we’ll get there? But if we do, that would shorten hospital stays. And then the Regeneron, as Trump calls it, also shortens stays. But not by that much, still by some amount anyway. Don’t the therapies reduce the hospital burden too, or is it just the death rate?
MICHAEL MINA: Yeah, they do. And so we would have to look at the balance. We’d have to take a good look at that balance and say, can we get into an equilibrium where we’re getting people out quick enough from the hospital to accommodate the filling up of the hospital? And so are we reducing stays fast enough? But the fact is, in a lot of the United States, hospitals are often already kind of near their limit. And so an additional huge number of people, even if you can get them out a little bit quicker, still runs a serious risk of overburdening the system. And so I would say those pieces will absolutely help. I think if we can scale those drugs up, in particular the monoclonal antibodies, those could technically be used in a whole different light where they could be used prophylactically, especially depending on their half-life, how long they take to be cleared from the body. And maybe you can actually give those, not once somebody becomes sick enough to require them, but one of the nice things about monoclonal antibodies like Regeneron, is that they could potentially be used almost as a vaccine where you give them before exposure and hope that actually prevents pupils from ever even getting a symptomatic infection. So there are ways that we can also use some of these therapies that are now coming about to, like you ask, really decrease the burden on the hospitals.
Q: OK. And if you’ve got to go, you got to go, I get it, I can ask next week if you’re on. But I never heard the phrase heard effects before, through frequent testing. Can you sell more on that? Or if you want to wait till next week. That’s fine.
MICHAEL MINA: Yeah, well, in short, that’s what this whole plan that I’ve been taking up for months says. That’s what my research has been about. If you can get enough people to know early enough that they are exposed and infected so that they stop their own transmission from propagating, and you can get just say, 40 percent of a population to be able to use these tests appropriately in a community every week or twice a week, all of our mathematical models suggest that we can really sever enough transmission chains that we’ve essentially pulled the fuel out of the fire. We’ve pulled up. We’ve stopped the momentum of the outbreak. The curve turns over very quickly and it leads to herd effects. It’s actually the exact same way that herd immunity works to create herd effects.
Q: I never heard it called that before, but I understand your point. Thanks.
MICHAEL MINA: Yeah. And you can look up. I had a New England Journal of Medicine paper on it just two weeks ago, I think. And then we have in the paper coming out soon. That really describes it mathematically.
Q: Excellent. Thank you for your time.
This concludes the October 23rd press conference.