You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Ashish Jha, the K. T. Li Professor of Global Health and director of the Harvard Global Health Institute. This call was recorded at 11:00 a.m. Eastern Time on Monday, August 3rd.
ASHISH JHA: Good morning, everybody. Let me just maybe speak for two, three minutes, kind of a bit of a reality check of where we are as a country and what I think are the big issues that are in people’s minds. Starting off maybe just saying I’ve been spending nearly all of my time in the last week speaking to school administrators, superintendents, mayors, governors, all of whom are focused on one question, which is, is there any way we can get kids back to school this fall?
That’s something I’ve written about, other colleagues at the Chan School have been writing about, and I’m happy to discuss where I think the conversation is on that. Second big picture thing is, if we look across our nation, we have had these incredible hot spots that really do seem like they’re starting to turn. So Arizona and Texas are clearly heading down. Florida has stabilized and maybe coming down similarly for South Carolina and Nevada. But then there is a host of states that are heading in the wrong direction and are not doing enough. And I wrote a little thread about this on Twitter, about Mississippi, which is really, I think, in quite bad shape and going in the wrong direction, like Missouri and a lot of states in the Midwest. And then last but not least, thinking much more locally when I look at where we are in Massachusetts, Rhode Island. I’m starting to get a little bit worried because these states have generally had lower levels of disease recently, but they are heading in the wrong direction. And I worry that a lot of people living in the Northeast think that we’re done with a pandemic. And if the lessons of the South in the last month of July are at all to be paid attention to, it is that we are not done with this pandemic. It is entirely possible we can find ourselves back in deep trouble if we don’t act aggressively.
Last thing I want to quickly mention is the issue around testing since Nicole brought up that we have spent a lot of time thinking about testing. It’s been a big focus of ours at the institute. There was a really terrific podcast that Michael Mina, a colleague at the School of Public Health, the Chan School, did about 10 days ago or so. And I’m confident many of you have heard it already just because it got a lot of attention. Malcolm Gladwell tweeted about it, but what Michael did in that was really brilliant was synthesize something that a bunch of us had been thinking about, and I have been thinking about, but had not really been able to articulate and scientifically explain in a way that he did. And I think he did a great service. And that led to a bunch of things, including a piece that I wrote in Time on Thursday or Friday last week, about why we need to shift our thinking on testing to move towards rapid tests, even if they are, quote unquote, less sensitive. And I know that this is becoming a big source of conversation nationally. I’m happy to delve into it. But I think that kind of flogging the system we have on PCR testing and trying to get more out of that is probably not a good idea. We may want to push a little bit, but we need to take a totally different national strategy on testing. And I’m actually optimistic that it’s possible if the federal government can play a helpful role and there’s a lot of pieces there that are starting to happen. So I’m happy to get into that as well. Last point I’m going to make, it is a global pandemic. So these issues are not just local to the United States. Things are happening around the world. But I think we have to really focus on getting our own act together. So let me just stop there. There are lots of directions we could go, but I’ll let the questions really drive the conversation. I want to say thank you to all of you for participating and being a part of this.
MODERATOR: Thank you, Dr. Jha. First question.
Q: Thank you, Nicole, and thank you, Ashish. You should be on Rate my Room, you have really nice walls. I’d like to ask you about, indeed, Michael Mina’s call for what I think he called, crappy tests, actually, which has to go in the headline, and your piece in Time as well about the need for cheap, fast, even if less accurate tests. So that idea was kind of floating around, but Michael Mina crystallized it? Or where did it actually come from? And then in the last week or so, it’s been kind of crystallized in this call for this paradigm shift in testing. What has been the response to these rising calls?
ASHISH JHA: It has been floating around for a while and a bunch of us have been talking about it. And I think Mike, I mean, he did a brilliant job. And sometimes it’s the moment is right, so I think there was an element of that. There’s something else that he said that was really critical, which is, you know, look, they’re not actually crappy tests. What they are is that they are less sensitive and they are in certain circumstances. So one of his key points is that they are not so sensitive when you have very mild, like low amounts of virus and you’re not doing much spreading. But when you’re actually really infectious, you have large amounts of virus in your throat elsewhere, the test becomes much, much better. So if you were to be certain about whether somebody is infected or not, these tests are not so great. If you want to identify whether they’re infectious or not, and go out and spread it to other people, these tests are actually quite good. And if you think about it from an epidemiological point of view, that’s when you want to capture people. You want to get them when they’re infectious. And so the lack of superb sensitivity of these tests is not a constant feature. It’s a feature of when somebody might have very mild disease or they’re asymptomatic, let’s say, not spreading. That’s when you may not be able to pick them up. So that, I think, is also a really critical part of this.
And then, of course, the big key point on this is these tests should be ubiquitous. They should be done on a regular basis, and you get results very, very quickly. And if you can do all of that, there’s very good data and some modeling that Mike has done, but other people have also done, that really shows you can drive the disease way, way down. And I think the country was ready for it, partly also because our current strategy is so woeful. Now that we’re seeing results take two weeks to come back or 10 days to come back. I think there’s a sense of desperation of we need to do something else and we’re not going to be able to improve our current testing strategy to a point where people will be able to get results quickly back. So there are a few different things. A moment was right. The testing infrastructure is kind of starting to fall apart and might crystallize it by reminding people that the test is actually really valuable when people are infectious. Maybe it’ll miss people when they’re less infectious. But that’s a totally fine concept we should be willing to live with.
Q: And super quick follow up. What response are you getting?
ASHISH JHA: Oh, yeah. The response in general has been really good. I do still hear from the administration some confusion about this. And, you know, I think Admiral Giroir was still saying, well, if we miss a lot of cases, that’s unacceptable. And I want to say we’re missing 80 to 90 percent of cases right now. So if you have a test that misses, let’s say, 20 percent or 30 percent of cases, but not when they’re infectious, that would be a dramatic improvement. The point isn’t we have to capture every case and the current system is missing so many cases, not because the tests are not sensitive, but we can only test so many people, and you know, infrequently. So I think most scientists get this. I think most public health people get this. Companies are responding. I’m worried that our federal government is still stuck in a mental model that doesn’t make sense for this pandemic.
Q: Thank you.
MODERATOR: Next question.
Q: Hi. Thanks for taking questions. I guess this sort of plugs into the last question a bit. I did notice this morning looking at the latest tracking numbers, that testing has come down in the last seven days a bit. We were doing almost 780,000, and we’re down to about 760,000 on average recently. What do you make of that trend? And I wonder, what you’re saying about the turnaround times and these tests just not being useful? Is there anything to be said for fewer tests in the system if maybe we could get them turned around faster?
ASHISH JHA: Yes. So I wrote this out on Twitter a couple of days ago, and I forget the exact number, around two days ago, maybe 18 or 20 states were doing fewer tests now, than they were doing two weeks ago. That’s largely a problem. You may say, well, maybe the outbreaks are getting better. But in a vast majority of those states, cases are still rising. If you’re doing fewer tests but finding more cases, that’s bad, and percent positive is rising in a vast majority of these states as well. So these states that we’re testing are declining. A couple of them like Arizona, Texas, are the two where tests have declined, but cases have declined even more, and percent positive has come down a little bit. At least Arizona, I can’t remember if Texas was the other one. But that to me is is progress. Most states where it’s declined, I would argue, things are worse off now because we’re finding fewer cases and percent positive has gone up. In terms of do we want to ultimately do fewer tests? Yeah, if we could bring the number of infections down, that would be a good reason to do fewer tests. But if infections are rising and testing is getting worse, that just means we’re missing a lot more infections. It’s definitely true that it’s putting a huge strain on the system. We’ve got to fix the system, not do fewer tests, especially in the context of rising infections, as we’re seeing in many of these states. Like Mississippi is actually one example.
MODERATOR: Do you have a follow up?
Q: Talking to all the people in your sphere, why are these states doing less testing? Or are people just getting so discouraged that they’re staying away? Any ideas?
ASHISH JHA: It’s a combination. In some places, you have to stand in line for four to six hours to get a test. And that’s a pretty good deterrent for a lot of people, I think, because of the stories about the long turnaround times, that’s also dissuading people. It’s probably raising the threshold for doctors to recommend it, so if you call your primary care physician, if they know that the tests lags are getting very substantial, they’re probably going to be less likely to recommend that you get tested. So I think it’s a variety of different things that’s leading to a declining number of tests. Especially in states with, you know, 10, 15, 20 percent positivity, there is no justification for declining number of tests as somehow a good thing. The number of tests would be increasing in those states. Even in Arizona, where things have gotten better than where they were, their percent positive is still like 18, 20 percent, which is just incredibly high. They should not be seeing a decline in their testing. They should be ramping up testing to capture more of the cases that they’re missing.
Q: Thank you.
MODERATOR: Next question.
Q: Thanks again for doing this, yet again. You mentioned the Northeast, which is a region that most of us, or at least I, have taken my eye off for a while. So two questions there. What concerns you about the Northeast? In the sense that if you look at the sort of gross number of new cases, it’s still dramatically lower than Mississippi or Missouri or Texas. Are there lessons from the Northeast experience in April and May that should be taken up by the rest of the country and that have even been forgotten in the Northeast?
ASHISH JHA: Yeah. Two related and great questions. So the short answer to the second one is yes, but I’ll give you a longer answer. Here’s what’s happening in the Northeast. So what the Northeast did, and I’m being a little bit broad because the Northeast has got a variety of different states and parts of Midwest, too, by the way, Lake Michigan. What they did was what the country needed to have done in April and May, which is really stayed shut down until the number of cases really came way, way down. So you what you want to do is not just flatten the curve, but kind of crush the curve, as we say. You want to bring the number of cases way down before you open back up, and then you open up slowly and methodically.
I think as a general rule, the Northeast states, New York, New Jersey, Connecticut, Rhode Island, Massachusetts, some places like Michigan, even Ohio, others too, but I won’t list them all. I think they generally did a pretty good job on that. What has been happening is first of all, I think we’re learning a lot about this disease, we’re really learning that indoor gatherings are the massive risk factors. I think we’ve let too much go in terms of indoor gatherings, and we’re starting to see case numbers really increase. And this is the problem. This disease lulls you, and when numbers start increasing and if you’re down at like 20 or 30 or 50 cases, it goes to like 70, then 120 and 180. And it still looks really small, but it’s actually starting to get into exponential growth. What happens is at some point, by the time it hits your signal that we have a problem, first of all, you’ve got a whole wall of infections already built in, and you’re starting to replicate from a much higher number, and the cases really start spiking. This is essentially what happened with Arizona, Texas, Florida, is that by June 5th or 6th, there was very clear that they were heading in the wrong direction. Then on June 14th, the vice president wrote a piece basically saying there’s not a problem here. And it was so disingenuous because on June 14th, you could look at the data and say, we have a real problem. But it wasn’t until about June 25th, 26th, kind of a bit later, that it really started becoming obvious how bad things were. And then obviously by July, it was a raging wildfire. So the point is there’s a two, three week period where if you aren’t paying attention, you can miss it. And that’s the two to three week period we’re in in a lot of these states in the Northeast and Midwest. And for those of us who, like I, stare at state data every single day, it’s very clear to me that these states are starting to head in the wrong direction. And if they wait three weeks to act, the amount of action they’ll have to do is much more aggressive, and they’ll probably lose out on the chance to open schools this fall. So that’s the other compelling reason for the Northeast would not have forgotten the lessons that they themselves learned.
Q: Thank you.
MODERATOR: Next question.
Q: I was going to ask something similar. Is the reason that we’re seeing these increasing cases in the Midwest and Northeast, is it just people becoming too relaxed? Because you’re saying, when reopening, they did do a pretty good job. Sorry, our questions ended up being similar.
ASHISH JHA: That was a great question. So let me build on that, because it is really central. The governors were careful in opening up. But when I look around what’s happening, and I live in Newton and I work in Cambridge, people are starting to kind of let their guard down. And we’re starting to get gathering’s. And I know of people who are hosting house parties where people are spending a lot of time indoors. So I think that’s part of the problem. The restaurants and bars are probably more open than they ought to be.
And the question is, what is ought to be? What are we willing to tolerate? And my general feeling on this is it just depends a little bit on how much we want to open schools this fall. Because if we said, look, forget schools, we don’t really care if kids are all online, they probably have a bit more running room. You can let the infection’s rate get higher. You will fill up your hospitals too much. And, I mean, people get sick and some people will die. But you can tolerate a certain level of infection. If you actually care about schools, then you probably need to tolerate a much, much lower level of indoor gatherings, so that means restaurants, bars, gyms. What do you do with house parties? In the last 48 hours, I’ve had conversations with three different governors, chiefs of staff, about what to do about house parties? I have no idea. Obviously, that’s a huge problem. That is another way that a lot is starting to spread. And that’s just people getting relaxed and feeling like it’s totally fine to have 20 people over to your house on a Saturday afternoon. And it probably isn’t.
Q: So should these states in the Northeast and the Midwest, should they be looking at reclosing efforts?
ASHISH JHA: I think at least some places need to dial back. And I keep emphasizing indoors because I actually think it’s fine to have outdoor dining. I don’t want people closing beaches, and I mean, there’s some beaches that get overly packed, maybe you want to do something about that. But getting people outside bars, restaurants, outside, beaches outside, I think all of that is probably fine. But I do think a lot of the states in the Northeast have to be looking at their restaurant, indoor dining, if they have gyms, if they have bars, and saying, can we afford this at all during this pandemic? And my argument largely is not right now.
MODERATOR: Next question.
Q: Hi. Thanks for doing this again. I was hoping you could talk a little bit about kids and COVID and kind of where do we stand? What’s the science on how infectious they are? And do you think it makes sense to bring back younger kids to school, for instance, and leave older ones at home?
ASHISH JHA: Yeah, it is the big question. So there’s been a lot, whether you look at the Georgia camp stuff, you look at this study in JAMA Pediatrics, looking at virus levels in young kids being even higher than older kids on the South Korea study, which feels like it was, you know, 10 years ago, but it is actually only about 10 days ago. There’s a lot on this. And I will give you my best synthesis across all the studies. And this is just, obviously, my interpretation.
Three things as I sort of see it. One is, we still believe that kids are much less likely to get really sick from the disease, and that data feels very solid. Second is, in terms of attack rate, are kids less likely to get infected, maybe. But that data is not so strong. There does seem to be that among younger kids are less likely to get infected. The big question is transmissibility. If you have a kid who’s infected, is he or she less likely to spread it to other kids or to adults? And when I put all of it together, the data on virus levels in the throat and etc. My best reading of the evidence is that older kids, high schoolers, treat them as adults. Assume that they’re adults. Younger kids, let’s say K through five, they probably transmit less, maybe as much as sort of 50 percent less and six to eight graders, I don’t know, they’re probably a little less than high schoolers, probably a bit more than young kids. And it really is about size of the of the human. How much air they’re expelling. There’s a whole bunch of mechanical and physical issues that go into this. So that’s why throat swabs that show a lot of virus don’t necessarily translate into infectivity because they may have a lot of virus, but they’re just not spreading it as much. That has implications in the following way, in my mind. It pushes me to push school leaders and mayors to have a lower threshold for getting K through five back in. Also, the overwhelming evidence that in-person teaching is really particularly beneficial for K through five, is a double whammy of why I think we should have a lower threshold for getting K through five back in for in-person teaching. And high schoolers, again, as I said, I just think of them, functionally, as adults, even though I have a high schooler, she’s great, but they’re not adults. We know this, but physically they essentially kind of function as adults. And so we have to sort of think of them as a large number of adults getting together indoors. And that means probably a higher threshold for when it’s safe to get kids back into school.
Q: And do you think in the Northeast that it’s safe to send them back in September?
ASHISH JHA: So in some parts of the Northeast, yes, others no. Vermont and Maine, absolutely. They look like the best places of Europe. New Hampshire and Massachusetts, probably. But you really want to in all of these places, you still have to do a lot of work in the schools in terms of getting ventilation, thinking about outdoor space. In Massachusetts, I’ve been talking to a bunch of cities and encouraging them try to hold as many classes outdoors as possible in September, October. So I think if you do all of that stuff, it’s pretty safe to have the kids back in a lot of these states.
Q: Thank you.
MODERATOR: Next question.
Q: Hi. Thanks so much for doing this. I wanted to go back to talking about the rapid tests that are less sensitive. I know you said that people, ideally, would be using them regularly. And is that every day, a few times a week, or some other amount? And then also, I had asked Admiral Giroir about this last week, and he seemed to indicate that anything with the sensitivity of less than 70 percent could potentially do more harm than good. And so I just wanted to see what your thoughts are on that and what kind of level of sensitivity would be appropriate.
ASHISH JHA: Yeah, so frequently probably depends on risks. And what I mean by that, I’ll give you specific examples. My parents are elderly. They live in New Jersey and they’re largely locked up at home. I mean not locked up, but, you know, they’re not doing a lot socially. They probably don’t need to be getting tested twice a week and they just don’t have enough frequent contacts with other people. If you’re a health care worker or you’re a nursing home worker or you’re a grocery store worker, it would be great if we could get you tested on an ongoing basis. And I think twice a week is probably the right number. There’s some modeling data that says three times is a bit better. And the reason is, these are not the numbers we’re making up on the off the top of our heads. If you think about when people get infected, when they’re infectious, when they’re symptomatic. What we know, our best data, is that a lot of the spreading happens in the day or two before you develop symptoms, and in the first few days after you develop symptoms. If we can get people when they develop symptoms to self isolate, the key becomes to capture them in those couple of days before they develop symptoms because they’re actually quite infectious during that time. And so if you’re testing twice a week, you’re gonna get most of those people in that high infectious period.
Now, the mental model shift, and I know I said this earlier, but I want to re-emphasize because then I’ll get to Admiral Giroir’s comment, is that as a doctor, as a practicing physician, a test that has a lot of false negatives is a problem because I’m only doing the test once and I want to know, do you have the diagnosis or not, today. So I need a highly sensitive test. But if you take your kind of doctor hat off and put on your public health hat, what you realize is you’re thinking about it from a population point of view because you want to drive the infections way down. So to use Michael Mina’s line of “crappy test”, imagine a really crappy test has a 50 percent sensitivity. And by the way, antigen tests and other things that are out there have sensitivities around kind of 80, 85 percent. So they’re much better. But imagine even a 50 percent, meaning half the people who have the infection are gonna get missed by this test. Sounds terrible. Well, first of all, it’s not 50 percent throughout the entire course of the disease in their first couple of days when they’re not all that infectious, it might be lower. Once they’re very infectious in that window where they’re spreading the disease quite a bit, it goes up much, much higher to, let’s say, 80 or 90 percent. So its overall sensitivity might be 50, but it’s going to do much better when people are highly infectious because you’re infectious when you have a lot of virus in your system. But even if, let’s say, you capture only half the people. Those half the people, you get them, they’re not going to spread and they then isolate. Then you’ve brought the number of infections in the community way down. You retest people three days later, a chunk of those that you missed on the first pass, you’ll get them on the second pass.
The bottom line is, if you walk through the data on the model, if you could get people, and again, I don’t want to push a 50 percent sensitivity test because that is really a problem. But even at 70, 80 percent sensitivity, which a lot of these antigen tests have, you drive the infection way, way down, because you bring the ability of anybody who’s infected to infect other people, way down. You really start bringing the virus under control in communities. So I don’t know what that threshold is, different models suggest different amounts. But we have to stop thinking about this as, somebody gets a negative test, they’ve got a clean bill of health and they can do whatever they want. That’s not what the point of these tests are. The point of these tests is we’re doing them frequently. You’re getting results frequently. If you tell somebody who has a negative test, you’re not infectious today, but you could be infectious tomorrow. You still need to wear a mask. You still need to do social distancing. And we’re going to test you in three days if we have that strategy for high risk people. We really can make a big difference.
MODERATOR: Are you all set?
Q: Yes. Thank you.
MODERATOR: All right, next question.
Q: Hey, thanks for doing the call. Can you comment at all on what we’ve learned about seasonality? Obviously, the summertime hasn’t saved us. There was a Sun Belt surge and the hottest places in America. Just wondering, if seasonality is not a factor, if you think things like our widespread susceptibility, indoor gathering and air conditioning is overcome whatever advantages we might have had from the warm season. Thanks.
ASHISH JHA: Yeah. Seasonality was always. In my mind, not overrated, but people kind of misunderstood it a little bit and I think unfortunately, a lot of people in the White House misunderstood it. There is evidence, and I still believe in the evidence that warmer temperatures, more humid temperatures, probably make the virus a little less transmittable. But that’s not where much of the transmission is happening. The transmission is happening largely indoors. And where I think seasonality plays an important role is to the extent that the season lets you spend time outdoors, then you’re getting a little seasonality benefit. So I’m in Cambridge, Massachusetts today, and it’s been a little hot, but in general, I can do a lot of stuff outdoors, and that makes it much easier to avoid indoor gatherings. Unlike the overwhelming evidence, is that much of the spread happens indoors, in gatherings with sizable number of people. So the seasonality effect will be that in Cambridge in November and December, life is going to get much, much harder because we will be spending a lot more time indoors. And it’s going be much easier for the virus to spread. So I think part of the reason we saw a big surge in the South was because, A, just really bad policies, but B, people spending so much time indoors.
Q: Right. So just real quick, I guess based on what you said, the fact that the Sun Belt plateauing seems to be pretty much exclusively a function of them tightening things up is not just the fact that it’s gone from hot to really hot, or anything like that.
ASHISH JHA: No, I don’t think. You know, Arizona was hot enough on June 10th that any benefit of seasonality from that point of view was going to be apparent. The fact that Arizona’s gotten a little hotter probably isn’t making much difference.
Q: Thank you.
MODERATOR: Next question.
Q: Good morning. Thank you. So I’m just thinking that a lot of K through five teachers, well, in fact, I’ve talked to some, are a little bit less excited about a return than you are. And then many parents want this to happen. But should young children and high schoolers be required to wear masks and or should they be tested regularly? I mean, should we be applying some of these things that we would apply to office workers and others, to K through five kids?
ASHISH JHA: Yes and yes. So let me build on that a little bit. One of the problems that has clearly become apparent to me as I’ve been speaking to folks around the country, and this is what I find so incredibly frustrating about our country’s inability to solve complex problems, is that we have politicized this in a way that it’s now somehow a setup of kids versus teachers. Like to me, that’s insane. We can’t run schools without teachers and if teachers don’t feel safe, it’s not going to work. And we can’t bully teachers, we shouldn’t even try. It’s a bad idea. So we’ve got to find a way to be able to create safety in schools so that teachers feel reasonably safe returning and that it’s safe for kids. And again, I generally try to stay away from overtly political things. But I found the president’s tweet this morning of just open schools to be so incredibly frustrating because literally, I feel like I’ve spent every waking hour of the last week working with parents, teachers, school administrators, mayors, on trying to solve this very, very complicated problem. It’s not a simple just open schools or just shut down schools, so we don’t want to take that lens.
Now, building on that, the thing that I’ve been very honest about is I am obviously an advocate for trying to get kids back to school, particularly K through five. And what I have been very clear about is I can’t guarantee anything. I can’t guarantee that a school will not have an outbreak. You can build in layers of safety, and every layer you build in makes the schools safer. If you’re in a relatively lower community transmission, that’s safer. I believe kids should absolutely be wearing masks, as should teachers and other staff. That’ll make it safer. I think my personal view, and this goes against the CDC recommendation, and I am flabbergasted that the CDC said what they said on this, but I think there should absolutely be testing in schools. It adds another layer of protection. It’s not perfect. You know, CDC’s argument is, well, you’ll miss cases. You’ll miss cases no matter what you do. But if it adds another layer of protection, let’s say it lowers the number of kids who are gonna walk in or teachers are going to walk in infected, that’s helpful. So there’s a lot we can do to make it safe enough that people are going to feel comfortable getting back in. Staying in the community is not without risk either. So that should be the strategy, adding layers of protection, and every layer of protection you forgo, you just understand that you’re increasing your risks. And the last point I want to say about this, and this is to me, a really critical issue. We get one shot at opening schools for kids this fall. If we mess that up, meaning imagine you open up without building in the safety precautions and then you get a large outbreak, 10 kids, four staff members, let’s imagine one or two of those staff members end up getting really sick. You are going to have completely destroyed the ability of that school to open up again anytime soon because people are going to get so incredibly gun shy about opening up a school where there’s been a large outbreak. You’re largely consigning that school to be online for a very extended period of time. So being irresponsible and just saying let’s just go for it, in my mind, is really problematic. And this is what we’re gonna see, I believe, in states across the country, a lot of schools opening up without building in the safeguards, then having large outbreaks, then the national mood is going to be what we just can’t do schools. And that’s going to frustrate those of us who think we can do it if we do it right.
Q: Thank you for that. A related following, and respectfully, I want to press you on something that I think is going to be a reader reaction, so I want to get ahead of it. You mentioned perhaps the transmissibility among K through fives is around 50 percent. We really don’t know. And we’re probably not going to have settled science on this before schools need to reopen. So what would you say to somebody who says, boy, this sounds like a scientific experiment to me, sending the kids back?
ASHISH JHA: Yeah, I don’t see it as an experiment. And what I say is there are real costs to kids and to adults of not sending kids back. And so what we know is that especially for K through five, there are going to be huge educational hits for those kids. And guess what? It’s going to be disproportionately bad in minority communities and in poor communities. So if the person who says I want complete certainty in this pandemic, of exactly what’s gonna happen, you’re right. We’re not going to get to that certainty, and if anything that doesn’t have complete certainty is an experiment, then we’re all living through an experiment. But in my mind, we know enough now to make it relatively safe. But what I would say to teachers, what I have been saying to teachers is, you know, my mom was a public school teacher for 25 years. She’s retired now. But I would not do this if I didn’t think that I would’ve been comfortable with my mom going to a school with with those safeguards. And that’s the model we have to use. Because what I know is that if there is an outbreak and if a couple of the kids in my kid’s school get infected, it will shut down that school for a very long time, and rightly so. So we need to do this as carefully as possible. But there is no scientific certainty in the middle of a pandemic of a novel virus. And if people are looking for it, it’s gonna be very hard to get.
ASHISH JHA: Thank you so much for that.
MODERATOR: Next question.
Q: Hi, thanks for having us. So you’ve talked a bit about the spread of the virus indoors. I’d just like to follow up on that in the context of cruise sailing’s. So some cruise lines are planning for their sailing resumptions as they wait out on the CDC’s no sail order. So what are your thoughts about cruising in the current situation and what precautions do these cruise lines need to take? Thanks.
ASHISH JHA: I have to tell you, on a personal level, I just would not feel comfortable at all getting on a cruise ship anytime in the near future. So if a cruise line called me and said we’re really anxious to sail, what could we do to make it relatively safe? Boy, it’s hard, partly because you’ve got people in packed quarters and they can spend some amount of time outdoors, but they can’t spend all their time outdoors. So I would generally think of cruising as a very high risk endeavor. Now, could you bring it to a low risk endeavor? You potentially could. What you would want to do is you want to test. You want to bring everybody together maybe five days or seven days before they should set sail. Quarantine them, start testing them on a regular basis, and then start testing people almost certainly every couple of days while they’re on the on the cruise ship and really try to improve ventilation. Maybe you could make it relatively safe. But it strikes me as extremely difficult. I personally feel like, especially given the demographics of who goes on cruise ships, which tends to be an older population, it would be a very risky thing. I would think there’s a very high risk that you get a lot of people infected and a lot of people would get sick. But not completely undoable, just very, very hard.
Q: Thank you.
MODERATOR: Next question.
Q: Hi. Thank you so much for joining us today. I have two questions. The first is about the lack of school nurses in many of these schools throughout this country, and how you feel that is going to impact our ability to open schools and do it correctly and safely.
ASHISH JHA: Yes. I don’t know if you have follow up or a second question related to this issue as well, but I’ll just say that one of the big issues, as I’ve been talking to school superintendents, is they’re just trying to think through the protocol if, what happens when the kid comes in and like 10:00 in the morning, they’ve got, you know, a little sore throat and the sniffles, who triages them? How do we manage that? And what’s the threshold for sending kids home to get tested if they don’t have testing in the schools?
You absolutely need some sort of a health care personnel. We can’t expect our teachers all of a sudden become nurses as well. And so you absolutely need some sort of a healthcare bill, whether you need a fully certified nurse or not, I don’t know. But you need somebody to be able to triage that kid, figure out what’s going on, or triage an adult and figure out whether they need to leave the premises to get tested or not. I’d be very worried about running a school where there was nobody with any kind of health care or training to be able to do all that.
Q: Right. And my second is actually unrelated, but in terms of the recent Nature study that showed cross reactivity with the virus and possibly more widespread T cell immunity than we think throughout the world. How do you think that will affect the course of the pandemic? And also some of the changes we’re seeing, it seems like, in the lethality and mortality. Is it possible there are subtle changes that are happening to the virus that we just haven’t picked up on?
ASHISH JHA: Great questions. And let me take the second one first, mostly because I feel a bit more confident about the science, as I understand it, which is really the issue of are there different strains emerging and are they potentially less lethal or more lethal or are they more infectious or less infectious? It’s hard business to sort out, partly because viruses mutate all the time. And literally how we track virus spread is by looking at a little minor mutations. Most of them have no clinical biological significance. When I speak to virologists and ask them how many strains of SARS-CoV-2 are there, most of them still tell me that there is one strain, that everything is a minor mutation on that, and there aren’t. There are some people who believe that one of the strains that kind of really took hold in Europe is a bit more infectious, not more lethal. But I haven’t seen any data at least that I’m aware of that compels me to think that the virus has become any more or any less lethal. So my sense is that some of the places we’re seeing lower mortality is because we’re getting better at treating the disease. And that really is making a difference. It’s not just the Dexamethasone and Remdesivir, but also just doctors are getting more experience at figuring out who needs to be ventilated, who doesn’t, how do you get people through this? I think all of that is also making a difference.
On the question of T cell immunity. See how I punted on that, because the short answer is I don’t know. But for those of you who have not been tracking this, here’s the big issue. There is now increasing amount of evidence that you can find T cells that seem to be activated against the SARS-CoV-2 virus in people who clearly have not been infected with this virus. And it is making people much more optimistic that maybe we have broader population level immunity. The short answer is we don’t know, because sometimes you can see T cells, but they alone may not offer much immunity or they may be making the disease a little milder or they may make it potentially, theoretically, the disease a bit more deadly.
There are, I think, immunologists who think maybe there is greater immunity than we have thought. What I’m trying to do is look at data, two types of data. One is, I want to see whether those T cells really do offer any level of protection. And then second, what I’m trying to do is look at data from communities that have had high levels of infection already and say, do I really see community level protection in places like New York City, places like Mumbai in India, and trying to infer from more population level disease dynamics whether we’re seeing more immunity than I would have expected. So it’s all kind of a tricky business at this point. I guess my feeling is in the next few weeks, I think we’ll have a better sense. Right now, it’s an honest I don’t know what the significance of all those extra T cells and a lot of people is.
MODERATOR: Next question.
Q: Hi. Thanks for doing this. A couple of people, I think, there was a Federal Reserve official the other day, are basically saying, we need to just totally start over and have like a nationwide shutdown for six weeks or something. I understand that might be politically not very feasible. But I mean, does that seem necessary from a from a public health standpoint? Or do we still need more state by state or target on closing bars, you know, indoor stuff. Do we not need to go that drastic at this point?
ASHISH JHA: Yeah, it’s a really good question. And there was a statement signed by about 150 epidemiologists and public health experts basically saying we need a nationwide shutdown. I chose not to sign that. I was asked several times and I chose not to do it. So that just as my way of telling you kind of a little bit of where my head is on this. First of all, forgetting the politics and the political possibilities are not my area of expertise. I don’t think it’s necessary if we define it the way we thought about it and kind of March and April, which was a shelter in place order. I think it’s largely reasonable to let people get outside, especially right now in the summer in large parts of the country where it’s pretty comfortable to get outside. I think it’s fine to have people outside. And why? Because the virus is very, very important, but there are large mental health effects and other types of effects of having a shelter in place order. So I would not support a national, let’s say, shelter in place or every state doing a shelter in place order.
That is not my way of saying we don’t need really aggressive action. Personally, I think most states, many states, need to probably move back to stage one. If you go back to the guidelines from the White House initially on opening up America again, stage one was that sort of first stage, where you had gatherings of 10 or less indoors, basically restaurants at twenty five percent or closed. And in the hot spots, I would have no indoor dining, no bars, no gyms. And so that starts feeling like a shut down. But I would not prevent people from going out to parks and beaches, mostly because I have not seen any data that those are really risky. Plus, also now I would definitely have mandates of mask wearing anytime you’re outside. So put all that together. I think there is a way to do this.
There are people who push back on me and say, you just gave a whole lot of kind of nuance and subtlety. Wouldn’t it be just easier if we just had a single national shut down? And my take is the pandemic looks very different in Massachusetts than it does in Mississippi. I really do think we just need different policies in Massachusetts than we do Mississippi.
Q: Got it. Thanks, that helps.
MODERATOR: Next question.
Q: Hi. Thank you so much. I have a question on something Dr. Birx said over the weekend about households where their multigenerational or have vulnerable people living there, considering wearing face masks inside, especially as kids go back to school. So I’m hoping maybe you could talk a little bit about what we’re seeing when it comes to household transmission. Is this something we should be really concerned about? Then, sort of how realistic or effective of a solution would this be?
ASHISH JHA: Yeah, so there is pretty good data on household transmission from China, from the U.S. and other places. It clearly happens. The attack rates are nowhere near 100 percent. There may maybe 15 or 20 percent. Another way of saying is, if you have an infected person living in your household, maybe 15, 20 percent of other people in that household end up getting infected. And again, if my entire kind of lens is what can I do to reduce infections from SARS-CoV-2 to. Sure. Indoor mask wearing would help. Again, I think it’s very hard to get people to wear masks. It’s hard enough to get people to wear masks when they’re outdoors all the time. I think asking kids, family to wear masks all the time when they’re awake, is gonna be a real challenge. So I have not pushed for that. And then I guess I sort of come back to, that’s such a heavy lift, why can’t we do other things that to me, feel like lower lifts that would have big benefits. So I would never ask for that in a community that has bars open. To me, that’s insane. Asking kids to wear masks indoors, but we are still gonna keep bars open. So once we have done all of the things that we can do to protect a community, if you’re still seeing high degrees of spread, then I think we can come back to it. But I haven’t seen the need for that. I’d much rather focus on a lot of the other stuff that I think is more realistic and doable than asking, for instance, kids to be wearing masks indoors all day when they’re with their families, or parents to do that as well.
Q: You answered my follow up question, so thank you.
MODERATOR: Next question.
Q: Hi. Thanks for doing this. I’m wondering about the feasibility of universal testing, both in K through 12 schools and then in university level, in a state with high spread. I’ve been asking folks about that for a story here. And there’s some resistance to the idea that it would be financially feasible or logistically feasible to do universal testing in schools and universities.
MODERATOR: And I will say real quick, that is in Alabama.
ASHISH JHA: So this is a very good question. And I’m getting this asked a lot, especially when some big state schools do the calculation, when they’ve asked me how often should we be testing? My personal view, again, we’re building in layers of safety. And if you want to build in a strong layer of safety with testing, you wanna be testing everybody twice a week. And they run the numbers and they come back with astronomically high numbers and they say, we just can’t do this. And then they say, well, what about if we just open up without testing? And my general take is it depends on how lucky you feel. But I don’t recommend it. You can try, but I would think it meaningfully increases your risk. So there’s both the cost and the feasibility. In a lot of places, PCR testing of everybody twice a week in schools and colleges is probably beyond the capacity, both logistically and financially, of schools and universities. And again, if we cared about schools, we could have found a way to pay for this and build the infrastructure. But that’s a different conversation. So what I’ve been recommending is that schools now really shift towards thinking about antigen testing and other testing modalities. And again, it’s one of those things where people say, what if I did that once a week? And I might take as it’s meaningfully less effective, but it’s better than probably nothing. I think antigen testing or some other modalities are probably fine. And going without it in a place like Alabama strikes me as extremely high risk. And I certainly would not send any of my kids, including my rising third grader, to a public school in almost any county in Alabama right now. Just because the numbers are so bad and without testing, there’s no way.
MODERATOR: Do you have a follow up?
Q: No, that helps. Thank you.
MODERATOR: Next question.
Q: Hi there. Thank you for doing this. I apologize if somebody asked question because I came on late. But my first question for you, sir, is I want your take on just how great the risk is of reopening brick and mortar schools here in our state of Florida, five days a week as mandated by our DOE as an option for folks.
ASHISH JHA: Yeah. So it is really community dependent and not kind of overall in the state. But when I look at where Florida is today, I think it’s extremely high risk to open up schools five days a week. Now, what could you do if you got to bring virus levels much, much lower? I guess what I’ve been saying for places like Florida and Texas is if the DOE or if the governor really cared about getting kids back in school, what they would do is put in very vigorous virus control measures that would bring the virus levels way down, and then think about October 1st potential start date. If the virus levels got low enough, I think that’s possible. I think the level of virus that exists in most counties in Florida, you can open up and you’ll find that you’re going to end up shutting down within three to four weeks. I’d be very surprised if any school in Florida is able to do five days a week in-person classes by Columbus Day. That would be very, very, very surprising.
MODERATOR: Do you have a follow up?
Q: Yes. So you talked to obviously being community dependent. I read a little bit from UT Austin this morning, and I know The Times had it in one of their articles, their research essentially projecting the number of people, county by county, that would come back infected at the start of school. And here in our biggest county that we cover, the projections said about 10 people would walk in, in Lee County, infected, in a school of 1,000 people. Looking at that case, can you assess the risk of teachers giving it to students, students giving it to teachers? What is your take in Lee County, given that report?
ASHISH JHA: So remember, I’ve spent this entire hour saying the biggest risk is when large numbers of people gather indoors for extended periods of time. Also talking about bars, restaurants and gyms, but you could say, well, I also could throw in schools. Of course, I think from a social value point of view, schools are so much more socially valuable that I don’t generally lump them in with bars, restaurants. Nothing against bars and restaurants. But that’s a judgment call that I’m making. The virus doesn’t care if you’re in a school or in a bar. So I think if you have, in a school of 1,000 people, 10 people walking in with the virus and you don’t know which 10 they are, you might get away for a few days. But if that happens on an ongoing basis, you’re going to have large super spreading events. And I think it’ll be very, very hard to keep that school open for any extended period of time.
MODERATOR: Thank you, Dr. Jha. Did you have any final thoughts before you need to go, or do you just need to run off?
ASHISH JHA: No, let me just say one quick thing. It’s really amazing to me that we are, as a country fighting this pandemic. Every community sorting this out on their own, every school district, every school superintendent. The lack of federal leadership and the lack of effective communication from both the federal and often state governments is very, very distressing. It’s making all of this much, much harder for kids and parents and people all around the country. And whenever we emerge from this, first, I’d like to see if we can figure out how to do this a bit better for this pandemic. And then whenever we emerge from this pandemic, we’ve got to make sure we don’t do this again because it’s been extremely difficult and it has meant that tens of thousands of people have died unnecessarily and that the biggest tragedy of all. So, anyway, thank you all for being here and listening, and I’m happy to follow up with individuals separately as well.
This concludes the August 3rd press conference.